Impact of Kenya's Frontline Epidemiology Training Program on Outbreak Detection and Surveillance Reporting: A Geographical Assessment, 2014-2017.

Rapid detection and response to infectious disease outbreaks requires a robust surveillance system with a sufficient number of trained public health workforce personnel. The Frontline Field Epidemiology Training Program (Frontline) is a focused 3-month program targeting local ministries of health to strengthen local disease surveillance and reporting capacities. Limited literature exists on the impact of Frontline graduates on disease surveillance completeness and timeliness reporting. Using routinely collected Ministry of Health data, we mapped the distribution of graduates between 2014 and 2017 across 47 Kenyan counties. Completeness was defined as the proportion of complete reports received from health facilities in a county compared with the total number of health facilities in that county. Timeliness was defined as the proportion of health facilities submitting surveillance reports on time to the county. Using a panel analysis and controlling for county-fixed effects, we evaluated the relationship between the number of Frontline graduates and priority disease reporting of measles. We found that Frontline training was correlated with improved completeness and timeliness of weekly reporting for priority diseases. The number of Frontline graduates increased by 700%, from 57 graduates in 2014 to 456 graduates in 2017. The annual average rates of reporting completeness increased from 0.8% in 2014 to 55.1% in 2017. The annual average timeliness reporting rates increased from 0.1% in 2014 to 40.5% in 2017. These findings demonstrate how global health security implementation progress in workforce development may influence surveillance and disease reporting.

One Field Epidemiologist per 200,000 Population: Lessons Learned from Implementing a Global Public Health Workforce Target.

The World Health Organization monitoring and evaluation framework for the International Health Regulations (IHR, 2005) describes the targets for the Joint External Evaluation (JEE) indicators. For workforce development, the JEE defines the optimal target for attaining and complying with the IHR (2005) as 1 trained field epidemiologist (or equivalent) per 200,000 population. We explain the derivation and use of the current field epidemiology workforce development target and identify the limitations and lessons learned in applying it to various countries' public health systems. This article also proposes a way forward for improvements and implementation of this workforce development target.

Secondary Infections with Ebola Virus in Rural Communities, Liberia and Guinea, 2014-2015.

Persons who died of Ebola virus disease at home in rural communities in Liberia and Guinea resulted in more secondary infections than persons admitted to Ebola treatment units. Intensified monitoring of contacts of persons who died of this disease in the community is an evidence-based approach to reduce virus transmission in rural communities.

Decreased Ebola Transmission after Rapid Response to Outbreaks in Remote Areas, Liberia, 2014.

We measured the reproduction number before and after interventions were implemented to reduce Ebola transmission in 9 outbreaks in Liberia during 2014. We evaluated risk factors for secondary cases and the association between patient admission to an Ebola treatment unit (ETU) and survival. The reproduction number declined 94% from 1.7 (95% CI 1.1-2.6) to 0.1 (95% CI 0.02-0.6) after interventions began. The risk for secondary infections was 90% lower for patients admitted to an ETU (risk ratio 0.1, 95% CI 0.04-0.3) than for those who died in the community. The case-fatality rate was 68% (95% CI 60-74), and ETU admission was associated with a 50% reduction in death (hazard ratio 0.5, 95% CI 0.4-0.8). Isolation and treatment of Ebola patients had the dual benefit of interrupting community transmission and improving survival.

Molecular characterisation and epidemiological investigation of an outbreak of blaOXA-181 carbapenemase-producing isolates of Klebsiella pneumoniae in South Africa.

BACKGROUND: Klebsiella pneumoniae is an opportunistic pathogen often associated with nosocomial infections. A suspected outbreak of K. pneumoniae isolates, exhibiting reduced susceptibility to carbapenem antibiotics, was detected during the month of May 2012 among patients admitted to a haematology unit of a tertiary academic hospital in Cape Town, South Africa (SA). OBJECTIVES: An investigation was done to determine possible epidemiological links between the case patients and to describe the mechanisms of carbapenem resistance of these bacterial isolates. METHODS: Relevant demographic, clinical and laboratory information was extracted from hospital records and an observational review of infection prevention and control practices in the affected unit was performed. Antimicrobial susceptibility testing including phenotypic testing and genotypic detection of the most commonly described carbapenemase genes was done. The phylogenetic relationship of all isolates containing the blaOXA-181 carbapenemase gene was determined by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing. RESULTS: Polymerase chain reaction analysis identified a total of seven blaOXA-181-positive, carbapenem-resistant K. pneumoniae isolates obtained from seven patients, all from a single unit. These isolates were indistinguishable using PFGE analysis and belonged to sequence type ST-14. No other carbapenemase enzymes were detected. CONCLUSION: This is the first documented laboratory-confirmed outbreak of OXA-181-producing K. pneumoniae in SA, and highlights the importance of enforcing strict adherence to infection control procedures and the need for ongoing surveillance of antibiotic-resistant pathogens in local hospitals.

From research to reality: from the National Cooperative Inner-City Asthma Study to the inner-city asthma implementation.

Several themes emerged from the information provided in this supplement. 1. Implementation of the protocol was feasible, although retention of participants was challenging and customization at each site was essential. 2. Master's degree level social workers were well suited to partnering with health care professionals to address the many issues involved in caring for children with asthma and their families. 3. Collaboration between team members and community partners was critical to successful implementation. 4. Sustainability beyond external funding is attainable if local funding is sought and outcome measures that are considered important to the community are measured and reported.

The Inner-City Asthma Intervention: description of a community-based implementation of an evidence-based approach to asthma management.

BACKGROUND: In 2000, the Centers for Disease Control and Prevention funded a 4-year project to implement the Inner-City Asthma Intervention (ICAI)-an asthma treatment and management project based on the protocol developed for the National Cooperative Inner-City Asthma Study (NCICAS) funded by the National Institutes of Health, National Institute of Allergy and Infectious Disease. OBJECTIVE: To describe the ICAI's major components and implementation issues. METHODS: Information contained in this article is based on project activity and management reports, site client tracking and data collection reports, site visit and other program oversight activity, and general subject matter knowledge. The site client tracking data collection process varied among sites during the intervention. Common definitions and processes were developed and implemented as needed. RESULTS: Three of the 24 original sites discontinued participation. The remaining sites enrolled 4,174 children into the intervention. Although the project ended earlier than originally scheduled, 1,035 children completed the entire intervention. Of the 3,139 children who did not complete the entire protocol, 1,355 children and their families completed the core activities or the core activities plus one or more follow-up activities. CONCLUSION: The ICAI project demonstrated that although there were a number of implementation issues to overcome, it is possible to implement effectively a proven National Institutes of Health protocol in the community setting.

Using billing data to describe patterns in asthma-related emergency department visits in children.

OBJECTIVES: To describe the development and evaluation of a pilot emergency department (ED)-based asthma surveillance system for childhood asthma visits based on billing data and to illustrate how the data can be used to document trends and patterns in ED visits for asthma in children. METHODS: During 2001 and 2002, aggregate reports based on ED billing data from 3 hospitals in western Michigan were obtained from a single physician billing company. Data were tabulated and graphed to show trends in the monthly number of ED visits for asthma in children. Comparisons were made by age, gender, and site. We evaluated the system by using established guidelines. RESULTS: The data illustrated strong seasonal trends, as well as marked differences in ED use according to age and gender. The total numbers of asthma ED visits were remarkably similar between the 2 years evaluated; however, the timing and duration of the seasonal peaks differed. Our evaluation of the system found that it met many of the characteristics that define successful surveillance systems, including simplicity, flexibility, acceptability, sensitivity and positive predictive value, timeliness, and stability. However, the surveillance system's representativeness was limited by the inability to calculate valid population-based ED-visit rates. Despite this limitation, the data provided useful information by documenting the burden and demographic profile of children who use the ED for asthma care and in identifying seasonal and time-related trends. CONCLUSIONS: We were able to successfully implement a pilot ED-based surveillance system for childhood asthma visits by using billing data. This system promotes the understanding of the burden of asthma among children visiting the ED. The development of an ED-based surveillance system for childhood asthma visits using billing data is recommended, particularly when there is a desire to understand the characteristics of children with asthma who use the ED and/or a need to understand the impact of local asthma quality-improvement programs.

Improving pediatric asthma care through surveillance: the Illinois Emergency Department Asthma Collaborative.

OBJECTIVES: To better understand and improve the care of asthma patients who require emergency department (ED) care, the Illinois Emergency Department Asthma Collaborative (IEDAC) was created to develop, test, and disseminate an ED-based surveillance system. This report describes the development and testing of the pediatric IEDAC surveillance instruments and demonstrates how these instruments can be used to describe the health status, healthcare delivery, and outcome of children using ED services. METHODS: A convenience sample of 128 children presenting to 5 EDs in Illinois for asthma care was the study base. Data were collected on monthly samples of children aged 2 through 17 years who presented to these EDs from May to November 2003. Three instruments were used to collect data regarding the children's pre-ED, ED, and post-ED experience. RESULTS: At the ED visit, 73.4% of children met national guideline criteria for persistent-level asthma symptoms. Among this group, 53.2% were using inhaled corticosteroid (ICS) medications. At 1 month follow-up, 66.6% of the children met the criteria for persistent-level asthma symptoms, which was statistically unchanged from the ED visit. Among the latter group, 64.2% were using ICS medications, again statistically unchanged compared with the ED visit. At follow-up, 24.5% of children were reported to have returned to an ED or were subsequently hospitalized. The majority of children were noted at follow-up to have limitation of at least some activity. CONCLUSIONS: Children who presented to IEDAC EDs were found to have a high level of asthma burden that continued at follow-up despite treatment. Moreover, a substantial proportion of children had returned to an ED or were subsequently hospitalized. Encouraging trends in medication use were observed, although suboptimal medication use was also observed.

Does a multifaceted environmental intervention alter the impact of asthma on inner-city children?

OBJECTIVE: To evaluate the impact of a multifaceted environmental and educational intervention on the indoor environment and health in 5-12-year-old children with asthma living in urban environments. DESIGN: Changes in indoor allergen levels and asthma severity measurements were compared between children who were randomized to intervention and delayed intervention groups in a 14-month prospective field trial. Intervention group households received dust mite covers, a professional house cleaning, and had roach bait and trays placed in their houses. RESULTS: Of 981 eligible children, 410 (42%) were enrolled; 161 (40%) completed baseline activities and were randomized: 84 to intervention and 77 to delayed intervention groups. At the study's end, dust mite levels were 163% higher than at baseline for the delayed intervention group. Overall asthma severity scores did not change. However, the median functional severity score (FSS) component of the severity score improved more in the intervention group (33% vs. 20%) than in the delayed intervention group. At the study's end, the median FSSs for the intervention group improved 25% compared with the delayed intervention group, (p<0.01). Differences between groups for medication use, emergency department (ED) visits or hospitalization were not significant. CONCLUSIONS: Despite low retention, the intervention resulted in decreased dust mite allergen levels and increased FSSs among the intervention group. The interventions probably contributed to the improvements, especially among the more severely affected children. This study highlights the complexities of designing and assessing the outcomes from a multifaceted asthma intervention.

Asthma and influenza vaccination: findings from the 1999-2001 National Health Interview Surveys.

STUDY OBJECTIVES: People with asthma are at high risk for complications from influenza; therefore, the Centers for Disease Control and Prevention recommends an annual influenza vaccination for people with asthma. Because little is known about such vaccination rates among adults, especially those aged 18 to 49 years and 50 to 64 years, we sought to estimate influenza vaccination rates among US adults. DESIGN: Cross-sectional analyses of the 1999 to 2001 National Health Interview Surveys. SETTING: US population. PARTICIPANTS: Representative samples of US adults aged > or =18 years. MEASUREMENTS AND RESULTS: Asthma status and receipt of influenza vaccination during the past 12 months were self-reported. We found that 35.1% (95% confidence interval [CI], 33.0 to 37.0%), 36.7% (95% CI, 34.7 to 38.6%), and 33.3% (95% CI, 31.6 to 35.0%) of participants with asthma reported having had an influenza vaccination in 1999 (n = 2,620), 2000 (n = 3,007), and 2001 (n = 3,582), respectively. Among participants aged 18 to 49 years, the vaccination rates were 20.9% (SE 1.2%), 22.7% (SE 1.2%), and 21.1% (SE 1.0%), respectively. Among participants aged 50 to 64 years, the vaccination rates were 46.2% (SE 2.6%), 47.8% (SE 2.3%), and 42.3% (SE 2.1%), respectively. Vaccination rates increased strongly with age and with education in each year. Associations with sex or with race or ethnicity were inconsistent during the 3 years. CONCLUSIONS: The suboptimal vaccination rates among people with asthma aged 18 to 64 years suggest the need to increase influenza vaccination rates in this age group.

Retention factors for participants of an inner-city community-based asthma intervention study.

Participant retention is a significant challenge for asthma field trials examining the effectiveness of prevention strategies in inner-city communities. Here, the authors evaluate factors associated with participant retention in an inner-city, pediatric, asthma intervention trial in Atlanta, Georgia, during 1998-2000. Demographic, clinical, residential, personnel, and logistical variables were analyzed by chi-square and Wilcoxon rank sum nonparametric tests to compare children who remained in the asthma study with those who were dropped. Of the 489 participants, 486 (99%) were African-American, 467 (96%) were non-Hispanic, 281 (57%) were male, and 142 (29%) remained in the study. Of the 347 dropouts, 149 (43%) were dropped because of missing study visits. Retention rates were significantly higher (P<.05) for participants enrolled in the second year of the study (2nd yr=43%, 1st yr=19%), for those who lived longer at the same residence (> or = 3 yrs=36%, 2-3 yrs=26%, 1-<2 yr=22%), and for those enrolled during a face-to-face follow-up home visit, rather than at the emergency department (ED) (follow-up=38%, ED=27%). Neither sex nor enrollment season were associated with retention. These findings underscore the importance of performing a comprehensive pilot study and considering a home residency period for participant enrollment eligibility, along with alternative study methods that take into account the challenges of retaining participants.

Key clinical activities for quality asthma care. Recommendations of the National Asthma Education and Prevention Program.

In 1997, the National Asthma Education and Prevention Program (NAEPP), coordinated by the National Heart, Lung, and Blood Institute, published the second Expert Panel Report (EPR-2): Guidelines for the Diagnosis and Management of Asthma (National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the diagnosis and management of asthma. Bethesda MD: US Department of Health and Human Services, National Institutes of Health, 1997; publication no. 97-4051. Available at http://www.nhlbi.nih.gov/guidelines/ asthma/asthgdln.pdf). Subsequently, the NAEPP Expert Panel identified key questions regarding asthma management that were submitted to an evidence practice center of the Agency for Healthcare Research and Quality to conduct a systematic review of the evidence. The resulting evidence report was used by the Expert Panel to update recommendations for clinical practice on selected topics. These recommendations (EPR-Update 2002) were published in 2002. (National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Guidelines for the diagnosis and management of asthma--update on selected topics 2002. J Allergy Clin Immunol 2002;110[November 2002, part 2]. Available at http://www.nhlbi.nih.gov/guidelines/asthma/index.htm). To improve the implementation of these guidelines, a working group of the Professional Education Subcommittee of the NAEPP extracted key clinical activities that should be considered as essential for quality asthma care in accordance with the EPR-2 guidelines and the EPR-Update 2002. The purpose was to develop a report that would help purchasers and planners of health care define the activities that are important to quality asthma care, particularly in reducing symptoms and preventing exacerbations, and subsequently reducing the overall national burden of illness and death from asthma. This report is intended to help employer health benefits managers and other health-care planners make decisions regarding delivery of health care for persons with asthma. Although this report is based on information directed to clinicians; it is not intended to substitute for recommended clinical practices for caring for persons with asthma, nor is it intended to replace the clinical decision-making required to meet individual patient needs. Readers are referred to the EPR-2 for the full asthma guidelines regarding diagnosis and management of asthma or to the abstracted Practical Guide (National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Practical guide for the diagnosis and management of asthma. Bethesda MD: US Department of Health and Human Services, National Institutes of Health, 1997; publication no. 97-4053. Available at http://www.nhlbi.nih.gov/health/prof/lung/asthma/practgde.htm) and to the EPR-Update 2002. The 1997 EPR-2 guidelines and EPR-Update 2002 were derived from a consensus of leading asthma researchers from academic, clinical, federal and voluntary institutions and based on scientific evidence supported by the literature. The 10 key activities highlighted here correspond to the four recommended-as-essential components of asthma management: assessment and monitoring, control of factors contributing to asthma severity, pharmacotherapy and education for a partnership in care. The key clinical activities are not intended for acute or hospital management of patients with asthma but rather for the preventive aspects of managing asthma long term. This report was developed as a collaborative activity between CDC and the NAEPP.