The state of integrated disease surveillance in seven countries: a synthesis report.

OBJECTIVES: Integrated disease surveillance (IDS) offers the potential for better use of surveillance data to guide responses to public health threats. However, the extent of IDS implementation worldwide is unknown. This study sought to understand how IDS is operationalized, identify implementation challenges and barriers, and identify opportunities for development. STUDY DESIGN: Synthesis of qualitative studies undertaken in seven countries. METHODS: Thirty-four focus group discussions and 48 key informant interviews were undertaken in Pakistan, Mozambique, Malawi, Uganda, Sweden, Canada, and England, with data collection led by the respective national public health institutes. Data were thematically analysed using a conceptual framework that covered governance, system and structure, core functions, finance and resourcing requirements. Emerging themes were then synthesised across countries for comparisons. RESULTS: None of the countries studied had fully integrated surveillance systems. Surveillance was often fragmented, and the conceptualization of integration varied. Barriers and facilitators identified included: 1) the need for clarity of purpose to guide integration activities; 2) challenges arising from unclear or shared ownership; 3) incompatibility of existing IT systems and surveillance infrastructure; 4) workforce and skills requirements; 5) legal environment to facilitate data sharing between agencies; and 6) resourcing to drive integration. In countries dependent on external funding, the focus on single diseases limited integration and created parallel systems. CONCLUSIONS: A plurality of surveillance systems exists globally with varying levels of maturity. While development of an international framework and standards are urgently needed to guide integration efforts, these must be tailored to country contexts and guided by their overarching purpose.

Health disparities based on neighbourhood and social conditions: Open Comparisons-an indicator-based comparative study in Sweden.

OBJECTIVE: The overarching goal of the Swedish public health policy is to create the right societal conditions for good and equitable health throughout the population and to reduce avoidable health inequalities within a generation. The objective of this article is to highlight the main findings of the Open Comparisons in Public Health (OCPH) 2019 study. STUDY DESIGN: The OCPH is a longitudinal indicator-based comparative study, encompassing 39 public health indicators with results from Sweden's 21 regions and 290 municipalities. METHODS: Descriptive statistics and 95% confidence intervals were used to compare results between municipalities, regions and time points. Correlation analysis was used to study the strength of the relationship between the results of municipalities and their socio-economic conditions. RESULTS: Across the population, levels of health are good and have, in some areas, improved over recent decades. However, some significant health disparities remain according to neighbourhood, sex, age and educational background. Health disparities related to the level of education are often larger than those between women and men, and there are larger differences within a region than between regions. Health disparities have, in some cases, increased, such as for life expectancy. CONCLUSION: If health equity is to be achieved, leaders at all levels must collaborate and advocate for political action and local efficient public health interventions to eliminate health disparities as a result of neighbourhood and social conditions.

High incidence of Plasmodium vivax malaria in newly arrived Eritrean refugees in Sweden since May 2014.

Since May 2014, an increase in Plasmodium vivax malaria has been observed in Sweden. As of 31 August 2014, 105 malaria cases have been reported in newly arrived Eritrean refugees, 84 of them P. vivax. The patients were mainly young men and reported migration through Ethiopia and/or Sudan. Severe anaemia and long symptom duration reflect inadequate healthcare during migration. Countries currently hosting Eritrean refugees need to consider P. vivax malaria in this group of migrants.

Increased incidence of invasive group A streptococcal infections in Sweden, January 2012-February 2013.

The incidence of invasive group A streptococcal infections in Sweden was 6.1 per 100,000 population in 2012, the highest since the disease became notifiable in 2004. Furthermore, January and February 2013 marked a dramatic increase of cases notified, partly explainable by an increase of emm1/T1 isolates, a type previously shown to cause severe invasive disease more often than other types. Healthcare providers in Sweden and health authorities in neighbouring countries have been informed about this increase.

Severe chickenpox disease and seroprevalence in Sweden - implications for general vaccination.

OBJECTIVES: To describe the current panorama of severe chickenpox disease and seroprevalence in Sweden, as a basis for the approaching decision on universal vaccination. METHODS: Patients discharged with an International Classification of Diseases 10th revision-code for chickenpox (B01-B01.9) in eight pediatric and infectious diseases departments in Stockholm and Gothenburg in 2012-2014 were included in the study and their medical charts were reviewed. Further, residual serum samples collected from 11 laboratories across Sweden were analyzed for varicella zoster IgG-antibodies to investigate age-specific seroprevalence. RESULTS: A total of 218 children and 46 adults were included in this hospital-based study; 87.2% of children and 63.0% of adults had complications. An underlying condition was not associated with an increased risk of complication. Dehydration (31.7%), bacterial skin infections (29.8%) and neurological involvement (20.6%) were the most frequent complications in children. Among adult cases, 63% were born abroad. The seroepidemiological analysis included 957 patient samples. Seroprevalence was 66.7% at 5 years and 91.5% at 12 years. Infants and adolescents/adults were overrepresented among admitted patients compared to seroprevalence data. CONCLUSIONS: Half of all complications in hospitalized chickenpox cases were seen in previously healthy children, which supports universal childhood vaccination. Adult migrants was a risk group for chickenpox hospitalization. Age-specific seroprevalence was similar to neighboring countries.

Micro-simulation of a smallpox outbreak using official register data.

To explore the efficacy of four vaccine-based policy strategies (ring vaccination, targeted vaccination, mass vaccination, and pre-vaccination of healthcare personnel combined with ring vaccination) for controlling smallpox outbreaks in Sweden, disease transmission on a spatially explicit social network was simulated. The mixing network was formed from high-coverage official register data of the entire Swedish population, building on the Swedish Total Population Register, the Swedish Employment Register, and the Geographic Database of Sweden. The largest reduction measured in the number of infections was achieved when combining ring vaccination with a pre-vaccination of healthcare personnel. In terms of per dose effectiveness, ring vaccination was by far the most effective strategy. The results can to some extent be adapted to other diseases and environments, including other countries, and the methods used can be analysed in their own right.

Introduction of human papillomavirus (HPV) vaccination in Sweden.

The Swedish National Board of Health and Welfare (NBH) decided that a vaccine that protects against cervical cancer caused by human papillomavirus (HPV) should be included in the childhood vaccination directive as a nationwide-programme targeting 12-year-old girls from 2010 as a part of the school-health programme. Currently, vaccination of girls 13-18 years of age is covered by the public insurance. In this paper we describe the decision-making process behind the introduction of HPV vaccination in Sweden.

Economic consequences to society of pandemic H1N1 influenza 2009 - preliminary results for Sweden.

Experiments using a microsimulation platform show that vaccination against pandemic H1N1 influenza is highly cost-effective. Swedish society may reduce the costs of pandemic by about SEK 2.5 billion (approximately EUR 250 million) if at least 60 per cent of the population is vaccinated, even if costs related to death cases are excluded. The cost reduction primarily results from reduced absenteeism. These results are preliminary and based on comprehensive assumptions about the infectiousness and morbidity of the pandemic, which are uncertain in the current situation.

Coverage of hepatitis B vaccination in Swedish healthcare workers.

The aim of this study was to assess how well the guidelines on vaccination against hepatitis B had been implemented among healthcare workers (HCWs) at risk for blood exposure. A point-prevalence survey was conducted in six departments of a university hospital in Sweden: the emergency room, intensive care unit, postoperative unit, surgical theatre, department of anaesthesiology and the laboratory for blood chemistry. All HCWs who worked in these departments during the 24h of the survey were asked to complete a questionnaire. In total, 369 questionnaires were analysed. Seventy-nine percent (293/369) of HCWs had received at least one dose of vaccine, but only 40% (147/369) reported that they were fully vaccinated and 21% (76/369) had not been vaccinated at all. The majority of unvaccinated HCWs (72/76, 95%) stated that they would accept vaccination if offered. The main barrier to better compliance with the guidelines is not lack of acceptance among the employees but the failure of the employer to ensure that policies are implemented.

Coagulase-negative staphylococci and sternal infections after cardiac operation.

BACKGROUND: Coagulase negative staphylococci (CoNS) have been recognized as important pathogens in nosocomial infections, especially in connection with implanted foreign materials. In cardiac operation they are among the most common pathogens isolated from infected sternal wounds. The definition of the infection is very important. In this study we focus on deep postoperative chest infections. METHODS: By studying 33 infected patients retrospectively and comparing them to 33 matched uninfected controls, we studied the characteristics and costs of the infections. RESULTS: Typical for these infections is the late and insidious onset, and that the infections initially give only minor symptoms such as pain, redness, and serous secretion. We found the following risk factors for infection: number of preoperative days in a hospital, the total length of the operation, and if the patient had undergone an early reoperation due to causes other than infection. This kind of infection more than doubled the hospital costs for the patients affected. CONCLUSIONS: Coagulase negative staphylococci are the most important pathogens in deep postoperative infections in this material. They cause infections that are difficult to recognize since they give only discrete symptoms and start well after the patients leave the hospital. The risk factors for patients with CoNS infections are mostly associated with a long exposure to the hospital environment. The treatment is often difficult and costly because of multiresistant bacteria and frequent need for repeated surgical revisions.

Biological warfare in a historical perspective.

There are some early examples of biological warfare (BW), but in modern times it was used first for sabotage by Germany during WWI. Development of biological weapons on a military significant scale was initiated in several countries in the period between the world wars. During WWII, several countries had active programs such as the USA, UK, Canada, Germany, Japan and the Soviet Union. It was only Japan that on a fairly large scale used BW. The US program continued until 1969, when President Nixon took a decision to end it in connection with signing the BTWC. The Soviet Union had also continued its program after the war, and this was enhanced after signing the BTWC: in the 1980s the program consisted of around fifty facilities and involved around 60,000 people. The Soviet Union produced and maintained a large stockpile of BW-agents. After the collapse of the Soviet Union, and due to pressure from USA and UK, President Yeltsin issued a decree in 1992 banning continued offensive BW activity. However, there are still concerns of residual activity in Russia. Another program of concern is the Iraqi BW-program. After 10 years of UN inspections that were stopped in 1998, there are still many unanswered questions concerning the BW program. There was also a covert BW-program in South Africa that was terminated around 1993. There have also been a number of allegations of alleged use or possession. In addition, there are indications that 10-12 states are now trying to acquire BW, and this assessment is based on intelligence information, mainly from the USA. For example Iraq, North Korea, Iran, Syria, Sudan and Libya. Another aspect is the strong driving force of technology developments to promote this type of program, opening new risks for future potential military misuse.

Smallpox--eradicated, but a growing terror threat.

Smallpox is a disease that followed humanity for thousands of years up until 30 years ago. It was possible to eradicate, because an effective live vaccine from crossreacting vaccinia could be developed. Twenty years have passed since vaccinations stopped and very few people are protected against the disease today. Variola today has become an object of discussion due to the possibility that it can be used as a bioweapon. Due to the number of complications that can be expected a general vaccination is probably not possible. Research is ongoing to develop new vaccines. Many countries are improving their capabilities to respond to a renewed threat of a smallpox epidemic.

Biological weapons and bioterrorism preparedness: importance of public-health awareness and international cooperation.

Biological weapons and biological terrorism have recently come into focus due to the deliberate release of Bacillus anthracis via mail delivered in the USA. Since the 1930s, biological weapons have been developed in a number of countries. In 1975, the Biological and Toxin Weapons Convention entered into force; this prohibits the use of these weapons and has been signed by a large majority of countries (144). Unfortunately, several countries failed to respect this treaty. The Soviet Union continued and expanded its biological weapons program, and after the Gulf War it was revealed that Iraq also had an extensive biological weapons program. Large-scale deliberate release of, Bacillus anthracis, for example, or an epidemic following a release of smallpox virus, would have a devastating effect. This has motivated the world community to strengthen the Biological and Toxin Weapons Convention with a control mechanism which has, as yet, not been successful. Sweden, like other countries, is enhancing its preparedness with regard to stocks of antibiotics and vaccines, related to these improving the diagnostics these and similar agents, and is setting up an epidemiologic task force that can be used in infectious disease emergencies such as the deliberate release of biological warfare agents. International cooperation in this area has to be enhanced, not least in the European Union.

Intrathecal production of specific IgA antibodies in CNS infections.

Cerebrospinal fluid (CSF) and serum from subjects with herpes simplex encephalitis, herpes zoster, mumps meningitis and neuroborreliosis were analysed for the presence of immunoglobulin A (IgA) and G (IgG) antibodies to the corresponding four antigens. Specific intrathecal IgA antibody synthesis as manifested by an elevated index was a frequent finding. Higher IgA index values than the corresponding IgG was seen in one third of the samples from subjects with herpes simplex encephalitis and herpes zoster. Correlation between specific IgG and IgA index was most pronounced for varicella-zoster virus (r = 0.66, P < 0.001). In subjects with mumps meningitis a strong intrathecal IgA and IgG antibody response to Borrelia burgdorferi was demonstrated. Specific herpes simplex and varicella-zoster virus IgA was not found to contain secretory component, thus contradicting an active secretion into the CNS compartment. In conclusion, our data indicate that specific IgA is intrathecally produced in herpes simplex encephalitis, herpes zoster and mumps meningitis but is a rare finding in neuroborreliosis.

Changes in the appearance and treatment of deep sternal infections.

The Department of Thoracic Surgery at the University Hospital, Linköping, Sweden, has actively followed up infectious complications of cardiac surgery since 1989. The aim of this study was to investigate whether changes occurred during the 1990s in the appearance and the management of deep infections. This was done by studying patients undergoing surgical revision of infected wounds. We studied 42 patients during 1990-94 and 49 during 1997-98 (total number of operations in these periods, 3075 and 1646, respectively). Pre-operative and intra-operative variables were recorded for the two patient populations. The proportion of cardiac surgery procedures followed by a surgical revision for an infection in the sternal wound increased between the two periods (1.4% vs. 3.0%). Variables associated with the surgical procedures preceding the infection remained unchanged. In the later period, treatment was started earlier (64 vs. 24 days), and the length of antibiotic treatment was decreased (115 vs. 72 days). The incidence of osteomyelitis of the sternal bone was lower (61% vs. 27%). It appears that as the proportion of patients undergoing surgical revision increased, management of the infections became more effective, with aggressive surgical and antibiotic treatment policies and shorter treatment periods. This indicates that in order to evaluate the overall impact of measures designed to reduce infections after cardiac surgery, not only the incidence of infection needs to be followed up but other factors also need to be taken into account.

A clone of coagulase-negative staphylococci among patients with post-cardiac surgery infections.

Coagulase-negative staphylococci (CoNS) are important causes of hospital-acquired infections such as infections after cardiac surgery. Efforts to reduce these infections are hampered by the lack of knowledge concerning the epidemiology of CoNS in this setting. Forty strains of CoNS collected during the surgical revision of 27 patients operated on between 1997 and 2000 were analysed. Strains were also collected from the ambient air in the operating suite. Their pulsed-field gel electrophoresis (PFGE) characteristics and antibiotic resistance were analysed. Using PFGE 19 of 40 strains from 15 of 27 patients were shown to belong to one clone, and strains from this clone were also isolated from the ambient air. This clone had caused infections throughout the period. Antibiotic resistance did not correlate with PFGE patterns. Using PFGE one clone could be identified that caused 56% of the CoNS infections during this period. A strain from this clone was also found in the air of the operating suite suggesting the origin of the CoNS causing infections was the hospital environment.

Basic Surveillance Network, a European database for surveillance data on infectious diseases.

The Basic Surveillance Network was started in 2000 and is one of the networks on infectious diseases funded by the European Commission. The network collects and makes readily available basic surveillance data on infectious diseases from all the 'old' (pre-2004) European Union member states. The aim is to provide easy access to descriptive data that already exist in national databases, so that it is possible to monitor and compare incidence trends for infectious diseases in the EU member states. The list of diseases covered by the network has recently been expanded from 10 initial 'pilot' diseases to over 40 diseases listed by the EU to be under surveillance. In the near future, the new member states will be invited to participate in the network. Data are case-based and comprise date of onset of disease, age and sex. Only a very short list of disease specific additional variables, such as country of infection or immunisation status, is collected. Classification of cases ( possible, probable, confirmed) is specified according to EU case definitions. The participants of the network have access to an internal web site were all the data is presented in tables and graphs. An open website is available for the public at https://www.eubsn.org./BSN/.

Bichat clinical guidelines for bioterrorist agents.

The deliberate release of anthrax in the United States shortly after the terrorist attacks of 11 September 2001 brought about a radical change in people's perception of the risk of bioterrorism. These bioterrorist events, unlike others before, had a worldwide impact not only in respect of security and public health but also in other sectors. Governments and international entities with responsibilities related to maintenance of peace, security, safety and health protection reviewed urgently their political, economic, diplomatic, military and legal means to face up to such attacks and embarked upon major efforts to increase their preparedness.

Basic Surveillance Network, a European database for surveillance data on infectious diseases.

The Basic Surveillance Network was started in 2000 and is one of the networks on infectious diseases funded by the European Commission. The network collects and makes readily available basic surveillance data on infectious diseases from all the 'old' (pre-2004) European Union member states. The aim is to provide easy access to descriptive data that already exist in national databases, so that it is possible to monitor and compare incidence trends for infectious diseases in the EU member states. The list of diseases covered by the network has recently been expanded from 10 initial 'pilot' diseases to over 40 diseases listed by the EU to be under surveillance. In the near future, the new member states will be invited to participate in the network. Data are case-based and comprise date of onset of disease, age and sex. Only a very short list of disease specific additional variables, such as country of infection or immunisation status, is collected. Classification of cases (possible, probable, confirmed) is specified according to EU case definitions. The participants of the network have access to an internal web site were all the data is presented in tables and graphs. An open website is available for the public at https://www.eubsn.org./BSN/

Bichat guidelines for the clinical management of glanders and melioidosis and bioterrorism-related glanders and melioidosis.

Glanders and melioidosis are two infectious diseases that are caused by Burkholderia mallei and Burkholderia pseudomallei respectively. Infection may be acquired through direct skin contact with contaminated soil or water. Ingestion of such contaminated water or dust is another way of contamination. Glanders and melioidosis have both been studied for weaponisation in several countries in the past. They produce similar clinical syndromes. The symptoms depend upon the route of infection but one form of the disease may progress to another, or the disease might run a chronic relapsing course. Four clinical forms are generally described: localised infection, pulmonary infection, septicaemia and chronic suppurative infections of the skin. All treatment recommendations should be adapted according to the susceptibility reports from any isolates obtained. Post-exposure prophylaxis with trimethoprim-sulfamethoxazole is recommended in case of a biological attack. There is no vaccine available for humans.