Rabies control in KwaZulu-Natal, South Africa.

PROBLEM: Urbanization, large dog populations and failed control efforts have contributed to continuing endemicity of dog-mediated rabies in KwaZulu-Natal province, South Africa. APPROACH: From 2007 to 2014 we used a OneHealth approach to rabies prevention, involving both the human and animal health sectors. We implemented mass vaccination campaigns for dogs to control canine rabies, and strategies to improve rabies awareness and access to postexposure prophylaxis for people exposed to rabies. LOCAL SETTING: A rabies-endemic region, KwaZulu-Natal is one of the smallest and most populous South African provinces (estimated population 10 900 000). Canine rabies has persisted since its introduction in 1976, causing an average of 9.2 human rabies cases per annum in KwaZulu-Natal from 1976 to 2007, when the project started. RELEVANT CHANGES: Between 2007 and 2014, the numbers of dog vaccinations rose from 358 611 to 395 000 and human vaccines purchased increased form 100 046 to 156 996. Strategic dog vaccination successfully reduced rabies transmission within dog populations, reducing canine rabies cases from 473 in 2007 to 37 in 2014. Actions taken to reduce the incidence of canine rabies, increase public awareness of rabies and improve delivery of postexposure prophylaxis contributed to reaching zero human rabies cases in KwaZulu-Natal in 2014. LESSONS LEARNT: Starting small and scaling up enabled us to build strategies that fitted various local settings and to successfully apply a OneHealth approach. Important to the success of the project were employing competent, motivated staff, and providing resources, training and support for field workers.

Elimination of dog-mediated human rabies: the burden of human rabies in Africa.

Hope exists for the elimination of dog-mediated human rabies in Africa. Momentum is gathering towards this goal, with an increasing number of successful demonstration projects showing that elimination is feasible. The Pan African Rabies Control Network is bringing Africa together against rabies, supported by the World Health Organization, the World Organisation for Animal Health and the Food and Agriculture Organization of the United Nations, which have a combined resolution to eliminate human deaths from dog-transmitted rabies by 2030. Furthermore, the inspiring examples of both rinderpest and smallpox eradication hold all the elements necessary to have confidence that this momentum can lead to success. Smallpox and rinderpest, whose last battles were fought on the African continent, highlight the simple fact that once the primary tools are available (such as vaccines), by far the greatest challenges lie within the realm of implementation. Science can effectively argue the subtleties of virology, immunology, vaccinology, etc. but it often fails to describe the science of implementation. In the face of other major diseases and socio-economic difficulties, rabies is not perceived as a threat by many African countries, despite the fact that the burden of the disease has been shown to be extensive. The challenge of mobilising mass interventions requires leadership and fortitude within resource-poor, infrastructurally challenged, politically uninterested and often bureaucratically restricted environments. Continent-wide elimination remains a daunting prospect for investors, who often lack insight into environmental disease dynamics, which is essential for enabling the implementation of strategic, community-based interventions. Implementation in Africa needs to be seen through African eyes. It needs local community support, and it needs effective transport and procurement systems and systems of self-development with a view to sustainability. The Aidto- Africa model needs to be replaced by a model that empowers communities to act, demonstrates that success is possible and stimulates the expansion of control efforts.

Il existe un espoir de réussir à éliminer la rage humaine transmise par les chiens en Afrique. Nous assistons actuellement à la montée en puissance d'une dynamique vers cet objectif, avec la réalisation d'un nombre croissant de projets de démonstration qui en confirment la faisabilité. Le continent africain a décidé de rassembler ses efforts contre la rage en lançant le Réseau panafricain de contrôle de la rage, soutenu par l'Organisation mondiale de la santé, l'Organisation mondiale de la santé animale et l'Organisation des Nations Unies pour l'alimentation et l'agriculture, c'est-à-dire les trois organisations signataires de la résolution visant à ramener à zéro le nombre de décès humains dans le monde dus à la rage transmise par les chiens à l'horizon 2030. En outre, les exemples édifiants d'éradication réussie de la peste bovine et de la variole offrent tous les éléments nécessaires pour envisager avec confiance le succès de cette entreprise. Les dernières batailles contre la variole et la peste bovine, qui ont été livrées sur le continent africain, mettent en lumière une vérité simple, à savoir qu'une fois garantie l'existence des outils essentiels (par exemple les vaccins), il reste à relever le défi de leur mise en oeuvre, de loin le plus important. Si la science apporte nombre d'éclairages argumentés sur les subtilités en matière de virologie, d'immunologie, de vaccinologie, etc., elle ne parvient pas toujours à expliquer la science de la mise en oeuvre. Face à d'autres maladies majeures et aux difficultés d'ordre socio-économique que traversent les pays, ceux-ci ne perçoivent pas toujours la rage comme une menace malgré le fardeau considérable qu'elle représente pour eux. Les difficultés liées à la mobilisation d'interventions à très grande échelle exigent de la détermination et des capacités de leadership dans un environnement insuffisamment doté en ressources et en infrastructures, peu motivé au plan politique et souvent limité par des contraintes bureaucratiques. L'élimination à l'échelle du continent reste une perspective intimidante pour les investisseurs, qui ne sont pas toujours conscients de la dynamique environnementale de la maladie, facteur pourtant essentiel pour mettre en oeuvre des interventions stratégiques basées sur les communautés locales. La mise en oeuvre en Afrique doit être envisagée dans une optique africaine. Elle nécessite le soutien des populations locales, des systèmes de transport et d'approvisionnement efficaces et des dispositifs de développement autonomes afin d'en assurer la durabilité. Le modèle d'aide à l'Afrique doit être remplacé par un modèle qui repose sur l'autonomisation et la capacité d'action des populations locales et qui puisse à la fois démontrer les perspectives de réussite et promouvoir l'intensification des efforts dédiés à la lutte.

Hay esperanza por lo que respecta a acabar con la rabia humana transmitida por perros en África. La dinámica para lograrlo va ganando impulso, con un creciente número de fructíferos proyectos experimentales que demuestran que es un objetivo factible. La Red Panafricana para el Control de la Rabia está federando a todo el continente en torno a la lucha antirrábica, con apoyo de la Organización Mundial de la Salud (OMS), la Organización Mundial de Sanidad Animal (OIE) y la Organización de las Naciones Unidas para la Alimentación y la Agricultura (FAO), que tienen suscrita una resolución común en la que afirman la voluntad de poner fin antes de 2030 a la muerte de personas por la rabia transmitida por perros. Además, los estimulantes ejemplos de la erradicación de la peste bovina y la viruela ofrecen todas las razones para confiar en que esta dinámica se vea coronada por el éxito. Las guerras contra esas dos enfermedades, cuyas últimas batallas se libraron en el continente africano, ponen de relieve un hecho simple: una vez están disponibles las herramientas básicas (como las vacunas), los mayores obstáculos, con diferencia, surgen en el terreno de la aplicación práctica. La ciencia puede adentrarse eficazmente en las sutilezas de la virología, la inmunología, la vacunología y demás, pero a menudo es incapaz de describir la ciencia de la aplicación. En comparación con otras importantes enfermedades y dificultades socioeconómicas, muchos países africanos no consideran que la rabia suponga una amenaza, pese a la probada magnitud de la carga que impone. El objetivo de poner en solfa intervenciones masivas exige liderazgo y fortaleza en contextos marcados no solo por la escasez de recursos, sino también por infraestructuras deficientes, desinterés político y, a menudo, cortapisas burocráticas. La eliminación de la rabia en todo el continente sigue pareciendo una empresa abrumadora a los inversores, que no suelen tener una idea clara de la dinámica ambiental de la enfermedad, algo esencial para posibilitar la aplicación de intervenciones estratégicas y enraizadas en el ámbito comunitario. En África este empeño hay que abordarlo desde una óptica africana. Ello pasa por el apoyo de las comunidades locales, por sistemas eficaces de compra y transporte y por sistemas de desarrollo autónomo que hagan posible la sostenibilidad a largo plazo. El modelo de la prestación de ayuda a África debe ser sustituido por un modelo que faculte a las comunidades para pasar a la acción, demuestre que el éxito es posible y estimule la extensión de las actividades de lucha antirrábica.

Long-term persistence of immunity and B-cell memory following Haemophilus influenzae type B conjugate vaccination in early childhood and response to booster.

BACKGROUND: Protection against Haemophilus influenzae type b (Hib), a rapidly invading encapsulated bacteria, is dependent on maintenance of an adequate level of serum antibody through early childhood. In many countries, Hib vaccine booster doses have been implemented after infant immunization to sustain immunity. We investigated the long-term persistence of antibody and immunological memory in primary-school children following infant (with or without booster) Hib vaccination. METHODS: Anti-polyribosylribitol phosphate (PRP) immunoglobulin G (IgG) concentration and the frequency of circulating Hib-specific memory B cells were measured before a booster of a Hib-serogroup C meningococcal (MenC) conjugate vaccine and again 1 week, 1 month, and 1 year after the booster in 250 healthy children aged 6-12 years in an open-label phase 4 clinical study. RESULTS: Six to 12 years following infant priming with 3 doses of Hib conjugate vaccine, anti-PRP IgG geometric mean concentrations were 3.11 µg/mL and 0.71 µg/mL and proportions with anti-PRP IgG ≥1.0 µg/mL were 79% and 43% in children who had or had not, respectively, received a fourth Hib conjugate vaccine dose (mean age, 3.9 years). Higher baseline and post-Hib-MenC booster responses (anti-PRP IgG and memory B cells) were found in younger children and in those who had received a fourth Hib dose. CONCLUSIONS: Sustained Hib conjugate vaccine-induced immunity in children is dependent on time since infant priming and receipt of a booster. Understanding the relationship between humoral and cellular immunity following immunization with conjugate vaccines may direct vaccine design and boosting strategies to sustain individual and population immunity against encapsulated bacteria in early childhood. Clinical Trials Registration ISRCTN728588998.

Antibody persistence after serogroup C meningococcal conjugate immunization of United Kingdom primary-school children in 1999-2000 and response to a booster: a phase 4 clinical trial.

BACKGROUND: After immunization with serogroup C meningococcal (MenC) conjugate vaccine, antibody responses and vaccine effectiveness are sustained in adolescents, in contrast to rapid waning in young children. We investigated the persistence of serum bactericidal antibody (SBA) titers in children 6 years after immunization with MenC vaccine (primed between 2 months and 6 years of age). The response to a Haemophilus influenzae type b-MenC conjugate (Hib-MenC) booster was also measured. METHODS: A phase 4 clinical trial was conducted among 250 healthy 6-12-year-old children. SBA titers were measured before, 1 month after, and 1 year after Hib-MenC administration. The correlate of protection was an SBA titer of 8. RESULTS: An SBA titer of 8 was observed in 61 (25% [95% confidence interval {CI}, 20%-30%]) of 244 participants (mean age, 9.1 years; mean interval since MenC immunization, 6.75 years). The proportion with an SBA titer of 8 and the SBA geometric mean titer increased with age, from 12% (95% CI, 4%-23%) to 48% (95% CI, 29%-67%) and from 2.90 (95% CI, 2.11-3.99) to 17.20 (95% CI, 6.80-43.5), respectively, from a mean age of 7.0 to 12.1 years. One month after the Hib-MenC booster, all participants had an SBA titer of 8, which was sustained in 99.6% at 1 year. CONCLUSIONS: As a result of waning antibody, the majority of 6-12-year-old children in the United Kingdom have inadequate serological protection against MenC. The persistence of MenC immunity and the response to a Hib-MenC booster is dependent on age at priming. A booster was highly effective in this cohort and could sustain population immunity against MenC disease. Trial registration. Current Controlled Trials ( http://www.controlled-trials.com ) identifier: ISRCTN72858898 .

A serological survey of leptospirosis in cattle of rural communities in the province of KwaZulu-Natal, South Africa.

A serological survey of leptospirosis in cattle originating from rural communities of the province of KwaZulu-Natal (KZN) in South Africa was carried out between March 2001 and December 2003. The survey was designed as a 2-stage survey, using the local diptank as the primary sampling point. In total, 2021 animals from 379 diptanks in 33 magisterial districts were sampled and tested with the microscopic agglutination test (MAT). The apparent prevalence at district level was adjusted for clustering and diagnostic test sensitivity and specificity and displayed in maps. The prevalence of leptospirosis in cattle originating from communal grazing areas of KZN was found to be 19.4% with a 95% confidence interval of 14.8-24.1%. At district level the prevalence of leptospirosis varied from 0 to 63% of cattle. Bovine leptospirosis was found to occur in communal grazing areas throughout the province with the exception of 2 districts. The southeastern regions showed a higher prevalence than other areas of the province; while in some of the northern and western districts a lower prevalence was noted. Several serovars were detected by the MAT and although Leptospira interrogans serovar pomona occurred most frequently, serovars tarrasovi, bratislava, hardjo, canicola and icterohaemorrhagica were also frequently identified. The findings of the survey are discussed.

A serological prevalence survey of Brucella abortus in cattle of rural communities in the province of KwaZulu-natal, South Africa.

A serological survey of Brucella abortus in cattle originating from communal grazing areas of Kwa Zulu Natal was carried out between March 2001 and December 2003. The survey was designed as a 2-stage survey, considering the diptank as the primary sampling unit. In total 46 025 animals from 446 diptanks of 33 magisterial districts were sampled and tested using the Rose Bengal test and Complement Fixation Test. The apparent prevalence at district level was adjusted for clustering, diagnostic test sensitivity and specificity, and mapped using ArcView version 3.3. The prevalence of brucellosis in communal grazing areas of Kwa-Zulu Natal was found to be 1.45 % (0.84-2.21%) and varied from 0 to 15.6 % between magisterial districts. In 19 of the 33 magisterial districts no serological reactors were observed. A large variation in prevalence was found within diptank areas. Brucellosis was found to be most prevalent in the northeastern area of the province. The findings of the survey are discussed.

Potential immediate hypersensitivity reactions following immunization in preschool aged children in Victoria, Australia.

Immediate hypersensitivity reactions (IHR) are rare but potentially serious adverse events following immunization (AEFI). Surveillance of Adverse Events following Vaccination in the Community (SAEFVIC) is an enhanced passive surveillance system that collects, analyses and reports information about AEFI in Victoria, Australia. We describe the incidence, timing and type of potential IHR following vaccination in preschool children reported over an 8-year period. A total of 2110 AEFI were reported in 1620 children, of which 23.5% (496) were classified as potential IHR. Of these, 37.1% (184) were suspected to be IgE-mediated, (including anaphylaxis, angioedema and/or urticaria) and 83.5% (414) occurred within 15 minutes of vaccination. The incidence of potential IHR was 5.4 per 100,000 doses, with that of suspected IgE-mediated IHR being 2.0 per 100,000 doses. The incidence of anaphylaxis was extremely low (0.13 per 100,000 doses) and is consistent with other published studies. Potential IHR following immunization should be reported to appropriate local pharmacovigilance systems and patients reviewed by specialists able to evaluate, investigate and manage future vaccinations.

Vaccine decision-making begins in pregnancy: Correlation between vaccine concerns, intentions and maternal vaccination with subsequent childhood vaccine uptake.

INTRODUCTION: Maternal and childhood vaccine decision-making begins prenatally. Amongst pregnant Australian women we aimed to ascertain vaccine information received, maternal immunisation uptake and attitudes and concerns regarding childhood vaccination. We also aimed to determine any correlation between a) intentions and concerns regarding childhood vaccination, (b) concerns about pregnancy vaccination, (c) socioeconomic status (SES) and (d) uptake of influenza and pertussis vaccines during pregnancy and routine vaccines during childhood. METHODS: Women attending public antenatal clinics were recruited in three Australian states. Surveys were completed on iPads. Follow-up phone surveys were done three to six months post delivery, and infant vaccination status obtained via the Australian Childhood Immunisation Register (ACIR). RESULTS: Between October 2015 and March 2016, 975 (82%) of 1184 mothers consented and 406 (42%) agreed to a follow up survey, post delivery. First-time mothers (445; 49%) had significantly more vaccine concerns in pregnancy and only 73% had made a decision about childhood vaccination compared to 89% of mothers with existing children (p-value<0.001). 66% of mothers reported receiving enough information during pregnancy on childhood vaccination. In the post delivery survey, 46% and 82% of mothers reported receiving pregnancy influenza and pertussis vaccines respectively. The mother's degree of vaccine hesitancy and two attitudinal factors were correlated with vaccine uptake post delivery. There was no association between reported maternal vaccine uptake or SES and childhood vaccine uptake. CONCLUSION: First time mothers are more vaccine hesitant and undecided about childhood vaccination, and only two thirds of all mothers believed they received enough information during pregnancy. New interventions to improve both education and communication on childhood and maternal vaccines, delivered by midwives and obstetricians in the Australian public hospital system, may reduce vaccine hesitancy for all mothers in pregnancy and post delivery, particularly first-time mothers.

A questionnaire survey of perceptions and preventive measures related to animal health amongst cattle owners of rural communities in KwaZulu-Natal, South Africa.

A questionnaire survey of 315 cattle owners from the rural districts of KwaZulu-Natal was carried out. The aim of the survey was to improve our understanding of local farmers' perceptions and practices of animal disease prevention and control and to establish the extent of their relationship with veterinary services. The survey showed that many owners practice preventive measures such as deworming, tick control and vaccination. Traditional medicines were in use by over half the respondents (58.9 %). Diseases are regarded as an important management problem (56.1 %); ticks, worms and diarrhoea dominated the mentioned health problems in cattle. Veterinary services still play an important role and are a frequent source of advice to owners. The findings of the survey and their context are discussed.

Surveillance of adverse events following the introduction of 13-valent pneumococcal conjugate vaccine in infants, and comparison with adverse events following 7-valent pneumococcal conjugate vaccine, in Victoria, Australia.

The 13-valent pneumococcal vaccine (PCV13) replaced the 7-valent vaccine (PCV7) on the Australian National Immunization Program (NIP) in 2011. Post-marketing surveillance of adverse events following immunization (AEFI) is crucial for detecting potential safety signals and maintaining confidence in the NIP. This study describes all AEFI reported to Surveillance of Adverse Events following Vaccination in the Community (SAEFVIC), Melbourne, Australia, following both the primary series of PCV13 (children <7 months) and the catch-up dose (12 months-35 months) in its first year of inclusion on the NIP. AEFI reporting rates per 100,000 doses of vaccine administered were compared for the PCV13 primary series and PCV7 primary series in the previous year. SAEFVIC received 229 reports describing 406 AEFI following PCV13 vaccine in the 12 months post introduction. There was no difference in the total number of AEFI cases reported between the vaccines but 7 AEFI categories were reported at a significantly higher rate following PCV13 compared with PCV7. No difference in reporting rate was observed for serious AEFI (p = 0.25). Post-hoc analysis of a further 12 months of PCV13 data revealed that all 7 AEFI categories that were initially reported at a significantly higher rate following PCV13 compared to PCV7 in the first 12 months post introduction, were no longer significantly increased in the 13-24 month period. The initial high reporting rate for several common AEFI post PCV13 compared to PCV7 may be explained by heightened awareness of the new vaccine. There were no safety signals detected for rare or serious AEFI that would require further investigation at this time.

Specialist outreach clinics in Sheffield: a faster tier of out-patient provision for the patients of fundholding GPs?

BACKGROUND: Little is known about the activity of the many new specialist outreach clinics in fundholding general practices that have emerged since the introduction of fundholding in 1991, though it has been claimed that specialist outreach clinics have shortened waiting times for fundholders' patients. This study describes the activity of specialist outreach clinics in fundholding practices in Sheffield, focusing on comparative waiting times between fundholding and non-fundholding practices. METHODS: A descriptive study was carried out using routine out-patient activity data and a listing of outreach clinics obtained from fundholding practices. RESULTS: Thirty-seven specialist outreach clinics were established in fundholding practices by November 1994; 23 in surgical specialties. In 1994-1995, for gynaecology, orthopaedics and general surgery, the leading outreach specialties, 22.5 per cent of fundholders' first attendances were in outreach clinics. In those three specialties, 87.0 per cent of patients in specialist outreach clinics in fundholding practices vs 67.1 per cent in hospital clinics were routine appointments, and 17.4 per cent vs 9.4 per cent, respectively, were added to an in-patient waiting list. The proportion of first attendees seen in less than three months was 97.0 per cent in specialist outreach clinics in fundholding practices vs 88.1 per cent in hospital clinics; 90.4 per cent for the patients of fundholders who had outreach clinics vs 85.2 per cent for fundholders who did not; 88.1 per cent for all fundholders' patients vs 88.6 per cent for non-fundholders' patients. CONCLUSIONS: The new specialist outreach service in fundholding practices in Sheffield is largely for surgical patients classified as routine patients. Although patients were seen more quickly in specialist outreach clinics, no overall inequality of waiting times between fundholding and non-fundholding practices was shown.

Gastroenteritis associated with oysters.

An outbreak of gastroenteritis occurred in catering students attending three classes at a Yorkshire college in February 1994. The three classes were held on the Monday, Tuesday, and Thursday of the same week and had identical menus. Thirty-seven of the 90 students were affected. A cohort study, with a 94% response rate, showed a highly significant association of illness with the consumption of raw oysters grown in English coastal waters.

The application of evidence-based priority setting in a District Health Authority.

BACKGROUND: Despite the current drive towards evidence-based medicine, it is not clear how commissioners actually use research findings in making decisions on priority setting. This study describes an attempt to directly introduce evidence on the effectiveness of interventions into the annual priority setting process of a District Health Authority (DHA). METHODS: Literature searches were undertaken on proposals for Health Authority funding. The identified literature was then critically appraised, and relevant information was used by members of the Department of Public Health to score the individual bids in terms of health gain. These scores were then fed into the priority setting process. RESULTS: A total of 144 proposals for funding were submitted. For 6.2 per cent of proposals there was strong evidence to support the intervention, for 21.2 per cent there was fair evidence in support, and for 38.1 per cent there was poor evidence. A search was not possible for 16.8 per cent of the proposals. There was a moderate correlation between the strength of evidence for the effectiveness of the proposal and initial scoring of the proposal for health gain (r = 0.41, p < 0.001). At the end of the priority setting process there was no correlation between strength of evidence and priority ranking (r = 0.01, p = 0.97). CONCLUSIONS: It is feasible, but difficult, to use information resources and critical assessment of research evidence as part of the priority setting process of a DHA. The research evidence did appear to influence the initial assessment of proposals. However, the strength of the research evidence was not associated with the priority choices made by the DHA in its purchasing plan.

Group A streptococcal bacteraemia in Yorkshire and the Humber: evidence of another problematic infection among injecting drug users.

It has been estimated that in England and Wales, in 2002, 15% of all invasive group A streptococcal (GAS) cases were amongst injecting drug users (IDUs). This study sought to clarify the extent of this problem in the Yorkshire and Humber region by asking laboratories for further information on reported cases. In our region we found that there was a near doubling of cases, from 64 reports of GAS bacteraemia in the first six months of 2001, to 121 reports in the same period of 2003. We estimated that 34% of all GAS cases, more than twice the previous national estimate, occurred in IDUs and that the proportion of cases occurring in IDUs nearly doubled from 2001 to 2002. Our findings should be viewed within the context of the increasing reports of several other problematic infections in IDUs.

Changing epidemiology of hepatitis A: should we be doing more to vaccinate injecting drug users?

Since 2001 there have been significant outbreaks of hepatitis A virus (HAV) across South Yorkshire, largely in intravenous drug users, and HAV infection has been reported to be an increasing problem in England and Scotland during this time. This paper reports a brief investigation to clarify current HAV epidemiology in England and Wales. The epidemiology of HAV in England, but not yet Wales, has recently changed. Laboratory reports now show that most cases are occurring in young adults, mainly young men, and that the commonest reported risk group is injecting drug users. That cases may now be concentrated in injecting drug users is supported by reports from consultants in communicable disease control (CsCDC). These detail fourteen outbreaks in England in 2002 alone, all involving injecting drug users. Links to prisons and to the homeless, usually those in hostels, were also common. A combined Hepatitis A/B vaccine is readily available and we recommend that this now be used to extend the national immunisation programme against Hepatitis B in injecting drug users to include HAV.

Outbreak of meningococcal disease in Rotherham illustrates the value of coordination, communication, and collaboration in management.

On New Year's Eve 1998, two teenagers from the same school in Rotherham died of serogroup C meningococcal septicaemia. A third linked case occurred three days later. Over eight days starting on New Year's Eve, a further five cases of meningococcal disease arose across Rotherham district, four of whom were severely ill with serogroup C meningococcal septicaemia. Intense media interest, high levels of public concern, and anxieties caused by several 'false alarm' cases added to the challenge faced by a small health district. This article describes the epidemiology of the incident and policy decisions made, but focuses on the operational aspects of outbreak management (coordination, communication, and collaboration), an area often neglected in outbreak reports.