Historical trends demonstrate a pattern of increasingly frequent and severe spillover events of high-consequence zoonotic viruses

The COVID-19 pandemic has focused attention on patterns of infectious disease spillover. Climate and land-use changes are predicted to increase the frequency of zoonotic spillover events, which have been the cause of most modern epidemics. Characterising historical trends in zoonotic spillover can provide insights into the expected frequency and severity of future epidemics, but historical epidemiological data remains largely fragmented and difficult to analyse. We utilised our extensive epidemiological database to analyse a specific subset of high-consequence zoonotic spillover events for trends in the annual frequency and severity of outbreaks. Our analysis, which excludes the ongoing SARS-CoV-2 pandemic, shows that the number of spillover events and reported deaths have been increasing by 4.98% (confidence interval [CI]95% [3.22%; 6.76%]) and 8.7% (CI 95% [4.06%; 13.62%]) annually, respectively. This trend can be altered by concerted global efforts to improve our capacity to prevent and contain outbreaks. Such efforts are needed to address this large and growing risk to global health.

Infectious Disease Underreporting Is Predicted by Country-Level Preparedness, Politics, and Pathogen Severity

Underreporting of infectious diseases is a pervasive challenge in public health that has emerged as a central issue in characterizing the dynamics of the COVID-19 pandemic. Infectious diseases are underreported for a range of reasons, including mild or asymptomatic infections, weak public health infrastructure, and government censorship. In this study, we investigated factors associated with cross-country and cross-pathogen variation in reporting. We performed a literature search to collect estimates of empirical reporting rates, calculated as the number of cases reported divided by the estimated number of true cases. This literature search yielded a dataset of reporting rates for 32 pathogens, representing 52 countries. We combined epidemiological and social science theory to identify factors specific to pathogens, country health systems, and politics that could influence empirical reporting rates. We performed generalized linear regression to test the relationship between the pathogen- and country-specific factors that we hypothesized could influence reporting rates, and the reporting rate estimates that we collected in our literature search. Pathogen- and country-specific factors were predictive of reporting rates. Deadlier pathogens and sexually transmitted diseases were more likely to be reported. Country epidemic preparedness was positively associated with reporting completeness, while countries with high levels of media bias in favor of incumbent governments were less likely to report infectious disease cases. Underreporting is a complex phenomenon that is driven by factors specific to pathogens, country health systems, and politics. In this study, we identified specific and measurable components of these broader factors that influence pathogen- and country-specific reporting rates and used model selection techniques to build a model that can guide efforts to diagnose, characterize, and reduce underreporting. Furthermore, this model can characterize uncertainty and correct for bias in reported infectious disease statistics, particularly when outbreak-specific empirical estimates of underreporting are unavailable. More precise estimates can inform control policies and improve the accuracy of infectious disease models.

Debunking highly prevalent health misinformation using audio dramas delivered by WhatsApp: evidence from a randomised controlled trial in Sierra Leone

Introduction

Infectious disease misinformation is widespread and poses challenges to disease control. There is limited evidence on how to effectively counter health misinformation in a community setting, particularly in low-income regions, and unsettled scientific debate about whether misinformation should be directly discussed and debunked, or implicitly countered by providing scientifically correct information.

Methods

The Contagious Misinformation Trial developed and tested interventions designed to counter highly prevalent infectious disease misinformation in Sierra Leone, namely the beliefs that (1) mosquitoes cause typhoid and (2) typhoid co-occurs with malaria. The information intervention for group A (n=246) explicitly discussed misinformation and explained why it was incorrect and then provided the scientifically correct information. The intervention for group B (n=245) only focused on providing correct information, without directly discussing related misinformation. Both interventions were delivered via audio dramas on WhatsApp that incorporated local cultural understandings of typhoid. Participants were randomised 1:1:1 to the intervention groups or the control group (n=245), who received two episodes about breast feeding.

Results

At baseline 51% believed that typhoid is caused by mosquitoes and 59% believed that typhoid and malaria always co-occur. The endline survey was completed by 91% of participants. Results from the intention-to-treat, per-protocol and as-treated analyses show that both interventions substantially reduced belief in misinformation compared with the control group. Estimates from these analyses, as well as an exploratory dose–response analysis, suggest that direct debunking may be more effective at countering misinformation. Both interventions improved people’s knowledge and self-reported behaviour around typhoid risk reduction, and yielded self-reported increases in an important preventive method, drinking treated water.

Conclusion

These results from a field experiment in a community setting show that highly prevalent health misinformation can be countered, and that direct, detailed debunking may be most effective.

Trial registration number

NCT04112680.

Challenges in reported COVID-19 data: best practices and recommendations for future epidemics

The proliferation of composite data sources tracking the COVID-19 pandemic emphasises the need for such databases during large-scale infectious disease events as well as the potential pitfalls due to the challenges of combining disparate data sources. Multiple organisations have attempted to standardise the compilation of disparate data from multiple sources during the COVID-19 pandemic. However, each composite data source can use a different approach to compile data and address data issues with varying results.

We discuss some best practices for researchers endeavouring to create such compilations while discussing three key categories of challenges: (1) data dissemination, which includes discrepant estimates and varying data structures due to multiple agencies and reporting sources generating public health statistics on the same event; (2) data elements, such as date formats and location names, lack standardisation, and differing spatial and temporal resolutions often create challenges when combining sources; and (3) epidemiological factors, including missing data, reporting lags, retrospective data corrections and changes to case definitions that cannot easily be addressed by the data compiler but must be kept in mind when reviewing the data.

Efforts to reform the global health data ecosystem should bear such challenges in mind. Standards and best practices should be developed and incorporated to yield more robust, transparent and interoperable data. Since no standards exist yet, we have highlighted key challenges in creating a comprehensive spatiotemporal view of outbreaks from multiple, often discrepant, reporting sources and provided guidelines to address them. In general, we caution against an over-reliance on fully automated systems for integrating surveillance data and strongly advise that epidemiological experts remain engaged in the process of data assessment, integration, validation and interpretation to identify, diagnose and resolve data challenges.

Measuring development assistance for health systems strengthening and health security: an analysis using the Creditor Reporting System database

Background: Health systems strengthening (HSS) and health security are two pillars of universal health coverage (UHC). Investments in these areas are essential for meeting the Sustainable Development Goals and are of heightened relevance given the emergence of the 2019 novel coronavirus disease (COVID-19). This study aims to generate information on development assistance for health (DAH) for these areas, including how to track it and how funding levels align with country needs.

Methods: We developed a framework to analyze the amount of DAH disbursed in 2015 for the six building blocks of the health system (‘system-wide HSS’) plus health security (emergency preparedness, risk management, and response) at both the global (transnational) and country level. We reviewed 2,427 of 32,801 DAH activities in the Creditor Reporting System (CRS) database (80% of the total value of disbursements in 2015) and additional public information sources. Additional aid activities were identified through a keyword search.

Results: In 2015, we estimated that US$3.1 billion (13.4%) of the US$22.9 billion of DAH captured in the CRS database was for system-wide HSS and health security: US$2.5 billion (10.9%) for system-wide HSS, mostly for infrastructure, and US$0.6 billion (2.5%) for system-wide health security. US$567.1 million (2.4%) was invested in supporting these activities at the global level. If responses to individual health emergencies are included, 7.5% of total DAH (US$1.7B) was for health security. We found a correlation between DAH for HSS and maternal mortality rates, and we interpret this as evidence that HSS aid generally flowed to countries with greater need.

Conclusions: Achieving UHC by 2030 will require greater investments in system-wide HSS and proactive health emergency preparedness. It may be appropriate for donors to more prominently consider country needs and global functions when investing in health security and HSS.

Using social media to estimate Zika's impact on tourism: #babymoon, 2014-2017

Zika virus infection during pregnancy can cause microcephaly and other birth defects. We hypothesized that the Latin America Zika epidemic resulted in pregnant women and their partners adopting behavioral changes to limit risk, leading them to forego travel to Zika-affected locations. We evaluated this hypothesis by studying travelers' intent and behavior through Twitter data related to babymoon: a holiday taken by parents-to-be before their baby is born. We found the odds of mentioning representative Zika-affected locations in #babymoon tweets dropped significantly (Odds ratio: 0.29, 95% CI: 0.20-0.40) after the Zika-microcephaly association became well-known. This result was further corroborated through a content analysis of #babymoon tweets mentioning Zika-affected locations, which identified if the Twitter user was physically present in the Zika-affected locations. Conversely, we found a small but statistically insignificant increase in the odds of mentioning Zika-free locations from #babymoon tweets (Odds Ratio: 1.11, 95% CI: 0.97-1.27) after the Zika-microcephaly association became well-known.

Assessing global preparedness for the next pandemic: development and application of an Epidemic Preparedness Index

Introduction

Robust metrics for national-level preparedness are critical for assessing global resilience to epidemic and pandemic outbreaks. However, existing preparedness assessments focus primarily on public health systems or specific legislative frameworks, and do not measure other essential capacities that enable and support public health preparedness and response.

Methods

We developed an Epidemic Preparedness Index (EPI) to assess national-level preparedness. The EPI is global, covering 188 countries. It consists of five subindices measuring each country’s economic resources, public health communications, infrastructure, public health systems and institutional capacity. To evaluate the construct validity of the EPI, we tested its correlation with proxy measures for preparedness and response capacity, including the timeliness of outbreak detection and reporting, as well as vaccination rates during the 2009 H1N1 influenza pandemic.

Results

The most prepared countries were concentrated in Europe and North America, while the least prepared countries clustered in Central and West Africa and Southeast Asia. Better prepared countries were found to report infectious disease outbreaks more quickly and to have vaccinated a larger proportion of their population during the 2009 pandemic.

Conclusion

The EPI measures a country’s capacity to detect and respond to infectious disease events. Existing tools, such as the Joint External Evaluation (JEE), have been designed to measure preparedness within a country over time. The EPI complements the JEE by providing a holistic view of preparedness and is constructed to support comparative risk assessment between countries. The index can be updated rapidly to generate global estimates of pandemic preparedness that can inform strategy and resource allocation.

Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.

The antibacterial activity and stability of acetic acid

Acetic acid has been shown to have good antibacterial activity against micro-organisms such as Pseudomonas aeruginosa. This study examined the activity against a range of bacterial pathogens and also assessed any reduction in antibacterial activity due to evaporation or inactivation by organic material in dressings. Acetic acid was active at dilutions as low as 0.166% and the activity was not reduced by evaporation nor by inactivation by cotton swabs. Burn injuries are a major problem in countries with limited resources. Acetic acid is an ideal candidate for use in patients who are treated in those parts of the world.

Outcome and six month follow up of patients after Ultra Rapid Opiate Detoxification (UROD)

OBJECTIVES

(1) Evaluate the safety and efficacy of Ultra Rapid Opiate Detoxification (UROD); and (2) evaluate six month outcome data of patients choosing this method.

DESIGN

Two center parallel group clinical trial. No grant funding.

SETTING

Two academic medical centers.

PARTICIPANTS

Ninety-three men and 27 women, aged 18 to 55 years, with opiate dependency self selected to undergo detoxification.

INTERVENTIONS

UROD followed by naltrexone maintenance and an aftercare program. UROD and aftercare costs were the responsibility of the patients and/or their significant others.

MAIN OUTCOMES MEASURE

(1) Completion of UROD as determined by a non reactive response to a naloxone challenge test under anesthesia and non reactive response to naltrexone administration before discharge. (2) Patient outcome as determined at six month follow up of UROD patients' self reported relapse free status confirmed by urine drug screen, significant other reports, and/or therapist reports.

RESULTS

One hundred percent successful detoxification with UROD with low morbidity and no mortality. Relapse data were available for 111/123 procedures performed (90%), with 61/111 patients (55%) with reported relapse free status at the six month follow up interval.

CONCLUSIONS

For individuals who are addicted to opioids, the Ultra Rapid Opiate Detoxification method appears to be a viable treatment option.

Is routine synovial fluid analysis necessary? Lessons and recommendations from an audit

This audit of 408 synovial fluid samples, analysed for cell counts and crystals, revealed that crystals were present in only 25 samples (6.1%). Of these, in only three patients was the diagnosis uncertain and therefore the analysis helpful. Cell counts and types generally reflected known underlying diagnoses of inflammatory arthritis or osteoarthritis. Routine synovial fluid analysis does not contribute to diagnosis or management in established rheumatic disorders and should be performed only when the underlying cause is uncertain or in newly presenting patients. Major savings can be made by abandoning routine synovial fluid analysis.

Routine synovial fluid culture: is it necessary? Lessons from an audit

An estimated third of rheumatologists send aspirated synovial fluid samples for culture routinely during the course of management of their patients irrespective of the underlying diagnosis. This is done apparently even when sepsis is not suspected. This audit of 507 synovial fluid culture requests revealed that positive bacterial growth was rare even when sepsis was queried on the request forms but none was positive in any of the routine samples. Our findings throw doubt on the value of routine synovial fluid culture. We recommend that such cultures are undertaken when infection is a possibility and in immuno-compromised patients. An average health district would save pounds 3000 per annum if such a policy was adopted, but across the National Health Service as a whole the total expenditure saved on this unnecessary investigation would be considerable.

Leg ulcer odour detection identifies beta-haemolytic streptococcal infection

beta-Haemolytic streptococci were identified in bacteriological cultures from 14 of 24 chronic venous leg ulcers in 21 patients. Multi-element odour detection (MEOD) analysis demonstrated a significant difference in odour in those ulcers from which beta-haemolytic streptococci were isolated (p < 0.01). MEOD has potential to detect pathogenic organisms instantaneously in the clinical setting.

Symptom-limited arm exercise increases detection of ischemia during dipyridamole tomographic thallium stress testing in patients with coronary artery disease

Exercise combined with dipyridamole during thallium stress testing in patients with coronary artery disease (CAD) increases the frequency of angina and ischemic ST changes in the electrocardiogram. Evidence for an increase in thallium abnormalities has been inconclusive. We prospectively examined 54 consecutive patients who underwent coronary angiography and tomographic thallium with dipyridamole (0.57 mg/kg) alone and combined with symptom-limited dynamic arm exercise. Most patients presented with a history of chest pain and 49 had angiographic evidence of significant coronary stenosis (50% diameter narrowing). Thallium abnormalities were scored blindly by consensus. The number of abnormal segments (total and ischemic) and indexes of left ventricular dysfunction, such as increased lung uptake or ischemic dilation, were compared in the 49 patients with CAD. During arm exercise more patients had evidence of ischemia (39 vs 30; p < 0.001), and the number of ischemic segments increased significantly from 1.3 +/- 1.5 to 2.5 +/- 2.2 (p < 0.001). There was also a significant increase in the indexes of left ventricular dysfunction, ischemic dilation (10 vs 4 patients; p < 0.03) and increased lung uptake (16 vs 5 patients; p < 0.001). Patients who exercised had increased thallium evidence of extent and severity of ischemia and more frequent indexes of left ventricular dysfunction. Thus, symptom-limited arm exercise improves detection of extent and severity of ischemia in patients with CAD undergoing dipyridamole thallium stress testing.

Post consolidation therapy for adult patients with acute myeloid leukaemia

One hundred and sixteen adult patients aged 14-73 with previously untreated acute myeloid leukaemia received induction and consolidation chemotherapy with daunorubicin, cytosine arabinoside and thioguanine. Two novel approaches to post consolidation therapy have been investigated. Patients aged 50 years or less who had no suitable matched allogeneic donor were considered for autologous bone marrow transplantation (BMT) using bone marrow which had been cultured in vitro for 14 d. Patients over the age of 50 years with normal bone marrow cellularity and peripheral blood count were treated with a single oral dose of busulphan 100 mg/m2 (without BMT rescue) 3 months following the completion of consolidation therapy. Eighty-seven patients (75%) achieved a complete remission. Of 70 patients who completed consolidation therapy, 40 were aged less than or equal to 50 years and 30 were greater than 50 years. Forty-three patients went on to receive post consolidation therapy in first CR (autologous BMT 12, allogeneic BMT 7, busulphan therapy 24). The event-free survival at 4 years was 47% for autologous BMT, 34% for allogeneic BMT and 45% for busulphan-treated patients. The survival for the older cohort of patients who received post consolidation therapy with single dose busulphan therapy was encouraging, and this agent should be considered for future post consolidation strategies.

Antibiotic-resistant pneumococcal disease in children at Baragwanath Hospital, Johannesburg

Seventeen of 60 cases of pneumococcal bacteremia in children at Baragwanath Hospital in 1983 were caused by strains not fully susceptible to penicillin G. Eight strains had minimal inhibitory concentrations of greater than 1 microgram/ml and five were resistant to four or more antimicrobial agents. Only three isolates were resistant to chloramphenicol. Antibiotic-resistant strains occurred in younger children with a mean age of 13.1 months compared with a mean age of 31.6 months in children with susceptible strains (P less than 0.01). Underlying conditions, including nutritional status, did not correlate with antibiotic resistance of isolates from blood. Some of the resistant strains were apparently community-acquired. Of 3379 nasopharyngeal swabs taken from hospitalized children 829 yielded pneumococci and 408 of these carrier strains were either relatively or fully resistant to penicillin while 241 were resistant to four or more antibiotics. Multiply resistant strains from patients and carriers belonged to serovars 6A, 6B and 19A.

High-contrast film copying for thallium 201 cardiac image processing

To evaluate the usefulness of high-contrast film copying as an economical means of enhancing contrast in thallium 201 cardiac images, stress and rest studies of 47 patients with and 19 patients without coronary artery disease were evaluated. A total of 66 sets of four different image formats were independently interpreted by five observers. The analysis of the receiver operating characteristic curves suggested that the high-contrast film copies were superior to their original analog images and comparable with computer-processed images in diagnostic yield. It appears that contrast enhancement by simple film copying can improve the accuracy of 201Tl image interpretation.

Human platelet function as a model for investigating the clinical efficacy of chlorpromazine

1 Enhancement of platelet aggregation response (PAR) to 5-hydroxytryptamine (5-HT) in some schizophrenic patients receiving chlorpromazine (CPZ) may provide a biological index for the efficacy of this drug. 2 In a double-blind study 33 schizophrenic patients hospitalized following their first psychotic breakdown were followed up clinically with concurrent assessment of their PAR to 5-HT. The patients followed a standardized treatment schedule with (CPZ) as the sole antipsychotic medication. 3 Twelve patients (Group A) developed an enhanced biphasic 5-HT PAR, within 2-3 weeks and improved clinically by the sixth week. In most cases, the appearance of the enhanced biphasic PAR preceded clinical improvement. Twenty-one patients (Group B) did not have enhanced biphasic PAR to 5-HT by the sixteenth week of treatment. However, twelve subjects from this group showed clinical response to CPZ by the end of this period, while the remaining patients did not improve. 4 The enhanced PAR to 5-HT in Group A discriminated best between good and bad outcome cases when Feighner's research diagnostic criteria were used. We could not confirm the previous reports of platelet aggregation response to dopamine in pre- or post-chlorpromazine treatment.

Synergism Between Adrenaline and Adenine Nucleotides in Producing Platelet Aggregation Responses

Recently we have shown that 5′-adenylylimidodiphosphate (AIP), a structural analogue of ATP, causes a transient aggregation of human blood platelets similar to that produced by 5-hydroxytryptamine (5-HT) (Brit. J. Pharmacol. 1979, in press). In addition AIP strongly inhibits the second phase of aggregation induced by adrenaline (A), noradrenaline, ADP and irreversible 5-HT when such a response is obtained. However, it does not affect collagen response, indicating that AIP is an inhibitor of release I (i.e. release is reversible. Like 5-HT, the aggregation to AIP can be enhanced by pretreatment (30-60 sec.) with low (0.1-0.5 μM) non-aggregating concentrations of A, but without exhibiting a second phase of aggregation. The synergistic effect of A (but not isoproterenol, 10-100 μM) was also observed with ATP and ADP. ATP by itself does not produce an aggregation response but it causes a 5-HT like response after preincubation with A. The potentiating effects of A on aggregation responses are selectively prevented by phentolamine (10 μM) but not by proparanolol (10 μM). The results suggest an α-adrenergic mediated effect.