Medication nonadherence and associated factors in patients with tuberculosis in Wau, South Sudan: a cross- sectional study using the world health organization multidimensional adherence model.

BACKGROUND: Tuberculosis medication nonadherence is a multi-dimensional public health problem with serious consequences worldwide. There is little information available for medication nonadherence in South Sudan. This study assessed the proportion, reasons, and associated factors for nonadherence among patients with TB in Wau Municipality, South Sudan. METHODS: A health facility based cross-sectional study was conducted among 234 tuberculosis (TB) patients receiving first line anti-TB regimen in Wau Municipality. Urine isoniazid metabolite testing (IsoScreen®) was used to determine nonadherence (visualized by negative test results) and a questionnaire was used to describe the reasons for nonadherence. Modified poisson regression with robust standard errors was performed since the proportion of nonadherence was < 10%, to identify nonadherence associated factors using the WHO Multidimensional adherence model. RESULTS: Out of 234 participants, 24.8% (95% CI, 19.2 - 30.3) were nonadherent to the TB treatment regimen. At multivariate analysis, nonadherence was significantly associated with: relief of symptoms (APR 1.93, 95% CI 1.12 - 3.34, p = 0.018), alcohol use (APR 2.12, 95% CI 1.33 - 3.96, p = 0.019) and waiting time to receive drugs (APR 1.77, 95% CI 1.11 - 2.83, p = 0.017). CONCLUSION: Tuberculosis medication nonadherence was high, and it's associated with patients' relived of symptoms, alcohol use, and prolonged waiting time at health facility. Hence, addressing these barriers and the use of multifaceted interventions e.g. counseling, health education and improve appointments are crucial to reduce nonadherence among patients with TB in South Sudan.

The geographic distribution, and the biotic and abiotic predictors of select zoonotic pathogen detections in Canadian polar bears.

Increasing Arctic temperatures are facilitating the northward expansion of more southerly hosts, vectors, and pathogens, exposing naïve populations to pathogens not typical at northern latitudes. To understand such rapidly changing host-pathogen dynamics, we need sensitive and robust surveillance tools. Here, we use a novel multiplexed magnetic-capture and droplet digital PCR (ddPCR) tool to assess a sentinel Arctic species, the polar bear (Ursus maritimus; n = 68), for the presence of five zoonotic pathogens (Erysipelothrix rhusiopathiae, Francisella tularensis, Mycobacterium tuberculosis complex, Toxoplasma gondii and Trichinella spp.), and observe associations between pathogen presence and biotic and abiotic predictors. We made two novel detections: the first detection of a Mycobacterium tuberculosis complex member in Arctic wildlife and the first of E. rhusiopathiae in a polar bear. We found a prevalence of 37% for E. rhusiopathiae, 16% for F. tularensis, 29% for Mycobacterium tuberculosis complex, 18% for T. gondii, and 75% for Trichinella spp. We also identify associations with bear age (Trichinella spp.), harvest season (F. tularensis and MTBC), and human settlements (E. rhusiopathiae, F. tularensis, MTBC, and Trichinella spp.). We demonstrate that monitoring a sentinel species, the polar bear, could be a powerful tool in disease surveillance and highlight the need to better characterize pathogen distributions and diversity in the Arctic.

Quality over quantity in active tick surveillance: Sentinel surveillance outperforms risk-based surveillance for tracking tick-borne disease emergence in southern Canada.

Background: Lyme disease (LD) emerged in southern Québec at the start of the century, with many municipalities now endemic. A coordinated active surveillance programme has been in place in the province of Québec since 2014, including a limited number of sentinel field sites resampled each year and a larger set of accessory field sites that change yearly according to the LD surveillance signal. We aimed to evaluate whether a sentinel approach to active surveillance was more representative of LD risk to human populations, compared to risk-based surveillance. Methods: We compared enzootic hazard measures (average nymph densities) from sentinel and accessory sites with LD risk (number of human LD cases) across the study area between 2015 and 2019 using local bivariate Moran's I analysis. Results: Hazard measures from sentinel sites captured spatial risk significantly better than data from accessory sites (χ2=20.473, p<0.001). In addition, sentinel sites successfully tracked the interannual trend in LD case numbers, whereas accessory sites showed no association despite the larger sample size. Conclusion: Where surveillance aims to document changes in tick-borne disease risk over time and space, we suggest that repeated sampling of carefully selected field sites may be most effective, while risk-based surveillance may be more usefully applied to confirm the presence of emerging disease risk in a specific region of interest or to identify suitable sites for long-term monitoring as LD and other tick-borne diseases continue to emerge.

California Serogroup Viruses in a Changing Canadian Arctic: A Review.

The Arctic is warming at four times the global rate, changing the diversity, activity and distribution of vectors and associated pathogens. While the Arctic is not often considered a hotbed of vector-borne diseases, Jamestown Canyon virus (JCV) and Snowshoe Hare virus (SSHV) are mosquito-borne zoonotic viruses of the California serogroup endemic to the Canadian North. The viruses are maintained by transovarial transmission in vectors and circulate among vertebrate hosts, both of which are not well characterized in Arctic regions. While most human infections are subclinical or mild, serious cases occur, and both JCV and SSHV have recently been identified as leading causes of arbovirus-associated neurological diseases in North America. Consequently, both viruses are currently recognised as neglected and emerging viruses of public health concern. This review aims to summarise previous findings in the region regarding the enzootic transmission cycle of both viruses. We identify key gaps and approaches needed to critically evaluate, detect, and model the effects of climate change on these uniquely northern viruses. Based on limited data, we predict that (1) these northern adapted viruses will increase their range northwards, but not lose range at their southern limits, (2) undergo more rapid amplification and amplified transmission in endemic regions for longer vector-biting seasons, (3) take advantage of northward shifts of hosts and vectors, and (4) increase bite rates following an increase in the availability of breeding sites, along with phenological synchrony between the reproduction cycle of theorized reservoirs (such as caribou calving) and mosquito emergence.

A circumpolar parasite: Evidence of a cryptic undescribed species of sucking louse, Linognathus sp., collected from Arctic foxes, Vulpes lagopus, in Nunavut (Canada) and Svalbard (Norway).

The North has experienced unprecedented rates of warming over the past few decades, impacting the survival and development of insects and the pathogens that they carry. Since 2019, Arctic foxes from Canada (Nunavut) have been observed with fur loss inconsistent with natural shedding of fur. Adult lice were collected from Arctic foxes from Nunavut (n = 1) and Svalbard (n = 2; Norway) and were identified as sucking lice (suborder Anoplura). Using conventional PCR targeting the mitochondrial cytochrome c oxidase subunit 1 gene (cox1), lice from Canada and Svalbard were 100% similar (8 pooled samples from Nunavut and 3 pooled samples from Svalbard), indicating that there is potential gene flow between ectoparasites on Scandinavian and North American Arctic fox populations. The cox1 sequences of Arctic fox lice and dog sucking lice (Linognathus setosus) had significant differences (87% identity), suggesting that foxes may harbour a cryptic species that has not previously been recognised. Conventional PCR targeting the gltA gene for Bartonella bacteria amplified DNA from an unknown gammaproteobacteria from two pooled louse samples collected from Svalbard foxes. The amplified sequences were 100% identical to each other but were only 78% like Proteus mirabilis reported in GenBank (CP053614), suggesting that lice on Arctic foxes may carry unique microorganisms that have yet to be described.

Widespread Exposure to Mosquitoborne California Serogroup Viruses in Caribou, Arctic Fox, Red Fox, and Polar Bears, Canada.

Northern Canada is warming at 3 times the global rate. Thus, changing diversity and distribution of vectors and pathogens is an increasing health concern. California serogroup (CSG) viruses are mosquitoborne arboviruses; wildlife reservoirs in northern ecosystems have not been identified. We detected CSG virus antibodies in 63% (95% CI 58%-67%) of caribou (n = 517), 4% (95% CI 2%-7%) of Arctic foxes (n = 297), 12% (95% CI 6%-21%) of red foxes (n = 77), and 28% (95% CI 24%-33%) of polar bears (n = 377). Sex, age, and summer temperatures were positively associated with polar bear exposure; location, year, and ecotype were associated with caribou exposure. Exposure was highest in boreal caribou and increased from baseline in polar bears after warmer summers. CSG virus exposure of wildlife is linked to climate change in northern Canada and sustained surveillance could be used to measure human health risks.

Combining deep sequencing and conventional molecular approaches reveals broad diversity and distribution of fleas and Bartonella in rodents and shrews from Arctic and Subarctic ecosystems.

BACKGROUND: Bartonella are intracellular bacteria that are transmitted via animal scratches, bites and hematophagous arthropods. Rodents and their associated fleas play a key role in the maintenance of Bartonella worldwide, with > 22 species identified in rodent hosts. No studies have addressed the occurrence and diversity of Bartonella species and vectors for small mammals in Arctic and Subarctic ecosystems, which are increasingly impacted by invasive species and climate change. METHODS: In this study, we characterized the diversity of rodent fleas using conventional PCR targeting the mitochondrial cytochrome c oxidase II gene (COII) and Bartonella species in rodents and shrews (n = 505) from northern Canada using conventional PCR targeting the ITS (intergenic transcribed spacer) region and gltA (citrate synthase) gene. Metagenomic sequencing of a portion of the gltA gene was completed on a subset of 42 rodents and four rodent flea pools. RESULTS: Year, total summer precipitation the year prior to sampling, average minimum spring temperature and small mammal species were significant factors in predicting Bartonella positivity. Occurrence based on the ITS region was more than double that of the gltA gene and was 34% (n = 349) in northern red-backed voles, 35% (n = 20) in meadow voles, 37% (n = 68) in deer mice and 31% (n = 59) in shrews. Six species of Bartonella were identified with the ITS region, including B. grahamii, B. elizabethae, B. washoensis, Candidatus B. rudakovii, B. doshiae, B. vinsonii subsp. berkhoffii and subsp. arupensis. In addition, 47% (n = 49/105) of ITS amplicons had < 97% identity to sequences in GenBank, possibly due to a limited reference library or previously unreported species. An additional Bartonella species (B. heixiaziensis) was detected during metagenomic sequencing of the gltA gene in 6/11 rodents that had ITS sequences with < 97% identity in GenBank, highlighting that a limited reference library for the ITS marker likely accounted for low sequence similarity in our specimens. In addition, one flea pool from a northern red-backed vole contained multiple species (B. grahamii and B. heixiaziensis). CONCLUSION: Our study calls attention to the usefulness of a combined approach to determine the occurrence and diversity of Bartonella communities in hosts and vectors.

Sentinel Surveillance Contributes to Tracking Lyme Disease Spatiotemporal Risk Trends in Southern Quebec, Canada.

Lyme disease (LD) is a tick-borne disease which has been emerging in temperate areas in North America, Europe, and Asia. In Quebec, Canada, the number of human LD cases is increasing rapidly and thus surveillance of LD risk is a public health priority. In this study, we aimed to evaluate the ability of active sentinel surveillance to track spatiotemporal trends in LD risk. Using drag flannel data from 2015-2019, we calculated density of nymphal ticks (DON), an index of enzootic hazard, across the study region (southern Quebec). A Poisson regression model was used to explore the association between the enzootic hazard and LD risk (annual number of human cases) at the municipal level. Predictions from models were able to track both spatial and interannual variation in risk. Furthermore, a risk map produced by using model predictions closely matched the official risk map published by provincial public health authorities, which requires the use of complex criteria-based risk assessment. Our study shows that active sentinel surveillance in Quebec provides a sustainable system to follow spatiotemporal trends in LD risk. Such a network can support public health authorities in informing the public about LD risk within their region or municipality and this method could be extended to support Lyme disease risk assessment at the national level in Canada.

Are foxes (Vulpes spp.) good sentinel species for Toxoplasma gondii in northern Canada?

BACKGROUND: In changing northern ecosystems, understanding the mechanisms of transmission of zoonotic pathogens, including the coccidian parasite Toxoplasma gondii, is essential to protect the health of vulnerable animals and humans. As high-level predators and scavengers, foxes represent a potentially sensitive indicator of the circulation of T. gondii in environments where humans co-exist. The objectives of our research were to compare serological and molecular assays to detect T. gondii, generate baseline data on T. gondii antibody and tissue prevalence in foxes in northern Canada, and compare regional seroprevalence in foxes with that in people from recently published surveys across northern Canada. METHODS: Fox carcasses (Vulpes vulpes/Vulpes lagopus, n = 749) were collected by local trappers from the eastern (Labrador and Québec) and western Canadian Arctic (northern Manitoba, Nunavut, and the Northwest Territories) during the winters of 2015-2019. Antibodies in heart fluid were detected using a commercial enzyme-linked immunosorbent assay. Toxoplasma gondii DNA was detected in hearts and brains using a magnetic capture DNA extraction and real-time PCR assay. RESULTS: Antibodies against T. gondii and DNA were detected in 36% and 27% of foxes, respectively. Detection of antibodies was higher in older (64%) compared to younger foxes (22%). More males (36%) than females (31%) were positive for antibodies to T. gondii. Tissue prevalence in foxes from western Nunavik (51%) was higher than in eastern Nunavik (19%). At the Canadian scale, T. gondii exposure was lower in western Inuit regions (13%) compared to eastern Inuit regions (39%), possibly because of regional differences in fox diet and/or environment. Exposure to T. gondii decreased at higher latitude and in foxes having moderate to little fat. Higher mean infection intensity was observed in Arctic foxes compared to red foxes. Fox and human seroprevalence showed similar trends across Inuit regions of Canada, but were less correlated in the eastern sub-Arctic, which may reflect regional differences in human dietary preferences. CONCLUSIONS: Our study sheds new light on the current status of T. gondii in foxes in northern Canada and shows that foxes serve as a good sentinel species for environmental circulation and, in some regions, human exposure to this parasite in the Arctic.

Tularemia above the Treeline: Climate and Rodent Abundance Influences Exposure of a Sentinel Species, the Arctic Fox (Vulpes lagopus), to Francisella tularensis.

Tularemia is a zoonotic disease found throughout most of the northern hemisphere that may experience range expansion with warming temperatures. Rodents and lagomorphs are reservoirs for the disease, and outbreaks of tularemia often follow peaks in their abundance. As small mammals dominate the diet of arctic foxes (Vulpes lagopus), we determined whether they may serve as sentinels by identifying antibodies in live-captured and harvested foxes from northern Canada. Overall seroprevalence was 2% (CI95 1-2%) in 176 foxes harvested in 2018-2019 compared to 17% (CI95 12-22%) of 230 foxes captured live in 2011-2021. Prevalence was at an all-time high in 2018, following a peak in vole abundance in 2017. Antibodies were identified in fox pups born in 2018 and 2019, suggesting that F. tularensis was actively transmitted during the summers. High precipitation during the summer, increased snow cover and colder temperatures in May, and a higher abundance of voles were all associated with increased seroprevalence in live-captured foxes. Thus, exposure to F. tularensis is largely mediated through climate and rodent populations in the Canadian Arctic, and arctic foxes are useful sentinels for F. tularensis in northern ecosystems. Further studies should investigate whether infection impacts arctic fox survival and reproductive success in the circumpolar North.

Long-term increases in pathogen seroprevalence in polar bears (Ursus maritimus) influenced by climate change.

The influence of climate change on wildlife disease dynamics is a burgeoning conservation and human health issue, but few long-term studies empirically link climate to pathogen prevalence. Polar bears (Ursus maritimus) are vulnerable to the negative impacts of sea ice loss as a result of accelerated Arctic warming. While studies have associated changes in polar bear body condition, reproductive output, survival, and abundance to reductions in sea ice, no long-term studies have documented the impact of climate change on pathogen exposure. We examined 425 serum samples from 381 adult polar bears, collected in western Hudson Bay (WH), Canada, for antibodies to selected pathogens across three time periods: 1986-1989 (n = 157), 1995-1998 (n = 159) and 2015-2017 (n = 109). We ran serological assays for antibodies to seven pathogens: Toxoplasma gondii, Neospora caninum, Trichinella spp., Francisella tularensis, Bordetella bronchiseptica, canine morbillivirus (CDV) and canine parvovirus (CPV). Seroprevalence of zoonotic parasites (T. gondii, Trichinella spp.) and bacterial pathogens (F. tularensis, B. bronchiseptica) increased significantly between 1986-1989 and 1995-1998, ranging from +6.2% to +20.8%, with T. gondii continuing to increase into 2015-2017 (+25.8% overall). Seroprevalence of viral pathogens (CDV, CPV) and N. caninum did not change with time. Toxoplasma gondii seroprevalence was higher following wetter summers, while seroprevalences of Trichinella spp. and B. bronchiseptica were positively correlated with hotter summers. Seroprevalence of antibodies to F. tularensis increased following years polar bears spent more days on land, and polar bears previously captured in human settlements were more likely to be seropositive for Trichinella spp. As the Arctic has warmed due to climate change, zoonotic pathogen exposure in WH polar bears has increased, driven by numerous altered ecosystem pathways.

Trichinella nativa and Trichinella T6 in arctic foxes (Vulpes lagopus) from northern Canada.

Parasitic zoonotic nematodes of the genus Trichinella circulate in wildlife and domestic hosts worldwide through the ingestion of infected meat. Due to their role as scavengers and predators in terrestrial and marine arctic ecosystems, Arctic foxes (Vulpes lagopus) are ideal sentinels for the detection of Trichinella spp. In this study, we determined the prevalence, larval intensity, and species of Trichinella from 91 trapped Arctic foxes collected around the northern Canadian communities of Sachs Harbour (Ikaahuk) on Banks Island (n = 23), and Ulukhaktok and Cambridge Bay (Ikaluktutiak) on Victoria Island (n = 68). Using pepsin-HCl digestion, larvae of Trichinella spp. were recovered from the left forelimb muscle (flexor carpi ulnaris) in 19 of the 91 foxes (21% prevalence, 95% CI: 14-30%). For the first time in Arctic foxes in Canada, Trichinella species were identified using multiplex PCR that was followed up with PCR-RFLP to distinguish between T. nativa and T. chanchalensis. All infected foxes harbored T. nativa, and one fox was co-infected with Trichinella T6; the latter is a new host record. Age of the fox was significantly associated with Trichinella spp. infection and the odds of being infected were three times higher in foxes ≥2 years of age (p = 0.026), indicating cumulative exposure with age. While Arctic foxes are seldom harvested for human consumption, they serve as sentinel hosts of Trichinella spp., confirming the presence of the parasite in wildlife in the region.

Hopping species and borders: detection of Bartonella spp. in avian nest fleas and arctic foxes from Nunavut, Canada.

BACKGROUND: In a warmer and more globally connected Arctic, vector-borne pathogens of zoonotic importance may be increasing in prevalence in native wildlife. Recently, Bartonella henselae, the causative agent of cat scratch fever, was detected in blood collected from arctic foxes (Vulpes lagopus) that were captured and released in the large goose colony at Karrak Lake, Nunavut, Canada. This bacterium is generally associated with cats and cat fleas, which are absent from Arctic ecosystems. Arctic foxes in this region feed extensively on migratory geese, their eggs, and their goslings. Thus, we hypothesized that a nest flea, Ceratophyllus vagabundus vagabundus (Boheman, 1865), may serve as a vector for transmission of Bartonella spp. METHODS: We determined the prevalence of Bartonella spp. in (i) nest fleas collected from 5 arctic fox dens and (ii) 37 surrounding goose nests, (iii) fleas collected from 20 geese harvested during arrival at the nesting grounds and (iv) blood clots from 57 adult live-captured arctic foxes. A subsample of fleas were identified morphologically as C. v. vagabundus. Remaining fleas were pooled for each nest, den, or host. DNA was extracted from flea pools and blood clots and analyzed with conventional and real-time polymerase chain reactions targeting the 16S-23S rRNA intergenic transcribed spacer region. RESULTS: Bartonella henselae was identified in 43% of pooled flea samples from nests and 40% of pooled flea samples from fox dens. Bartonella vinsonii berkhoffii was identified in 30% of pooled flea samples collected from 20 geese. Both B. vinsonii berkhoffii (n = 2) and B. rochalimae (n = 1) were identified in the blood of foxes. CONCLUSIONS: We confirm that B. henselae, B. vinsonii berkhoffii and B. rochalimae circulate in the Karrak Lake ecosystem and that nest fleas contain B. vinsonii and B. henselae DNA, suggesting that this flea may serve as a potential vector for transmission among Arctic wildlife.