Addressing mpox at a Frontline Community Health Center: Lessons for the Next Outbreak

The 2022 mpox (formerly monkeypox) outbreak affected predominantly men who have sex with men (MSM), likely through sexual transmission, which resulted in institutions specializing in sexual health being at the frontlines of the mpox outbreak. Fenway Health in Boston serves close to 10 000 MSM annually, which includes more than 2400 MSM who are living with HIV and 3320 MSM with active HIV preexposure prophylaxis (PrEP) prescriptions. We report on the programs implemented and changes to clinical practice at Fenway Health during the mpox outbreak. Fenway Health diagnosed its first case of mpox in June 2022 and treated this patient with tecovirimat. In early July 2022, Fenway Health administered its first dose of the Jynneos vaccine under the Emergency Use Authorization for protection against mpox. As of October 6, 2022, 69 people had tested positive for the mpox virus at Fenway Health. Among the 69 people who tested positive, 43 (62.3%) self-identified as male, with the remaining not reporting a sex or gender identity, and 40 (58.0%) reported their sexual orientation as gay or bisexual. Twenty-five people (36.2%) were treated with tecovirimat. As of October 30, 2022, Fenway Health had administered 6376 doses of the Jynneos vaccine. The programmatic changes involved in rollout and scale-up of vaccination, treatment, and community outreach services at Fenway Health during the 2022 mpox outbreak that we describe here could inform strategies to address subsequent outbreaks.

The Last Mile in Polio Eradication: Program Challenges and Perseverance

As the Global Polio Eradication Initiative (GPEI) strategizes towards the final steps of eradication, routine immunization schedules evolve, and high-quality vaccination campaigns and surveillance systems remain essential. New tools are consistently being developed, such as the novel oral poliovirus vaccine to combat outbreaks more sustainably, as well as non-infectiously manufactured vaccines such as virus-like particle vaccines to eliminate the risk of resurgence of polio on the eve of a polio-free world. As the GPEI inches towards eradication, re-strategizing in the face of evolving challenges and preparing for unknown risks in the post-certification era are critical.

Assessment of the impact of integrated disease surveillance and response system on surveillance management at healthcare facilities in Pakistan

Background

Disease surveillance is very crucial especially in high vulnerability settings like Pakistan. However, surveillance and outbreak response management are still evolving in the country and research studies are needed to assess the existing system.

Aim

To assess the impact of integrated disease surveillance and response system (IDSRS) implemented by the provincial government to strengthen infectious disease surveillance and reporting in 6 districts of Pakistan in 2016.

Methods

A baseline cross-sectional assessment of health facilities and the healthcare workforce was conducted in 2016 to identify needs and gaps in public sector health facilities and the health system of 6 selected districts of Khyber Pakhtunkhwa Province, Pakistan. This was followed by a 2018 endline survey of the same facilities using the same variables.

Results

Overall, there was improvement in district management and facility level performance (χ2 (1, 314) = 21.19, P < 0.001, V = 0.26). District level management improved significantly in areas with relatively lower Gross Domestic Product (GDP)? χ2(1, 154) = 30.41, P <0.001, V = 0.44). Facilitation domain variables improved in the lower GDP districts (χ2 (1, 74) = 5.76, P = 0.016, V = 0.28) and showed counterintuitive deterioration (χ2 (1, 74) = 4.80, P = 0.028, V = 0.25) in relatively higher GDP areas.

Conclusion

IDSRS is effective in improving surveillance and response systems, however, its effectiveness appears to depend on locale-specific economies and can be enhanced by modifying the implementation approach. Better empowerment of the local workforce can contribute to such improvement.

Enabling countries to manage outbreaks: statistical, operational, and contextual analysis of the early warning and response system (EWARS-csd) for dengue outbreaks

Introduction

Dengue is currently the fastest-spreading mosquito-borne viral illness in the world, with over half of the world's population living in areas at risk of dengue. As dengue continues to spread and become more of a health burden, it is essential to have tools that can predict when and where outbreaks might occur to better prepare vector control operations and communities' responses. One such predictive tool, the Early Warning and Response System for climate-sensitive diseases (EWARS-csd), primarily uses climatic data to alert health systems of outbreaks weeks before they occur. EWARS-csd uses the robust Distribution Lag Non-linear Model in combination with the INLA Bayesian regression framework to predict outbreaks, utilizing historical data. This study seeks to validate the tool's performance in two states of Colombia, evaluating how well the tool performed in 11 municipalities of varying dengue endemicity levels.

Methods

The validation study used retrospective data with alarm indicators (mean temperature and rain sum) and an outbreak indicator (weekly hospitalizations) from 11 municipalities spanning two states in Colombia from 2015 to 2020. Calibrations of different variables were performed to find the optimal sensitivity and positive predictive value for each municipality.

Results

The study demonstrated that the tool produced overall reliable early outbreak alarms. The median of the most optimal calibration for each municipality was very high: sensitivity (97%), specificity (94%), positive predictive value (75%), and negative predictive value (99%; 95% CI).

Discussion

The tool worked well across all population sizes and all endemicity levels but had slightly poorer results in the highly endemic municipality at predicting non-outbreak weeks. Migration and/or socioeconomic status are factors that might impact predictive performance and should be further evaluated. Overall EWARS-csd performed very well, providing evidence that it should continue to be implemented in Colombia and other countries for outbreak prediction.

Modeling undetected poliovirus circulation following the 2022 outbreak in the United States

BACKGROUND

New York State (NYS) reported a polio case (June 2022) and outbreak of imported type 2 circulating vaccine-derived poliovirus (cVDPV2) (last positive wastewater detection in February 2023), for which uncertainty remains about potential ongoing undetected transmission.

RESEARCH DESIGN AND METHODS

Extending a prior deterministic model, we apply an established stochastic modeling approach to characterize the confidence about no circulation (CNC) of cVDPV2 as a function of time since the last detected signal of transmission (i.e. poliovirus positive acute flaccid myelitis case or wastewater sample).

RESULTS

With the surveillance coverage for the NYS population majority and its focus on outbreak counties, modeling suggests a high CNC (95%) within 3-10 months of the last positive surveillance signal, depending on surveillance sensitivity and population mixing patterns. Uncertainty about surveillance sensitivity implies longer durations required to achieve higher CNC.

CONCLUSIONS

In populations that maintain high overall immunization coverage with inactivated poliovirus vaccine (IPV), rare polio cases may occur in un(der)-vaccinated individuals. Modeling demonstrates the unlikeliness of type 2 outbreaks reestablishing endemic transmission or resulting in large absolute numbers of paralytic cases. Achieving and maintaining high immunization coverage with IPV remains the most effective measure to prevent outbreaks and shorten the duration of imported poliovirus transmission.

Rapid response teams in the Eastern Mediterranean Region: Results from the baseline survey of country-level capacities, operations and outbreak response capabilities

The aim of this study is to assess WHO/Eastern Mediterranean region (WHO/EMR) countries capacities, operations and outbreak response capabilities. Cross-sectional study was conducted targeting 22 WHO/EMR countries from May to June 2021. The survey covers 8 domains related to 15 milstones and key performance indicators (KPIs) for RRT. Responses were received from 14 countries. RRTs are adequately organised in 9 countries (64.3%). The mean retention rate of RRT members was 85.5% ± 22.6. Eight countries (57.1%) reported having standard operating procedures, but only three countries (21.4%) reported an established mechanism of operational fund allocation. In the last 6 months, 10,462 (81.9%) alerts were verified during the first 24 h. Outbreak response was completed by the submission of final RRT response reports in 75% of analysed outbreaks. Risk Communication and Community Engagement (RCCE) activities were part of the interventional response in 59.5% of recent outbreaks. Four countries (28.6%) reported an adequate system to assess RRTs operations. The baseline data highlights four areas to focus on: developing and maintaining the multidisciplinary nature of RRTs through training, adequate financing and timely release of funds, capacity and system building for implementing interventions, for instance, RCCE, and establishing national monitoring and evaluation systems for outbreak response.

Accelerated and intensified manufacturing of an adenovirus-vectored vaccine to enable rapid outbreak response

The Coalition for Epidemic Preparedness Innovations' "100-day moonshot" aspires to launch a new vaccine within 100 days of pathogen identification, followed by large-scale vaccine availability within the "second hundred days." Here, we describe work to optimize adenoviral vector manufacturing for rapid response, by minimizing time to clinical trial and first large-scale supply, and maximizing output from the available manufacturing footprint. We describe a rapid virus seed expansion workflow that allows vaccine release to clinical trials within 60 days of antigen sequence identification, followed by vaccine release from globally distributed sites within a further 40 days. We also describe a perfusion-based upstream production process, designed to maximize output while retaining simplicity and suitability for existing manufacturing facilities. This improves upstream volumetric productivity of ChAdOx1 nCoV-19 by approximately fourfold and remains compatible with the existing downstream process, yielding drug substance sufficient for 10,000 doses from each liter of bioreactor capacity. This accelerated manufacturing process, along with other advantages such as thermal stability, supports the ongoing value of adenovirus-vectored vaccines as a rapidly adaptable and deployable platform for emergency response.

Fractional Dosing of Yellow Fever Live Attenuated 17D Vaccine: A Perspective

Yellow fever virus (YFV) is a mosquito-borne flavivirus that causes over 109,000 severe infections and over 51,000 deaths annually in endemic areas of sub-Saharan Africa and tropical South America. The virus has a transmission cycle involving mosquitoes and humans or non-human primates (NHPs) as the vertebrate hosts. Although yellow fever (YF) is prevented by a live attenuated vaccine (strain 17D), recent epidemics in Angola, the Democratic Republic of the Congo (DRC), and Brazil put great pressure on vaccine stockpiles. This resulted in the World Health Organization (WHO) and Pan American Health Organization (PAHO) implementing, on an emergency basis only, off-label dose-sparing techniques and policies during 2016-2018 to protect as many people in DRC and Brazil as possible from disease during unexpected large outbreaks of YF. Subsequently non-inferiority studies involving full doses compared to fractional doses indicated promising results, leading some policy-makers and scientists to consider utilizing YF vaccine fractional doses in non-emergency scenarios. Although the additional data on the immunogenicity and safety of fractional doses are promising, there are several questions and considerations that remain regarding the use of fractional doses, including differences in the initial antibody kinetics, differences in the immune response in certain populations, and durability of the immune response to fractional doses compared to full doses. Until the remaining knowledge gaps are addressed, full doses instead of fractional doses should continue to be used unless there are insufficient doses of the vaccine available to control outbreaks of YF.

The role of digital surveillance during outbreaks: the Ghana experience from COVID-19 response

Over the years, Ghana has made notable strides in adopting digital approaches to address societal challenges and meet demands. While the health sector, particularly the disease surveillance structure, has embraced digitization to enhance case detection, reporting, analysis, and information dissemination, critical aspects remain to be addressed. Although the Integrated Disease Surveillance and Response (IDSR) structure has experienced remarkable growth in digitization, certain areas require further attention as was observed during the COVID-19 pandemic. Ghana during the COVID-19 pandemic, recognized the importance of leveraging digital technologies to bolster the public health response. To this end, Ghana implemented various digital surveillance tools to combat the pandemic. These included the 'Surveillance Outbreak Response Management and Analysis System (SORMAS)', the digitalized health declaration form, ArcGIS Survey123, Talkwalker, 'Lightwave Health information Management System' (LHIMS), and the 'District Health Information Management System (DHIMS)'. These digital systems significantly contributed to the country's success in responding to the COVID-19 pandemic. One key area where digital systems have proved invaluable is in the timely production of daily COVID-19 situational updates. This task would have been arduous and delayed if reliant solely on paper-based forms, which hinder efficient reporting to other levels within the health system. By adopting these digital systems, Ghana has been able to overcome such challenges and provide up-to-date information for making informed public health decisions. This paper attempts to provide an extensive description of the digital systems currently employed to enhance Ghana's paper-based disease surveillance system in the context of its response to COVID-19. The article explores the strengths and challenges or limitations associated with these digital systems for responding to outbreaks, offering valuable lessons that can be learned from their implementation.

Facilitators and Barriers in the Implementation of a Digital Surveillance and Outbreak Response System in Ghana Before and During the COVID-19 Pandemic: Qualitative Analysis of Stakeholder Interviews

BACKGROUND

In the past 2 decades, many countries have recognized the use of electronic systems for disease surveillance and outbreak response as an important strategy for disease control and prevention. In low- and middle-income countries, the adoption of these electronic systems remains a priority and has attracted the support of global health players. However, the successful implementation and institutionalization of electronic systems in low- and middle-income countries have been challenged by the local capacity to absorb technologies, decisiveness and strength of leadership, implementation costs, workforce attitudes toward innovation, and organizational factors. In November 2019, Ghana piloted the Surveillance Outbreak Response Management and Analysis System (SORMAS) for routine surveillance and subsequently used it for the national COVID-19 response.

OBJECTIVE

This study aims to identify the facilitators of and barriers to the sustainable implementation and operation of SORMAS in Ghana.

METHODS

Between November 2021 and March 2022, we conducted a qualitative study among 22 resource persons representing different stakeholders involved in the implementation of SORMAS in Ghana. We interviewed study participants via telephone using in-depth interview guides developed consistent with the model of diffusion of innovations in health service organizations. We transcribed the interviews verbatim and performed independent validation of transcripts and pseudonymization. We performed deductive coding using 7 a priori categories: innovation, adopting health system, adoption and assimilation, diffusion and dissemination, outer context, institutionalization, and linkages among the aspects of implementation. We used MAXQDA Analytics Pro for transcription, coding, and analysis.

RESULTS

The facilitators of SORMAS implementation included its coherent design consistent with the Integrated Disease Surveillance and Response system, adaptability to evolving local needs, relative advantages for task performance (eg, real-time reporting, generation of case-base data, improved data quality, mobile offline capability, and integration of laboratory procedures), intrinsic motivation of users, and a smartphone-savvy workforce. Other facilitators were its alignment with health system goals, dedicated national leadership, political endorsement, availability of in-country IT capacities, and financial and technical support from inventors and international development partners. The main barriers were unstable technical interoperability between SORMAS and existing health information systems, reliance on a private IT company for data hosting, unreliable internet connectivity, unstable national power supply, inadequate numbers and poor quality of data collection devices, and substantial dependence on external funding.

CONCLUSIONS

The facilitators of and barriers to SORMAS implementation are multiple and interdependent. Important success conditions for implementation include enhanced scope and efficiency of task performance, strong technical and political stewardship, and a self-motivated workforce. Inadequate funding, limited IT infrastructure, and lack of software development expertise are mutually reinforcing barriers to implementation and progress to country ownership. Some barriers are external, relate to the overall national infrastructural development, and are not amenable even to unlimited project funding.

Task Force for a rapid response to an outbreak of severe acute hepatitis of unknown aetiology in children in Portugal in 2022

On 5 April 2022, the United Kingdom reported an increase of cases of severe acute hepatitis of unknown aetiology in children, several needing hospitalisation and some required liver transplant or died. Thereafter, 35 countries reported probable cases, almost half of them in Europe. Facing the alert, on 28 April, Portugal created a multidisciplinary Task Force (TF) for rapid detection of probable cases and response. The experts of the TF came from various disciplines: clinicians, laboratory experts, epidemiologists, public health experts and national and international communication. Moreover, Portugal adopted the European Centre for Disease Prevention and Control (ECDC) and the World Health Organization (WHO) case definition and recommendations. By 31 December 2022, 28 probable cases of severe acute hepatitis of unknown aetiology were reported: 16 male and 17 aged under 2 years. Of these cases, 23 were hospitalised but none required liver transplant or died. Adenovirus was detected from nine of 26 tested cases. No association was observed between adenovirus infection and hospital admission after adjusting for age, sex and region in a binomial regression model. The TF in Portugal may have contributed to increase awareness among clinicians, enabling early detection and prompt management of the outbreak.

The East African Community mobile laboratory network prepares for monkeypox outbreaks

In response to the largest recorded monkeypox virus outbreak outside of endemic Central and Western Africa, the East African Community (EAC), in cooperation with the Bernhard-Nocht- Institute for Tropical Medicine, coordinated an emergency monkeypox diagnostic training for the East African Region. As of June 2022, the Democratic Republic of Congo reported a steady increase of suspected monkeypox cases, increasing the risk of spill-over into the remaining six EAC Partner States. Within the existing EAC Mobile Laboratories project, laboratory experts of the National Public Health Laboratories of the remaining six EAC Partner States (Burundi, Rwanda, Tanzania, Kenya, Uganda, and South Sudan) participated in the workshop and were trained in the reception of suspect samples, DNA extraction and diagnosis using real-time polymerase chain reaction (RT-PCR). The EAC region is now equipped with the tools to prepare and rapidly respond to any emerging monkeypox outbreak.

Regional Evaluation of Two SARS-CoV-2 Antigen Rapid Diagnostic Tests in East Africa

The clinical performance of two rapid antigen tests for the diagnosis of Severe Acute Respiratory Coronavirus (SARS-CoV-2) were regionally evaluated in East African populations. Swabs were collected from 1,432 individuals from five Partner States of the East African Community (Tanzania, Uganda, Burundi, Rwanda and South Sudan). The two rapid antigen tests (Bionote NowCheck COVID-19 Ag and SD Biosensor STANDARD Q COVID-19 Ag) were evaluated against the detection of SARS-CoV-2 RNA by the Reverse Transcription PCR (RT-PCR) gold standard. Of the concordant results with both RT-PCR and rapid antigen test data (862 for Bionote and 852 for SD Biosensor), overall clinical sensitivity was 60% and 50% for the Bionote NowCheck and the SD Biosensor STANDARD Q, respectively. Stratification by viral load, including samples with RT-PCR cycle thresholds (Ct) of <25, improved sensitivity to 90% for both rapid diagnostic tests (RDTs). Overall specificity was good at 99% for both antigen tests. Taken together, the clinical performance of both Ag-RDTs in real world settings within the East African target population was lower than has been reported elsewhere and below the acceptable levels for sensitivity of >80%, as defined by the WHO. Therefore, the rapid antigen test alone should not be used for diagnosis but could be used as part of an algorithm to identify potentially infectious individuals with high viral load. IMPORTANCE Accurate diagnostic tests are essential to both support the management and containment of outbreaks, as well as inform appropriate patient care. In the case of the SARS-CoV-2 pandemic, antigen Rapid Diagnostic Tests (Ag-RDTs) played a major role in this function, enabling widespread testing by untrained individuals, both at home and within health facilities. In East Africa, a number of SARS-CoV-2 Ag-RDTs are available; however, there remains little information on their true test performance within the region, in the hands of the health workers routinely carrying out SARS-CoV-2 diagnostics. This study contributes test performance data for two commonly used SARS-CoV-2 Ag-RDTs in East Africa, which will help inform the use of these RDTs within the region.

Development of an Accessible and Scalable Quantitative Polymerase Chain Reaction Assay for Monkeypox Virus Detection

During the 2022 monkeypox (MPX) outbreak, testing has been limited and results delayed, allowing ongoing transmission. Gold-standard quantitative polymerase chain reaction (qPCR) diagnostics are difficult to obtain. This research adapted the June 2022 CDC MPX qPCR assay for broad implementation. Validated using MPX stocks in a matrix with multiple sample types, MPX was detected with cycle threshold (Ct) values 17.46-35.59 and titer equivalents 8.01 × 106 to 2.45 × 100 plaque-forming unit (PFU)/mL. The detection limit was 3.59 PFU/mL. Sensitivity and specificity were both 100%. This qPCR assay can be quickly and broadly implemented in research and public health laboratories to increase diagnostic capacity amid the growing MPX outbreak.

Serial Interval and Incubation Period Estimates of Monkeypox Virus Infection in 12 Jurisdictions, United States, May-August 2022

Using data from 12 US health departments, we estimated mean serial interval for monkeypox virus infection to be 8.5 (95% credible interval 7.3-9.9) days for symptom onset, based on 57 case pairs. Mean estimated incubation period was 5.6 (95% credible interval 4.3-7.8) days for symptom onset, based on 35 case pairs.

Communicating risk during early phases of COVID-19: Comparing governing structures for emergency risk communication across four contexts

Background

Emergency risk communication (ERC) is key to achieving compliance with public health measures during pandemics. Yet, the factors that facilitated ERC during COVID-19 have not been analyzed. We compare ERC in the early stages of the pandemic across four socio-economic settings to identify how risk communication can be improved in public health emergencies (PHE).

Methods

To map and assess the content, process, actors, and context of ERC in Germany, Guinea, Nigeria, and Singapore, we performed a qualitative document review, and thematically analyzed semi-structured key informant interviews with 155 stakeholders involved in ERC at national and sub-national levels. We applied Walt and Gilson's health policy triangle as a framework to structure the results.

Results

We identified distinct ERC strategies in each of the four countries. Various actors, including governmental leads, experts, and organizations with close contact to the public, collaborated closely to implement ERC strategies. Early integration of ERC into preparedness and response plans, lessons from previous experiences, existing structures and networks, and clear leadership were identified as crucial for ensuring message clarity, consistency, relevance, and an efficient use of resources. Areas of improvement primarily included two-way communication, community engagement, and monitoring and evaluation. Countries with recurrent experiences of pandemics appeared to be more prepared and equipped to implement ERC strategies.

Conclusion

We found that considerable potential exists for countries to improve communication during public health emergencies, particularly in the areas of bilateral communication and community engagement as well as monitoring and evaluation. Building adaptive structures and maintaining long-term relationships with at-risk communities reportedly facilitated suitable communication. The findings suggest considerable potential and transferable learning opportunities exist between countries in the global north and countries in the global south with experience of managing outbreaks.

Knowledge, Attitude and Conspiracy Beliefs of Healthcare Workers in Lebanon towards Monkeypox

The emergence of a monkeypox (MPOX) outbreak in 2022 represented the most recent recognizable public health emergency at a global level. Improving knowledge and attitude towards MPOX, particularly among healthcare workers (HCWs), can be a valuable approach in public health preventive efforts aiming to halt MPOX virus spread. The aim of the current study was to evaluate the knowledge and attitude of HCWs in Lebanon towards MPOX and to assess their conspiratorial attitude towards emerging virus infections (EVIs). The current study was based on a cross-sectional online survey distributed via Google Forms during September-December 2022 implementing a convenience sampling approach. The final study sample comprised a total of 646 HCWs: physicians (n = 171, 26.5%), pharmacists (n = 283, 43.8%), and nurses (n = 168, 26.0%), among others (n = 24, 3.7%). Variable defects in MPOX knowledge were detected, with a third of the participants having MPOX knowledge above the 75th percentile (n = 218, 33.7%). Satisfactory attitude towards MPOX (>75th percentile) was observed in less than a third of the participants (n = 198, 30.7%), while a quarter of the study sample endorsed conspiracy beliefs towards EVIs at a high level (>75th percentile, n = 164, 25.4%). Slightly more than two thirds of the participants agreed that MPOX vaccination should be used in disease prevention (n = 440, 68.1%). Better levels of MPOX knowledge and attitude were significantly associated with postgraduate education and older age. Physicians had significantly higher MPOX knowledge compared to other occupational categories. Less endorsement of conspiracies towards EVIs was significantly associated with male sex, occupation as a physician, and postgraduate education. Higher MPOX knowledge was associated with better attitude towards the disease. The current study showed unsatisfactory MPOX knowledge among Lebanese HCWs. Educational efforts can be valuable to improve the attitude towards the disease. Despite the relatively low level of embracing conspiracy beliefs regarding EVIs among HCWs in this study compared to previous studies, this area should be considered based on its potential impact on health-seeking behavior.

Looking back at prospective modeling of outbreak response strategies for managing global type 2 oral poliovirus vaccine (OPV2) cessation

Introduction

Detection of poliovirus transmission and ongoing oral poliovirus vaccine (OPV) use continue to delay poliomyelitis eradication. In 2016, the Global Polio Eradication Initiative (GPEI) coordinated global cessation of type 2 OPV (OPV2) for preventive immunization and limited its use to emergency outbreak response. In 2019, GPEI partners requested restart of some Sabin OPV2 production and also accelerated the development of a genetically modified novel OPV2 vaccine (nOPV2) that promised greater genetic stability than monovalent Sabin OPV2 (mOPV2).

Methods

We reviewed integrated risk, economic, and global poliovirus transmission modeling performed before OPV2 cessation, which recommended multiple risk management strategies to increase the chances of successfully ending all transmission of type 2 live polioviruses. Following OPV2 cessation, strategies implemented by countries and the GPEI deviated from model recommended risk management strategies. Complementing other modeling that explores prospective outbreak response options for improving outcomes for the current polio endgame trajectory, in this study we roll back the clock to 2017 and explore counterfactual trajectories that the polio endgame could have followed if GPEI had: (1) managed risks differently after OPV2 cessation and/or (2) developed nOPV2 before and used it exclusively for outbreak response after OPV2 cessation.

Results

The implementation of the 2016 model-based recommended outbreak response strategies could have ended (and could still substantially improve the probability of ending) type 2 poliovirus transmission. Outbreak response performance observed since 2016 would not have been expected to achieve OPV2 cessation with high confidence, even with the availability of nOPV2 prior to the 2016 OPV2 cessation.

Discussion

As implemented, the 2016 OPV2 cessation failed to stop type 2 transmission. While nOPV2 offers benefits of lower risk of seeding additional outbreaks, its reduced secondary spread relative to mOPV2 may imply relatively higher coverage needed for nOPV2 than mOPV2 to stop outbreaks.

Analysis of a Dengue Virus Outbreak in Rosso, Senegal 2021

Senegal is hyperendemic for dengue. Since 2017, outbreaks have been noticed annually in many regions around the country, marked by the co-circulation of DENV1-3. On 8 October 2021, a Dengue virus outbreak in the Rosso health post (sentinel site of the syndromic surveillance network) located in the north of the country was notified to the WHO Collaborating Center for arboviruses and hemorrhagic fever viruses at Institut Pasteur de Dakar. A multidisciplinary team was then sent for epidemiological and virologic investigations. This study describes the results from investigations during an outbreak in Senegal using a rapid diagnostic test (RDT) for the combined detection of dengue virus non-structural protein 1 (NS1) and IgM/IgG. For confirmation, samples were also tested by real-time RT-PCR and IgM ELISA at the reference lab in Dakar. qRT-PCR positive samples were subjected to whole genome sequencing using nanopore technology. Virologic analysis scored 102 positives cases (RT-PCR, NS1 antigen detection and/or IgM) out of 173 enrolled patients; interestingly, virus serotyping showed that the outbreak was caused by the DENV-1, a serotype different from DENV-2 involved during the outbreak in Rosso three years earlier, indicating a serotype replacement. Nearly all field-tested NS1 positives samples were confirmed by qRT-PCR with a concordance of 92.3%. Whole genome sequencing and phylogenetic analysis of strains suggested a re-introduction in Rosso of a DENV-1 strain different to the one responsible for the outbreak in the Louga area five years before. Findings call for improved dengue virus surveillance in Senegal, with a wide deployment of DENV antigenic tests, which allow easy on-site diagnosis of suspected cases and early detection of outbreaks. This work highlights the need for continuous monitoring of circulating serotypes which is crucial for a better understanding of viral epidemiology around the country.

Building on Capacity Established through US Centers for Disease Control and Prevention Global Health Programs to Respond to COVID-19, Cameroon

The COVID-19 pandemic has highlighted the need for resilient health systems with the capacity to effectively detect and respond to disease outbreaks and ensure continuity of health service delivery. The pandemic has disproportionately affected resource-limited settings with inadequate health capacity, resulting in disruptions in health service delivery and worsened outcomes for key health indicators. As part of the US government's goal of ensuring health security, the US Centers for Disease Control and Prevention has used its scientific and technical expertise to build health capacity and address health threats globally. We describe how capacity developed through global health programs of the US Centers for Disease Control and Prevention in Cameroon was leveraged to respond to coronavirus disease and maintain health service delivery. The health system strengthening efforts in Cameroon can be applied in similar settings to ensure preparedness for future global public health threats and improve health outcomes.

Fielding vaccines-challenges and opportunities in outbreaks, complex emergencies, and mass gatherings

With the recent COVID-19 pandemic, the importance of vaccine development, distribution, and uptake has come to the forefront of the public eye. Effectively fielding vaccines during an emergency-whether that emergency is a result of an infectious disease or not-requires an understanding of usual vaccine-related processes; the impact of outbreak, complex emergencies, mass gatherings, and other events on patients, communities, and health systems; and ways in which diverse resources can be applied to successfully achieve needed vaccine uptake. In this review, both the emergency setting and briefly vaccine product design are discussed in these contexts in order to provide a concise source of general knowledge from experts in fielding vaccines that can aid in future vaccine ventures and increase general awareness of the process and barriers in various settings.

Optimizing response to an introduction of African swine fever in wild pigs

African swine fever virus (ASFv) is a virulent pathogen that threatens domestic swine industries globally and persists in wild boar populations in some countries. Persistence in wild boar can challenge elimination and prevent disease-free status, making it necessary to address wild swine in proactive response plans. In the U.S., invasive wild pigs are abundant and found across a wide range of ecological conditions that could drive different epidemiological dynamics among populations. Information on size of control areas required to rapidly eliminate ASFv in wild pigs and how this area should change with management constraints and local ecology are needed to optimize response planning. We developed a spatially-explicit disease transmission model contrasting wild pig movement and contact ecology in two ecosystems in southeastern U.S. We simulated ASFv spread and determined optimal response area (reported as radius of a circle) for eliminating ASFv rapidly over a range of detection times (when ASFv is detected relative to true date of introduction), culling capacities (proportion of wild pigs in the culling zone removed weekly), and wild pig densities. Large radii for response areas (14 km) were needed under most conditions but could be shortened with early detection (≤ 8 weeks) and high culling capacities (≥ 15% weekly). Under most conditions ASFv was eliminated in less than 22 weeks using optimal control radii, although ecological conditions with high rates of wild pig movement required higher culling capacities (≥ 10% weekly) for elimination within one year. Results highlight the importance of adjusting response plans based on local ecology and show wild pig movement is a better predictor of optimal response area than numbers of ASFv cases early in the outbreak trajectory. Our framework provides a tool for determining optimal control plans in different areas, guiding expectations of response impacts, and planning resources needed for rapid elimination. This article is protected by copyright. All rights reserved.

Enhancing Response to Foodborne Disease Outbreaks: Findings of the Foodborne Diseases Centers for Outbreak Response Enhancement (FoodCORE), 2010-2019

CONTEXT

Each year, foodborne diseases cause an estimated 48 million illnesses resulting in 128000 hospitalizations and 3000 deaths in the United States. Fast and effective outbreak investigations are needed to identify and remove contaminated food from the market to reduce the number of additional illnesses that occur. Many state and local health departments have insufficient resources to identify, respond to, and control the increasing burden of foodborne illnesses.

PROGRAM

The Centers for Disease Control and Prevention (CDC) Foodborne Diseases Centers for Outbreak Response Enhancement (FoodCORE) program provides targeted resources to state and local health departments to improve completeness and timeliness of laboratory, epidemiology, and environmental health activities for foodborne disease surveillance and outbreak response.

IMPLEMENTATION

In 2009, pilot FoodCORE centers were selected through a competitive application process and then implemented work plans to achieve faster and more complete surveillance and outbreak response activities in their jurisdiction. By 2019, 10 centers participated in FoodCORE: Colorado, Connecticut, Minnesota, New York City, Ohio, Oregon, South Carolina, Tennessee, Utah, and Wisconsin.

EVALUATION

CDC and FoodCORE centers collaboratively developed performance metrics to evaluate the impact and effectiveness of FoodCORE activities. Centers used performance metrics to document successes, identify gaps, and set goals for their jurisdiction. CDC used performance metrics to evaluate the implementation of FoodCORE priorities and identify successful strategies to develop replicable model practices. This report provides a description of implementing the FoodCORE program during year 1 (October 2010 to September 2011) through year 9 (January 2019 to December 2019).

DISCUSSION

FoodCORE centers address gaps in foodborne disease response through enhanced capacity to improve timeliness and completeness of surveillance and outbreak response activities. Strategies resulting in faster, more complete surveillance and response are documented as model practices and are shared with state and local foodborne disease programs across the country.

Infectious Disease Control and Management in Ethiopia: A Case Study of Cholera

Cholera remains a significant public health problem among the vulnerable populations living in many resource-limited settings with poor access to safe and clean water and hygiene practice. Around 2.86 million cholera cases and 95,000 deaths are estimated to occur in endemic countries. In Ethiopia, cholera has been one of the major epidemic diseases since 1634 when the first cholera outbreak was recorded in-country. Several cholera epidemics occurred with recent outbreaks in 2019–2021. Cholera has been often reported as acute watery diarrhea due to limited diagnostic capacity in remote areas in Ethiopia and sensitivities around cholera outbreaks. The government of Ethiopia has been executing several phases of multi-year health sector development plan in the past decades and has recently developed a national cholera control plan. Here, we aim to present the existing cholera control guidelines and health system in Ethiopia, including case detection and reporting, outbreak declaration, case management, and transmission control. Challenges and way forward on further research and public health interventions are also discussed to address the knowledge and health service gaps related to cholera control in Ethiopia.

Rapid Multilateral and Integrated Public Health Response to a Cross-City Outbreak of Salmonella Enteritidis Infections Combining Analytical, Molecular, and Genomic Epidemiological Analysis

On September 21, 2019, the Shenzhen and Dongguan Centers for Disease Control and Prevention received notification of a large cluster of suspected gastroenteritis involving primarily children who sought medical care at hospitals throughout two adjacent cities in China, Shenzhen, and Dongguan. A joint outbreak response was promptly initiated across jurisdictions in a concerted effort between clinical microbiologists, epidemiologists, and public health scientists. Concurrently, multiplex PCRs were used for rapid laboratory diagnosis of suspected cases; epidemiological investigations were conducted to identify the outbreak source, complemented by near real-time multicenter whole-genome analyses completed within 34 h. Epidemiological evidence indicated that all patients had consumed egg sandwiches served on September 20 as snacks to children and staff at a nursery in Dongguan, located near Shenzhen. Salmonella Enteritidis was isolated from case-patients, food handlers, kitchenware, and sandwiches with kitchen-made mayonnaise. Whole-genome single-nucleotide polymorphism (SNP)-based phylogenetic analysis demonstrated a well-supported cluster with pairwise distances of ≤1 SNP between genomes for outbreak-associated isolates, providing the definitive link between all samples. In comparison with historical isolates from the same geographical region, the minimum pairwise distance was >14 SNPs, suggesting a non-local outbreak source. Genomic source tracing revealed the possible transmission dynamics of a S. Enteritidis clone throughout a multi-provincial egg distribution network. The efficiency and scale with which multidisciplinary and integrated approaches were coordinated in this foodborne disease outbreak response was unprecedented in China, leading to the timely intervention of a large cross-jurisdiction Salmonella outbreak.

Potential test-negative design study bias in outbreak settings: application to Ebola vaccination in Democratic Republic of Congo

BACKGROUND

Infectious disease outbreaks present unique challenges to study designs for vaccine evaluation. Test-negative design (TND) studies have previously been used to estimate vaccine effectiveness and have been proposed for Ebola virus disease (EVD) vaccines. However, there are key differences in how cases and controls are recruited during outbreaks and pandemics of novel pathogens, whcih have implications for the reliability of effectiveness estimates using this design.

METHODS

We use a modelling approach to quantify TND bias for a prophylactic vaccine under varying study and epidemiological scenarios. Our model accounts for heterogeneity in vaccine distribution and for two potential routes to testing and recruitment into the study: self-reporting and contact-tracing. We derive conventional and hybrid TND estimators for this model and suggest ways to translate public health response data into the parameters of the model.

RESULTS

Using a conventional TND study, our model finds biases in vaccine effectiveness estimates. Bias arises due to differential recruitment from self-reporting and contact-tracing, and due to clustering of vaccination. We estimate the degree of bias when recruitment route is not available, and propose a study design to eliminate the bias if recruitment route is recorded.

CONCLUSIONS

Hybrid TND studies can resolve the design bias with conventional TND studies applied to outbreak and pandemic response testing data, if those efforts collect individuals' routes to testing. Without route to testing, other epidemiological data will be required to estimate the magnitude of potential bias in a conventional TND study. Since these studies may need to be conducted retrospectively, public health responses should obtain these data, and generic protocols for outbreak and pandemic response studies should emphasize the need to record routes to testing.

Design and Implementation of a COVID-19 Case Investigation Program: An Academic-Public Health Partnership, Arizona, 2020

From May through July 2020, Arizona was a global hotspot for new COVID-19 cases. In response to the surge of cases, local public health departments looked for innovative ways to form external partnerships to address their staffing needs. In collaboration with the Maricopa County Department of Public Health, the Arizona State University Student Outbreak Response Team (SORT) created and implemented a virtual call center to conduct public health case investigations for COVID-19. SORT officially launched a dedicated COVID-19 case investigation program after 3 weeks of program design and training. From June 29 through November 8, 2020, SORT recruited and trained 218 case investigators, completed 5000 case patient interviews, and closed 10 000 cases. Our team also developed process improvements to address disparities in case investigation timeliness. A strong infrastructure designed to accommodate remote case investigations, paired with a large workforce, enabled SORT to provide additional surge capacity for the county's high volume of cases. University-driven multidisciplinary case investigator teams working in partnership with state, tribal, and local public health staff members can be an effective tool for supporting a diverse and growing public health workforce. We discuss the essential design factors involved in building a university program to complement local COVID-19 response efforts, including workflows for case management, volunteer case investigator recruitment and training, secure technology platforms for conducting case investigations remotely, and robust data-tracking procedures for maintaining quality control and timely case reporting.

Availability and Suitability of Digital Health Tools in Africa for Pandemic Control: Scoping Review and Cluster Analysis

Background

Gaining oversight into the rapidly growing number of mobile health tools for surveillance or outbreak management in Africa has become a challenge.

Objective

The aim of this study is to map the functional portfolio of mobile health tools used for surveillance or outbreak management of communicable diseases in Africa.

Methods

We conducted a scoping review by combining data from a systematic review of the literature and a telephone survey of experts. We applied the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching for articles published between January 2010 and December 2020. In addition, we used the respondent-driven sampling method and conducted a telephone survey from October 2019 to February 2020 among representatives from national public health institutes from all African countries. We combined the findings and used a hierarchical clustering method to group the tools based on their functionalities (attributes).

Results

We identified 30 tools from 1914 publications and 45 responses from 52% (28/54) of African countries. Approximately 13% of the tools (4/30; Surveillance Outbreak Response Management and Analysis System, Go.Data, CommCare, and District Health Information Software 2) covered 93% (14/15) of the identified attributes. Of the 30 tools, 17 (59%) tools managed health event data, 20 (67%) managed case-based data, and 28 (97%) offered a dashboard. Clustering identified 2 exceptional attributes for outbreak management, namely contact follow-up (offered by 8/30, 27%, of the tools) and transmission network visualization (offered by Surveillance Outbreak Response Management and Analysis System and Go.Data).

Conclusions

There is a large range of tools in use; however, most of them do not offer a comprehensive set of attributes, resulting in the need for public health workers having to use multiple tools in parallel. Only 13% (4/30) of the tools cover most of the attributes, including those most relevant for response to the COVID-19 pandemic, such as laboratory interface, contact follow-up, and transmission network visualization.

A Conceptual Framework for Analysing Partnership and Synergy in a Global Health Alliance: Case of the UK Public Health Rapid Support Team (UK-PHRST)

Partnerships have become increasingly important in addressing complex global health challenges, a reality exemplified by the COVID-19 pandemic and previous infectious disease epidemics. Partnerships offer opportunities to create synergistic outcomes by capitalizing on complimentary skills, knowledge and resources. Despite the importance of understanding partnership functioning, research on collaboration is sparse and fragmented, with few conceptual frameworks applied to evaluate real-life partnerships in global health. In this study, we aimed to adapt and apply the Bergan Model of Collaborative Functioning (BMCF) to analyse partnership functioning in the UK Public Health Rapid Support Team (UK-PHRST), a government–academic partnership, dedicated to outbreak response and research in low- and middle-income countries. We conducted a literature review identifying important elements to adapt the framework, followed by a qualitative case study to characterize how each element, and the dynamics between them, influenced functioning in the UK-PHRST, exploring emerging themes to further refine the framework. Elements of the BMCF that our study reinforced as important included the partnership’s mission, partner resources (skills, expertise and networks), leadership, the external environment, management systems and communication. Additional elements identified in the literature and critical to partnership functioning of the UK-PHRST included governance and financial structures adopted, trust and power balance, organizational culture, strategy and evaluation and knowledge management. Because of the way the UK-PHRST was structured, fostering team cohesion was an important indicator of synergy, alongside collaborative advantage. Dividing the funding and governance equally between organizations was considered crucial for maintaining institutional balance; however, diverse organizational cultures, weak communication practices and perceived power imbalances compromised team cohesion. Our analysis allowed us to make recommendations to improve partnership functioning at a critical time in the evolution of the UK-PHRST. The analysis approach and framework presented here can be used to evaluate and strengthen the management of global health partnerships to realize synergy.

Coping with the third wave of the COVID-19 pandemic in Africa: implications for an improved outbreak response

The third wave of the COVID-19 pandemic has commenced. To avert increase in cases and avert preventable deaths, community engagement strategies such as the promotion of vaccination, voluntary testing and debunking of COVID-19-related rumors need to be undertaken.

Pediatricians' Knowledge and Practices Related to Mumps Diagnosis and Prevention

OBJECTIVES

To assess pediatricians' mumps knowledge and testing practices, to identify physician and practice characteristics associated with mumps testing practices, and to assess reporting and outbreak response knowledge and practices.

STUDY DESIGN

Between January and April 2020, we surveyed a nationally representative network of pediatricians. Descriptive statistics were generated for all items. The χ² test, t tests, and Poisson regression were used to compare physician and practice characteristics between respondents who would rarely or never versus sometimes or often/always test for mumps in a vaccinated 17-year-old with parotitis in a non-outbreak setting.

RESULTS

The response rate was 67% (297 of 444). For knowledge, more than one-half of the pediatricians responded incorrectly or "don't know" for 6 of the 9 true/false statements about mumps epidemiology, diagnosis, and prevention, and more than one-half reported needing additional guidance on mumps buccal swab testing. For testing practices, 59% of respondents reported they would sometimes (35%) or often/always (24%) test for mumps in a vaccinated 17-year-old with parotitis in a non-outbreak setting; older physicians, rural physicians, and physicians from the Northeast or Midwest were more likely to test for mumps. Thirty-six percent of the pediatricians reported they would often/always report a patient with suspected mumps to public health authorities.

CONCLUSIONS

Pediatricians report mumps knowledge gaps and practices that do not align with public health recommendations. These gaps may lead to underdiagnosis and underreporting of mumps cases, delaying public health response measures and contributing to ongoing disease transmission.

The deployment of mobile diagnostic laboratories for Ebola virus disease diagnostics in Sierra Leone and Guinea

BACKGROUND

Ebola virus emerged in West Africa in December 2013. The ease of mobility, porous borders, and lack of public health infrastructure led to the largest Ebola virus disease (EVD) outbreak to date.

INTERVENTION

The 2013 EVD outbreak signalled the need for laboratory diagnostic capabilities in areas without strong public health systems. As part of the United States' Department of Defense response, MRIGlobal was contracted to design, fabricate, equip, deploy, and operate two mobile diagnostic laboratories (MDLs). The first laboratory analysed blood samples from patients in an adjacent Ebola Treatment Centre (ETC) and buccal swabs from the deceased in the community in Moyamba, Sierra Leone. The second laboratory was deployed to support an ETC in Conakry, Guinea. The Department of Defense provided real-time quantitative reverse transcription polymerase chain reaction assays that were deployed and validated on-site.

LESSONS LEARNT

Prompt and accurate molecular diagnostics reduced sample turn-around times from over 24 h to under 4 h. Experienced laboratory staff tested up to 110 samples per day and on-site engineering proved necessary for MDL setup and operation. As the Ebola response slowed, the sustainment of the MDLs' operations was prioritised, including staff training and the transition of the MDLs to local governments. Training programmes for local staff were prepared in Sierra Leone and Guinea.

RECOMMENDATIONS

The MRIGlobal MDL team significantly contributed to establishing increased laboratory capacity during the EVD outbreak in West Africa. Using the MDLs for molecular diagnosis is highly recommended until more sustainable solutions can be provided.

A qualitative study of injection and sexual risk behavior among unstably housed people who inject drugs in the context of an HIV outbreak in Northeast Massachusetts, 2018

BACKGROUND

To investigate the underlying causes of a sudden increase in HIV among people who inject drugs (PWID) and initiate an appropriate response to the outbreak, we engaged in in-depth qualitative interviews with members of the PWID community in Lawrence and Lowell, Massachusetts.

METHODS

We interviewed 34 PWID who were currently or recently unstably housed, then transcribed interviews and coded transcripts, grouping codes into categories from which we identified key themes.

RESULTS

Participants described a heightened threat of overdose prompting PWID to inject together, increasing opportunities for sharing injection equipment. There were misunderstandings about safe injection practices to prevent HIV transmission and a low threshold for injection-related risk taking. Stigma regarding HIV prevented conversations about HIV status. Less thought was given to sexual risks than injection-related risks for HIV transmission.

CONCLUSIONS

We found multiple facilitators of HIV transmission. Additional HIV education and prevention interventions focusing on both injection and sexual risk practices would benefit this population, in addition to structural interventions such as increased access and availability of syringe service programs.

Perspectives of Nurses About Factors Affecting Quality of Care at the Solomon Islands National Referral Hospital During the 2016-2017 Dengue Outbreak: A Qualitative Study

During the 2016-2017 Solomon Islands dengue outbreak, the National Referral Hospital (NRH) in Honiara was the epicenter for the national response. High-quality nursing care is critical for successful management and this study investigated the factors affecting the quality of nursing care for patients admitted to NRH with dengue. Data were collected using 2 methods: (a) Focus group discussions with nurses who cared for dengue patients and (b) a self-administered questionnaire completed by a senior manager. Analysis of qualitative data using a thematic technique found 2 key factors affected care: (a) training on protocols and guidelines for clinical management and (b) planning and preparedness of NRH. Quality of care was influenced by lack of basic equipment, transport provided for nursing staff to attend shifts, and confusion between allowances for regular salaried staff and extra staff assisting with the outbreak. Specific attention is needed in future outbreaks to ensure staff understand protocols, follow guidelines, and that adequate equipment is provided.

Missed Opportunities for Human Immunodeficiency Virus (HIV) Testing During Injection Drug Use-Related Healthcare Encounters Among a Cohort of Persons Who Inject Drugs With HIV Diagnosed During an Outbreak-Cincinnati/Northern Kentucky, 2017-2018

BACKGROUND

Persons who inject drugs (PWID) have frequent healthcare encounters related to their injection drug use (IDU) but are often not tested for human immunodeficiency virus (HIV). We sought to quantify missed opportunities for HIV testing during an HIV outbreak among PWID.

METHODS

PWID with HIV diagnosed in 5 Cincinnati/Northern Kentucky counties during January 2017-September 2018 who had ≥1 encounter 12 months prior to HIV diagnosis in 1 of 2 Cincinnati/Northern Kentucky area healthcare systems were included in the analysis. HIV testing and encounter data were abstracted from electronic health records. A missed opportunity for HIV testing was defined as an encounter for an IDU-related condition where an HIV test was not performed and had not been performed in the prior 12 months.

RESULTS

Among 109 PWID with HIV diagnosed who had ≥1 healthcare encounter, 75 (68.8%) had ≥1 IDU-related encounters in the 12 months before HIV diagnosis. These 75 PWID had 169 IDU-related encounters of which 86 (50.9%) were missed opportunities for HIV testing and occurred among 46 (42.2%) PWID. Most IDU-related encounters occurred in the emergency department (118/169; 69.8%). Using multivariable generalized estimating equations, HIV testing was more likely in inpatient compared with emergency department encounters (adjusted relative risk [RR], 2.72; 95% confidence interval [CI], 1.70-4.33) and at the healthcare system receiving funding for emergency department HIV testing (adjusted RR, 1.76; 95% CI, 1.10-2.82).

CONCLUSIONS

PWID have frequent IDU-related encounters in emergency departments. Enhanced HIV screening of PWID in these settings can facilitate earlier diagnosis and improve outbreak response.

Measuring Timeliness of Outbreak Response in the World Health Organization African Region, 2017-2019

Large-scale protracted outbreaks can be prevented through early detection, notification, and rapid control. We assessed trends in timeliness of detecting and responding to outbreaks in the African Region reported to the World Health Organization during 2017–2019. We computed the median time to each outbreak milestone and assessed the rates of change over time using univariable and multivariable Cox proportional hazard regression analyses. We selected 296 outbreaks from 348 public reported health events and evaluated 184 for time to detection, 232 for time to notification, and 201 for time to end. Time to detection and end decreased over time, whereas time to notification increased. Multiple factors can account for these findings, including scaling up support to member states after the World Health Organization established its Health Emergencies Programme and support given to countries from donors and partners to strengthen their core capacities for meeting International Health Regulations.

Mitigation of a Coronavirus Disease 2019 Outbreak in a Nursing Home Through Serial Testing of Residents and Staff

Nursing homes and long-term care facilities represent highly vulnerable environments for respiratory disease outbreaks, such as COVID-19. We describe a COVID-19 outbreak in a nursing home that was rapidly contained by using a universal testing strategy of all residents and nursing home staff.

Updated characterization of poliovirus transmission in Pakistan and Afghanistan and the impacts of different outbreak response vaccine options

Background

Pakistan and Afghanistan remain the only reservoirs of wild poliovirus transmission. Prior modeling suggested that before the COVID-19 pandemic, plans to stop the transmission of serotype 1 wild poliovirus (WPV1) and persistent serotype 2 circulating vaccine-derived poliovirus (cVDPV2) did not appear on track to succeed.

Methods

We updated an existing poliovirus transmission and Sabin-strain oral poliovirus vaccine (OPV) evolution model for Pakistan and Afghanistan to characterize the impacts of immunization disruptions and restrictions on human interactions (i.e., population mixing) due to the COVID-19 pandemic. We also consider different options for responding to outbreaks and for preventive supplementary immunization activities (SIAs).

Results

The modeling suggests that with some resumption of activities in the fall of 2020 to respond to cVDPV2 outbreaks and full resumption on January 1, 2021 of all polio immunization activities to pre-COVID-19 levels, Pakistan and Afghanistan would remain off-track for stopping all transmission through 2023 without improvements in quality.

Conclusions

Using trivalent OPV (tOPV) for SIAs instead of serotype 2 monovalent OPV (mOPV2) offers substantial benefits for ending the transmission of both WPV1 and cVDPV2, because tOPV increases population immunity for both serotypes 1 and 2 while requiring fewer SIA rounds, when effectively delivered in transmission areas.

Responding to Outbreaks of Human Immunodeficiency Virus Among Persons Who Inject Drugs-United States, 2016-2019: Perspectives on Recent Experience and Lessons Learned

In 2015, a large human immunodeficiency virus (HIV) outbreak occurred among persons who inject drugs (PWID) in Indiana. During 2016-2019, additional outbreaks among PWID occurred across the United States. Based on information disseminated by responding health departments and Centers for Disease Control and Prevention (CDC) involvement, we offer perspectives about characteristics of and public health responses to 6 such outbreaks. Across outbreaks, injection of opioids (including fentanyl) or methamphetamine predominated; many PWID concurrently used opioids and methamphetamine or cocaine. Commonalities included homelessness or unstable housing, previous incarceration, and hepatitis C virus exposure. All outbreaks occurred in metropolitan areas, including some with substantial harm reduction and medical programs targeted to PWID. Health departments experienced challenges locating case patients and contacts, linking and retaining persons in care, building support to strengthen harm-reduction programs, and leveraging resources. Expanding the concept of vulnerability to HIV outbreaks and other lessons learned can be considered for preventing, detecting, and responding to future outbreaks among PWID.

Tuberculosis Outbreak Associated With Delayed Diagnosis and Long Infectious Periods in Rural Arkansas, 2010-2018

OBJECTIVES

During 2010-2018, the Arkansas Department of Health reported 21 genotype-matched cases of tuberculosis (TB) among residents of a rural county in Arkansas with a low incidence of TB and in nearby counties. The Arkansas Department of Health and the Centers for Disease Control and Prevention investigated to determine the extent of TB transmission and provide recommendations for TB control.

METHODS

We reviewed medical and public health records, interviewed patients, and reviewed patients' social media posts to describe patient characteristics, identify epidemiologic links, and establish likely chains of transmission.

RESULTS

We identified 21 cases; 11 reported during 2010-2013 and 10 during 2016-2018. All case patients were US-born non-Hispanic Black people. Eighteen case patients had the outbreak genotype, and 3 clinically diagnosed (non-culture-confirmed) case patients had epidemiologic links to patients with the outbreak genotype. Social media reviews revealed epidemiologic links among 10 case patients not previously disclosed during interviews. Eight case patients (38%) had ≥1 health care visit during their infectious period, and 7 patients had estimated infectious periods of >12 months.

CONCLUSIONS

Delayed diagnoses and prolonged infectiousness led to TB transmission in this rural community. TB education and awareness is critical to reducing transmission, morbidity, and mortality, especially in areas where health care providers have limited TB experience. Use of social media can help elucidate people at risk, especially when traditional TB investigation techniques are insufficient.

Expansion of Preexposure Prophylaxis Capacity in Response to an HIV Outbreak Among People Who Inject Drugs-Cabell County, West Virginia, 2019

From January 1, 2018, through October 9, 2019, 82 HIV diagnoses occurred among people who inject drugs (PWID) in Cabell County, West Virginia. Increasing the use of HIV preexposure prophylaxis (PrEP) among PWID was one of the goals of a joint federal, state, and local response to this HIV outbreak. Through partnerships with the local health department, a federally qualified health center, and an academic medical system, we integrated PrEP into medication-assisted treatment, syringe services program, and primary health care settings. During the initial PrEP implementation period (April 18-May 17, 2019), 110 health care providers and administrators received PrEP training, the number of clinics offering PrEP increased from 2 to 15, and PrEP referrals were integrated with partner services, outreach, and testing activities. The number of people on PrEP increased from 15 in the 6 months before PrEP expansion to 127 in the 6 months after PrEP implementation. Lessons learned included the importance of implementing PrEP within existing health care services, integrating PrEP with other HIV prevention response activities, adapting training and material to fit the local context, and customizing care to meet the needs of PWID. The delivery of PrEP to PWID is challenging but complements other HIV prevention interventions. The expansion of PrEP in response to this HIV outbreak in Cabell County provides a framework for expanding PrEP in other outbreak and non-outbreak settings.

Updated Characterization of Outbreak Response Strategies for 2019-2029: Impacts of Using a Novel Type 2 Oral Poliovirus Vaccine Strain

Delays in achieving the global eradication of wild poliovirus transmission continue to postpone subsequent cessation of all oral poliovirus vaccine (OPV) use. Countries must stop OPV use to end all cases of poliomyelitis, including vaccine-associated paralytic polio (VAPP) and cases caused by vaccine-derived polioviruses (VDPVs). The Global Polio Eradication Initiative (GPEI) coordinated global cessation of all type 2 OPV (OPV2) use in routine immunization in 2016 but did not successfully end the transmission of type 2 VDPVs (VDPV2s), and consequently continues to use type 2 OPV (OPV2) for outbreak response activities. Using an updated global poliovirus transmission and OPV evolution model, we characterize outbreak response options for 2019-2029 related to responding to VDPV2 outbreaks with a genetically stabilized novel OPV (nOPV2) strain or with the currently licensed monovalent OPV2 (mOPV2). Given uncertainties about the properties of nOPV2, we model different assumptions that appear consistent with the evidence on nOPV2 to date. Using nOPV2 to respond to detected cases may reduce the expected VDPV and VAPP cases and the risk of needing to restart OPV2 use in routine immunization compared to mOPV2 use for outbreak response. The actual properties, availability, and use of nOPV2 will determine its effects on type 2 poliovirus transmission in populations. Even with optimal nOPV2 performance, countries and the GPEI would still likely need to restart OPV2 use in routine immunization in OPV-using countries if operational improvements in outbreak response to stop the transmission of cVDPV2s are not implemented effectively.

Reconciling model predictions with low reported cases of COVID-19 in Sub-Saharan Africa: insights from Madagascar

COVID-19 has wreaked havoc globally with particular concerns for sub-Saharan Africa (SSA), where models suggest that the majority of the population will become infected. Conventional wisdom suggests that the continent will bear a higher burden of COVID-19 for the same reasons it suffers from other infectious diseases: ecology, socio-economic conditions, lack of water and sanitation infrastructure, and weak health systems. However, so far SSA has reported lower incidence and fatalities compared to the predictions of standard models and the experience of other regions of the world. There are three leading explanations, each with different implications for the final epidemic burden: (1) low case detection, (2) differences in epidemiology (e.g. low R 0 ), and (3) policy interventions. The low number of cases have led some SSA governments to relaxing these policy interventions. Will this result in a resurgence of cases? To understand how to interpret the lower-than-expected COVID-19 case data in Madagascar, we use a simple age-structured model to explore each of these explanations and predict the epidemic impact associated with them. We show that the incidence of COVID-19 cases as of July 2020 can be explained by any combination of the late introduction of first imported cases, early implementation of non-pharmaceutical interventions (NPIs), and low case detection rates. We then re-evaluate these findings in the context of the COVID-19 epidemic in Madagascar through August 2020. This analysis reinforces that Madagascar, along with other countries in SSA, remains at risk of a growing health crisis. If NPIs remain enforced, up to 50,000 lives may be saved. Even with NPIs, without vaccines and new therapies, COVID-19 could infect up to 30% of the population, making it the largest public health threat in Madagascar for the coming year, hence the importance of clinical trials and continually improving access to healthcare.

Mycoplasma bovis outbreak in New Zealand cattle: An assessment of transmission trends using surveillance data

Mycoplasma bovis most likely infected New Zealand cattle in the latter half of 2015. Infection was detected in mid-2017 after which control activities were implemented. An official eradication programme commenced in mid-2018, which is ongoing. We examined farm-level tracing and surveillance data to describe the outbreak, analyse transmission trends and make inference on progress towards eradication. Results indicate that cattle movements were the primary means of spread. Although case farms were distributed throughout both islands of New Zealand, most animal movements off infected farms did not result in newly infected farms, indicating Mycoplasma bovis is not highly transmissible between farms. To describe and analyse outbreak trends, we undertook a standard descriptive outbreak investigation, including construction of an epidemic curve and calculation of estimated dissemination ratios. We then employed three empirical models-a non-linear growth model, time series model and branching process model based on time-varying effective reproduction numbers-to further analyse transmission trends and provide short-term forecasts of farm-level incidence. Our analyses suggest that Mycoplasma bovis transmission in New Zealand has declined and progress towards eradication has been made. Few incident cases were forecast for the period between 8 September and 17 December 2019. To date, no case farms with an estimated infection date assigned to this period have been detected; however, case detection is ongoing, and these results need to be interpreted cautiously considering model validation and other important contextual information on performance of the eradication programme, such as the time between infection, detection and implementation of movement controls on case farms.

Transmission Dynamics of the COVID-19 Epidemic at the District Level in India: Prospective Observational Study

BACKGROUND

On March 9, 2020, the first COVID-19 case was reported in Jodhpur, Rajasthan, in the northwestern part of India. Understanding the epidemiology of COVID-19 at a local level is becoming increasingly important to guide measures to control the pandemic.

OBJECTIVE

The aim of this study was to estimate the serial interval and basic reproduction number (R0) to understand the transmission dynamics of the COVID-19 outbreak at a district level. We used standard mathematical modeling approaches to assess the utility of these factors in determining the effectiveness of COVID-19 responses and projecting the size of the epidemic.

METHODS

Contact tracing of individuals infected with SARS-CoV-2 was performed to obtain the serial intervals. The median and 95th percentile values of the SARS-CoV-2 serial interval were obtained from the best fits with the weibull, log-normal, log-logistic, gamma, and generalized gamma distributions. Aggregate and instantaneous R0 values were derived with different methods using the EarlyR and EpiEstim packages in R software.

RESULTS

The median and 95th percentile values of the serial interval were 5.23 days (95% CI 4.72-5.79) and 13.20 days (95% CI 10.90-18.18), respectively. R0 during the first 30 days of the outbreak was 1.62 (95% CI 1.07-2.17), which subsequently decreased to 1.15 (95% CI 1.09-1.21). The peak instantaneous R0 values obtained using a Poisson process developed by Jombert et al were 6.53 (95% CI 2.12-13.38) and 3.43 (95% CI 1.71-5.74) for sliding time windows of 7 and 14 days, respectively. The peak R0 values obtained using the method by Wallinga and Teunis were 2.96 (95% CI 2.52-3.36) and 2.92 (95% CI 2.65-3.22) for sliding time windows of 7 and 14 days, respectively. R0 values of 1.21 (95% CI 1.09-1.34) and 1.12 (95% CI 1.03-1.21) for the 7- and 14-day sliding time windows, respectively, were obtained on July 6, 2020, using method by Jombert et al. Using the method by Wallinga and Teunis, values of 0.32 (95% CI 0.27-0.36) and 0.61 (95% CI 0.58-0.63) were obtained for the 7- and 14-day sliding time windows, respectively. The projection of cases over the next month was 2131 (95% CI 1799-2462). Reductions of transmission by 25% and 50% corresponding to reasonable and aggressive control measures could lead to 58.7% and 84.0% reductions in epidemic size, respectively.

CONCLUSIONS

The projected transmission reductions indicate that strengthening control measures could lead to proportionate reductions of the size of the COVID-19 epidemic. Time-dependent instantaneous R0 estimation based on the process by Jombart et al was found to be better suited for guiding COVID-19 response at the district level than overall R0 or instantaneous R0 estimation by the Wallinga and Teunis method. A data-driven approach at the local level is proposed to be useful in guiding public health strategy and surge capacity planning.

Optimizing Pandemic Preparedness and Response Through Health Information Systems: Lessons Learned From Ebola to COVID-19

Strengthening health systems and maintaining essential service delivery during health emergencies response is critical for early detection and diagnosis, prompt treatment, and effective control of pandemics, including the novel coronavirus disease 2019 (COVID-19). Health information systems (HIS) developed during recent Ebola outbreaks in West Africa and the Democratic Republic of the Congo (DRC) provided opportunities to collect, analyze, and distribute data to inform both day-to-day and long-term policy decisions on outbreak preparedness. As COVID-19 continues to sweep across the globe, HIS and related technological advancements remain vital for effective and sustained data sharing, contact tracing, mapping and monitoring, community risk sensitization and engagement, preventive education, and timely preparedness and response activities. In reviewing literature of how HIS could have further supported mitigation of these Ebola outbreaks and the ongoing COVID-19 pandemic, 3 key areas were identified: governance and coordination, health systems infrastructure and resources, and community engagement. In this concept study, we outline scalable HIS lessons from recent Ebola outbreaks and early COVID-19 responses along these 3 domains, synthesizing recommendations to offer clear, evidence-based approaches on how to leverage HIS to strengthen the current pandemic response and foster community health systems resilience moving forward.

Laboratory response checklist for infectious disease outbreaks-preparedness and response considerations for emerging threats

The purpose of the Laboratory Response Checklist for Infectious Disease Outbreaks (the Checklist) is to provide public health laboratories and laboratory networks operating at multiple jurisdictional levels with a useful, adaptable tool to help rapidly identify important outbreak response considerations, particularly when investigating a previously unknown infectious disease threat. The Checklist was developed by the National Microbiology Laboratory of Canada in collaboration with provincial/territorial, national and international laboratory experts, including the Canadian Public Health Laboratory Network, and the Global Health Security Action Group Laboratory Network. While the Checklist was initially designed to reflect lessons learned through National Microbiology Laboratory participation in extended national and international outbreak responses (e.g. Zika virus epidemic [2015-2016], Ebola virus epidemic, West Africa [2014-2016]), the importance of optimizing laboratory response coordination has only been underscored by the ongoing challenges presented by the coronavirus disease 2019 (COVID-19) pandemic response requirements. The Checklist identifies five highly interdependent laboratory response themes, each of which encompasses multiple considerations that may be critical to a coordinated, strategic outbreak response. As such, the comprehensive review of Checklist considerations by responding laboratory organizations may provide a valuable opportunity to quickly detect key response considerations and interdependencies, and mitigate risks with the potential to impact public health action.

Real-Time Standard Analysis of Disease Investigation (SADI)-A Toolbox Approach to Inform Disease Outbreak Response

An incursion of an important exotic transboundary animal disease requires a prompt and intensive response. The routine analysis of up-to-date data, as near to real time as possible, is essential for the objective assessment of the patterns of disease spread or effectiveness of control measures and the formulation of alternative control strategies. In this paper, we describe the Standard Analysis of Disease Investigation (SADI), a toolbox for informing disease outbreak response, which was developed as part of New Zealand's biosecurity preparedness. SADI was generically designed on a web-based software platform, Integrated Real-time Information System (IRIS). We demonstrated the use of SADI for a hypothetical foot-and-mouth disease (FMD) outbreak scenario in New Zealand. The data standards were set within SADI, accommodating a single relational database that integrated the national livestock population data, outbreak data, and tracing data. We collected a well-researched, standardised set of 16 epidemiologically relevant analyses for informing the FMD outbreak response, including farm response timelines, interactive outbreak/network maps, stratified epidemic curves, estimated dissemination rates, estimated reproduction numbers, and areal attack rates. The analyses were programmed within SADI to automate the process to generate the reports at a regular interval (daily) using the most up-to-date data. Having SADI prepared in advance and the process streamlined for data collection, analysis and reporting would free a wider group of epidemiologists during an actual disease outbreak from solving data inconsistency among response teams, daily “number crunching,” or providing largely retrospective analyses. Instead, the focus could be directed into enhancing data collection strategies, improving data quality, understanding the limitations of the data available, interpreting the set of analyses, and communicating their meaning with response teams, decision makers and public in the context of the epidemic.

Infectious disease outbreak preparedness and response in Nigeria: history, limitations and recommendations for global health policy and practice

Effective disease outbreak response has historically been a challenging accomplishment for the Nigerian health system due to an array of hurdles not unique to Nigeria but also found in other African nations which share its large size and complexity. However, the efficiency of the response mounted against the Ebola Virus Disease (EVD) outbreak of 2014 proved that indeed, though challenging, proactive and effective outbreak response is not impossible. With over 20 public health emergencies and infectious disease outbreaks between 2016 and 2018 alone, Nigeria is one of only five members of the World Health Organization (WHO) African Region to report five or more public health events per annum. There are many lessons that can be drawn from Nigeria's experience in handling outbreaks of infectious diseases. In this review, we discuss the history of emerging and re-emerging infectious disease outbreaks in Nigeria and explore the response strategies mounted towards each. We also highlight the significant successes and note-worthy limitations, which we have then utilized to proffer policy recommendations to strengthen the Nigerian public health emergency response systems.