U.S. Preparedness and Response to Increasing Clade I Mpox Cases in the Democratic Republic of the Congo - United States, 2024.

Clade I monkeypox virus (MPXV), which can cause severe illness in more people than clade II MPXVs, is endemic in the Democratic Republic of the Congo (DRC), but the country has experienced an increase in suspected cases during 2023-2024. In light of the 2022 global outbreak of clade II mpox, the increase in suspected clade I cases in DRC raises concerns that the virus could spread to other countries and underscores the importance of coordinated, urgent global action to support DRC's efforts to contain the virus. To date, no cases of clade I mpox have been detected outside of countries in Central Africa where the virus is endemic. CDC and other partners are working to support DRC's response. In addition, CDC is enhancing U.S. preparedness by raising awareness, strengthening surveillance, expanding diagnostic testing capacity for clade I MPXV, ensuring appropriate specimen handling and waste management, emphasizing the importance of appropriate medical treatment, and communicating guidance on the recommended contact tracing, containment, behavior modification, and vaccination strategies.

Early Detection and Surveillance of the SARS-CoV-2 Variant BA.2.86 - Worldwide, July-October 2023.

Early detection of emerging SARS-CoV-2 variants is critical to guiding rapid risk assessments, providing clear and timely communication messages, and coordinating public health action. CDC identifies and monitors novel SARS-CoV-2 variants through diverse surveillance approaches, including genomic, wastewater, traveler-based, and digital public health surveillance (e.g., global data repositories, news, and social media). The SARS-CoV-2 variant BA.2.86 was first sequenced in Israel and reported on August 13, 2023. The first U.S. COVID-19 case caused by this variant was reported on August 17, 2023, after a patient received testing for SARS-CoV-2 at a health care facility on August 3. In the following month, eight additional U.S. states detected BA.2.86 across various surveillance systems, including specimens from health care settings, wastewater surveillance, and traveler-based genomic surveillance. As of October 23, 2023, sequences have been reported from at least 32 countries. Continued variant tracking and further evidence are needed to evaluate the full public health impact of BA.2.86. Timely genomic sequence submissions to global public databases aided early detection of BA.2.86 despite the decline in the number of specimens being sequenced during the past year. This report describes how multicomponent surveillance and genomic sequencing were used in real time to track the emergence and transmission of the BA.2.86 variant. This surveillance approach provides valuable information regarding implementing and sustaining comprehensive surveillance not only for novel SARS-CoV-2 variants but also for future pathogen threats.

COVID-19 Mortality and Progress Toward Vaccinating Older Adults - World Health Organization, Worldwide, 2020-2022.

After the emergence of SARS-CoV-2 in late 2019, transmission expanded globally, and on January 30, 2020, COVID-19 was declared a public health emergency of international concern.* Analysis of the early Wuhan, China outbreak (1), subsequently confirmed by multiple other studies (2,3), found that 80% of deaths occurred among persons aged ≥60 years. In anticipation of the time needed for the global vaccine supply to meet all needs, the World Health Organization (WHO) published the Strategic Advisory Group of Experts on Immunization (SAGE) Values Framework and a roadmap for prioritizing use of COVID-19 vaccines in late 2020 (4,5), followed by a strategy brief to outline urgent actions in October 2021.† WHO described the general principles, objectives, and priorities needed to support country planning of vaccine rollout to minimize severe disease and death. A July 2022 update to the strategy brief§ prioritized vaccination of populations at increased risk, including older adults,¶ with the goal of 100% coverage with a complete COVID-19 vaccination series** for at-risk populations. Using available public data on COVID-19 mortality (reported deaths and model estimates) for 2020 and 2021 and the most recent reported COVID-19 vaccination coverage data from WHO, investigators performed descriptive analyses to examine age-specific mortality and global vaccination rollout among older adults (as defined by each country), stratified by country World Bank income status. Data quality and COVID-19 death reporting frequency varied by data source; however, persons aged ≥60 years accounted for >80% of the overall COVID-19 mortality across all income groups, with upper- and lower-middle-income countries accounting for 80% of the overall estimated excess mortality. Effective COVID-19 vaccines were authorized for use in December 2020, with global supply scaled up sufficiently to meet country needs by late 2021 (6). COVID-19 vaccines are safe and highly effective in reducing severe COVID-19, hospitalizations, and mortality (7,8); nevertheless, country-reported median completed primary series coverage among adults aged ≥60 years only reached 76% by the end of 2022, substantially below the WHO goal, especially in middle- and low-income countries. Increased efforts are needed to increase primary series and booster dose coverage among all older adults as recommended by WHO and national health authorities.

Determining Gaps in Publicly Shared SARS-CoV-2 Genomic Surveillance Data by Analysis of Global Submissions.

Viral genomic surveillance has been a critical source of information during the COVID-19 pandemic, but publicly available data can be sparse, concentrated in wealthy countries, and often made public weeks or months after collection. We used publicly available viral genomic surveillance data submitted to GISAID and GenBank to examine sequencing coverage and lag time to submission during 2020-2021. We compared publicly submitted sequences by country with reported infection rates and population and also examined data based on country-level World Bank income status and World Health Organization region. We found that as global capacity for viral genomic surveillance increased, international disparities in sequencing capacity and timeliness persisted along economic lines. Our analysis suggests that increasing viral genomic surveillance coverage worldwide and decreasing turnaround times could improve timely availability of sequencing data to inform public health action.

Trends in Percentages of the US Population Covered by State-Issued COVID-19 Nonpharmaceutical Interventions, March 1, 2020-August 15, 2021.

Trends in the percentages of the US population covered by state-issued nonpharmaceutical interventions (NPIs), including restaurant and bar restrictions, stay-at-home orders, gathering limits, and mask mandates, were examined by using county-specific data sets on state-issued orders for NPIs from March 1, 2020, to August 15, 2021. Most of the population was covered by multiple NPIs early in the pandemic. Most state-issued orders were lifted or relaxed as COVID-19 cases decreased during summer 2020. Few states reimplemented strict NPIs during later surges in US COVID-19 cases over the winter of 2020-2021. The exceptions were mask mandates, which covered about 80% of the population between August 2020 and February 2021, and the most restrictive gathering limits, which covered a maximum of 66% of the population in early 2020 and 68% of the population in winter 2020-2021. Most NPIs were lifted by the end of the analysis period.

Mitigation Policies and COVID-19-Associated Mortality - 37 European Countries, January 23-June 30, 2020.

As cases and deaths from coronavirus disease 2019 (COVID-19) in Europe rose sharply in late March, most European countries implemented strict mitigation policies, including closure of nonessential businesses and mandatory stay-at-home orders. These policies were largely successful at curbing transmission of SARS-CoV-2, the virus that causes COVID-19 (1), but they came with social and economic costs, including increases in unemployment, interrupted education, social isolation, and related psychosocial outcomes (2,3). A better understanding of when and how these policies were effective is needed. Using data from 37 European countries, the impact of the timing of these mitigation policies on mortality from COVID-19 was evaluated. Linear regression was used to assess the association between policy stringency at an early time point and cumulative mortality per 100,000 persons on June 30. Implementation of policies earlier in the course of the outbreak was associated with lower COVID-19-associated mortality during the subsequent months. An increase by one standard deviation in policy stringency at an early timepoint was associated with 12.5 cumulative fewer deaths per 100,000 on June 30. Countries that implemented stringent policies earlier might have saved several thousand lives relative to those countries that implemented similar policies, but later. Earlier implementation of mitigation policies, even by just a few weeks, might be an important strategy to reduce the number of deaths from COVID-19.

West Nile Virus Lineage 2 in Horses and Other Animals with Neurologic Disease, South Africa, 2008-2015.

During 2008-2015 in South Africa, we conducted West Nile virus surveillance in 1,407 animals with neurologic disease and identified mostly lineage 2 cases in horses (7.4%, 79/1,069), livestock (1.5%, 2/132), and wildlife (0.5%, 1/206); 35% were fatal. Geographic correlation of horse cases with seropositive veterinarians suggests disease in horses can predict risk in humans.

The joint effects of water and sanitation on diarrhoeal disease: a multicountry analysis of the Demographic and Health Surveys.

OBJECTIVES: To assess whether the joint effects of water and sanitation infrastructure, are acting antagonistically (redundant services preventing the same cases of diarrhoeal disease), independently, or synergistically; and to assess how these effects vary by country and over time. METHODS: We used data from 217 Demographic and Health Surveys conducted in 74 countries between 1986 and 2013. We used modified Poisson regression to assess the impact of water and sanitation infrastructure on the prevalence of diarrhoea among children under 5. RESULTS: The impact of water and sanitation varied across surveys, and adjusting for socio-economic status drove these estimates towards the null. Sanitation had a greater effect than water infrastructure when all 217 surveys were pooled; however, the impact of sanitation diminished over time. Based on survey data from the past 10 years, we saw no evidence for benefits in improving drinking water or sanitation alone, but we estimated a 6% reduction of both combined (prevalence ratio = 0.94, 95% confidence limit 0.91-0.98). CONCLUSIONS: Water and sanitation interventions should be combined to maximise the number of cases of diarrhoeal disease prevented in children under 5. Further research should identify the sources of variability seen between countries and across time. These national surveys likely include substantial measurement error in the categorisation of water and sanitation, making it difficult to interpret the roles of other pathways.

Association of the CT values of real-time PCR of viral upper respiratory tract infection with clinical severity, Kenya.

Quantitative real-time polymerase chain reaction (qRT-PCR) assay of the upper respiratory tract is used increasingly to diagnose lower respiratory tract infections. The cycle threshold (CT ) values of qRT-PCR are continuous, semi-quantitative measurements of viral load, although interpretation of diagnostic qRT-PCR results are often categorized as positive, indeterminate, or negative, obscuring potentially useful clinical interpretation of CT values. From 2008 to 2010, naso/oropharyngeal swabs were collected from outpatients with influenza-like illness, inpatients with severe respiratory illness, and asymptomatic controls in rural Kenya. CT values of positive specimens (i.e., CT values < 40.0) were compared by clinical severity category for five viruses using Mann-Whitney U-test and logistic regression. Among children <5 years old we tested with respiratory syncytial virus (RSV), inpatients had lower median CT values (27.2) than controls (35.8, P = 0.008) and outpatients (34.7, P < 0.001). Among children and older patients infected with influenza virus, outpatients had the lowest median CT values (29.8 and 24.1, respectively) compared with controls (P = 0.193 for children, P < 0.001 for older participants) and inpatients (P = 0.009 for children, P < 0.001 for older participants). All differences remained significant in logistic regression when controlling for age, days since onset, and coinfection. CT values were similar for adenovirus, human metapneumovirus, and parainfluenza virus in all severity groups. In conclusion, the CT values from the qRT-PCR of upper respiratory tract specimens were associated with clinical severity for some respiratory viruses.

The population-based burden of influenza-associated hospitalization in rural western Kenya, 2007-2009.

OBJECTIVE: To estimate the burden and age-specific rates of influenza-associated hospitalization in rural western Kenya. METHODS: All 3924 patients with respiratory illness (defined as acute cough, difficulty in breathing or pleuritic chest pain) who were hospitalized between June 2007 and May 2009 in any inpatient health facility in the Kenyan district of Bondo were enrolled. Nasopharyngeal and oropharyngeal swabs were collected and tested for influenza viruses using real-time reverse transcriptase polymerase chain reaction (RT-PCR). In the calculation of annual rates, adjustments were made for enrolled patients who did not have swabs tested for influenza virus. FINDINGS: Of the 2079 patients with tested swabs, infection with influenza virus was confirmed in 204 (10%); 176, 27 and 1 were found to be RT-PCR-positive for influenza A virus only, influenza B virus only, and both influenza A and B viruses, respectively. Among those tested for influenza virus, 6.8% of the children aged < 5 years and 14.0% of the patients aged ≥ 5 years were found positive. The case-fatality rate among admitted patients with PCR-confirmed infection with influenza virus was 2.0%. The annual rate of hospitalization (per 100,000 population) was 699.8 among patients with respiratory illness and 56.2 among patients with influenza (with 143.7, 18.8, 55.2, 65.1 and 57.3 hospitalized patients with influenza virus per 100,000 people aged < 5, 5-19, 20-34, 35-49 and ≥ 50 years, respectively). CONCLUSION: In a rural district of western Kenya, the rate of influenza-associated hospitalization was highest among children aged less than 5 years.

Observations of the global epidemiology of COVID-19 from the prepandemic period using web-based surveillance: a cross-sectional analysis.

Background Scant data are available about global patterns of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread and global epidemiology of early confirmed cases of COVID-19 outside mainland China. We describe the global spread of SARS-CoV-2 and characteristics of COVID-19 cases and clusters before the characterisation of COVID-19 as a pandemic. METHODS: Cases of COVID-19 reported between Dec 31, 2019, and March 10, 2020 (ie, the prepandemic period), were identified daily from official websites, press releases, press conference transcripts, and social media feeds of national ministries of health or other government agencies. Case characteristics, travel history, and exposures to other cases were abstracted. Countries with at least one case were classified as affected. Early cases were defined as those among the first 100 cases reported from each country. Later cases were defined as those after the first 100 cases. We analysed reported travel to affected countries among the first case reported from each country outside mainland China, demographic and exposure characteristics among cases with age or sex information, and cluster frequencies and sizes by transmission settings. FINDINGS: Among the first case reported from each of 99 affected countries outside of mainland China, 75 (76%) had recent travel to affected countries; 60 (61%) had travelled to China, Italy, or Iran. Among 1200 cases with age or sex information, 874 (73%) were early cases. Among 762 early cases with age information, the median age was 51 years (IQR 35-63); 25 (3%) of 762 early cases occurred in children younger than 18 years. Overall, 21 (2%) of 1200 cases were in health-care workers and none were in pregnant women. 101 clusters were identified, of which the most commonly identified transmission setting was households (76 [75%]; mean 2·6 cases per cluster [range 2-7]), followed by non-health-care occupational settings (14 [14%]; mean 4·3 cases per cluster [2-14]), and community gatherings (11 [11%]; mean 14·2 cases per cluster [4-36]). INTERPRETATION: Cases with travel links to China, Italy, or Iran accounted for almost two-thirds of the first reported COVID-19 cases from affected countries. Among cases with age information available, most were among adults aged 18 years and older. Although there were many clusters of household transmission among early cases, clusters in occupational or community settings tended to be larger, supporting a possible role for physical distancing to slow the progression of SARS-CoV-2 spread. FUNDING: None.

Building Laboratory-Based Arbovirus Sentinel Surveillance Capacity During an Ongoing Dengue Outbreak, Burkina Faso, 2017.

In West Africa, identification of nonmalarial acute febrile illness (AFI) etiologic pathogens is challenging, given limited epidemiologic surveillance and laboratory testing, including for AFI caused by arboviruses. Consequently, public health action to prevent, detect, and respond to outbreaks is constrained, as experienced during dengue outbreaks in several African countries. We describe the successful implementation of laboratory-based arbovirus sentinel surveillance during a dengue outbreak in Burkina Faso during fall 2017. We describe implementation, surveillance methods, and associated costs of enhanced surveillance during an outbreak response as an effort to build capacity to better understand the burden of disease caused by arboviruses in Burkina Faso. The system improved on existing routine surveillance through an improved case report form, systematic testing of specimens, and linking patient information with laboratory results through a data management system. Lessons learned will improve arbovirus surveillance in Burkina Faso and will contribute to enhancing global health security in the region. Elements critical to the success of this intervention include responding to a specific and urgent request by the government of Burkina Faso and building on existing systems and infrastructure already supported by CDC's global health security program.

Herd Protection from Drinking Water, Sanitation, and Hygiene Interventions.

Herd immunity arises when a communicable disease is less able to propagate because a substantial portion of the population is immune. Nonimmunizing interventions, such as insecticide-treated bednets and deworming drugs, have shown similar herd-protective effects. Less is known about the herd protection from drinking water, sanitation, and hand hygiene (WASH) interventions. We first constructed a transmission model to illustrate mechanisms through which different WASH interventions may provide herd protection. We then conducted an extensive review of the literature to assess the validity of the model results and identify current gaps in research. The model suggests that herd protection accounts for a substantial portion of the total protection provided by WASH interventions. However, both the literature and the model suggest that sanitation interventions in particular are the most likely to provide herd protection, since they reduce environmental contamination. Many studies fail to account for these indirect effects and thus underestimate the total impact an intervention may have. Although cluster-randomized trials of WASH interventions have reported the total or overall efficacy of WASH interventions, they have not quantified the role of herd protection. Just as it does in immunization policy, understanding the role of herd protection from WASH interventions can help inform coverage targets and strategies that indirectly protect those that are unable to be reached by WASH campaigns. Toward this end, studies are needed to confirm the differential role that herd protection plays across the WASH interventions suggested by our transmission model.

I get height with a little help from my friends: herd protection from sanitation on child growth in rural Ecuador.

BACKGROUND: Infectious disease interventions, such as vaccines and bed nets, have the potential to provide herd protection to non-recipients. Similarly, improved sanitation in one household may provide community-wide benefits if it reduces contamination in the shared environment. Sanitation at the household level is an important predictor of child growth, but less is known about the effect of sanitation coverage in the community. METHODS: From 2008 to 2013, we took repeated anthropometric measurements on 1314 children under 5 years of age in 24 rural Ecuadorian villages. Using mixed effects regression, we estimated the association between sanitation coverage in surrounding households and child growth. RESULTS: Sanitation coverage in the surrounding households was strongly associated with child height, as those with 100% coverage in their surroundings had a 67% lower prevalence of stunting [prevalence ratio (PR) 0.32, 95% CI 0.15-0.69] compared with those with 0% coverage. Children from households with improved sanitation had a lower prevalence of stunting (PR 0.86, 95% CI 0.64-1.15). When analysing height as a continuous outcome, the protective effect of sanitation coverage is manifested primarily among girls during the second year of life, the time at which growth faltering is most likely to occur. CONCLUSIONS: Our study highlights that a household's sanitation practices can provide herd protection to the overall community. Studies which fail to account for the positive externalities that sanitation provides will underestimate the overall protective effect. Future studies could seek to identify a threshold of sanitation coverage, similar to a herd immunity threshold, to provide coverage and compliance targets.

Tracking progress towards global drinking water and sanitation targets: A within and among country analysis.

INTRODUCTION: Global access to safe drinking water and sanitation has improved dramatically during the Millennium Development Goal (MDG) period. However, there is substantial heterogeneity in progress between countries and inequality within countries. METHODS: We assessed countries' temporal patterns in access to drinking water and sanitation using publicly available data. We then classified countries using non-linear modeling techniques as having one of the following trajectories: 100% coverage, linear growth, linear decline, no change, saturation, acceleration, deceleration, negative acceleration, or negative deceleration. We further assessed the degree to which temporal profiles follow a sigmoidal pattern and how these patterns might vary within a given country between rural and urban settings. RESULTS: Among countries with more than 10 data points, between 15% and 38% showed a non-linear trajectory, depending on the indicator. Overall, countries' progress followed a sigmoidal trend, but some countries are making better progress and some worse progress than would be expected. We highlight several countries that are not on track to meet the MDG for water or sanitation, but whose access is accelerating, suggesting better performance during the coming years. Conversely, we also highlight several countries that have made sufficient progress to meet the MDG target, but in which access is decelerating. DISCUSSION: Patterns were heterogeneous and non-linearity was common. Characterization of these heterogeneous patterns will help policy makers allocate resources more effectively. For example, policy makers can identify countries that could make use of additional resources or might be in need of additional institutional capacity development to properly manage resources; this will be essential to meet the forthcoming Sustainable Development Goals.

Shared sanitation and the prevalence of diarrhea in young children: evidence from 51 countries, 2001-2011.

Shared sanitation is defined as unimproved because of concerns that it creates unsanitary conditions; this policy is being reconsidered. We assessed whether sharing a toilet facility was associated with an increased prevalence of diarrhea among children < 5 years of age. We use data from Demographic and Health Surveys conducted in 51 countries. Crude and adjusted prevalence ratios (PRs) for diarrhea, comparing children from households that used a shared facility with children from households that used a non-shared facility, were estimated for each country and pooled across countries. Unadjusted PRs varied across countries, ranging from 2.15 to 0.65. The pooled PR was 1.09; differences in socioeconomic status explained approximately half of this increased prevalence (adjusted PR = 1.05). Shared sanitation appears to be a risk factor for diarrhea although differences in socioeconomic status are important. The heterogeneity across countries, however, suggests that the social and economic context is an important factor.

Estimation of the national disease burden of influenza-associated severe acute respiratory illness in Kenya and Guatemala: a novel methodology.

BACKGROUND: Knowing the national disease burden of severe influenza in low-income countries can inform policy decisions around influenza treatment and prevention. We present a novel methodology using locally generated data for estimating this burden. METHODS AND FINDINGS: This method begins with calculating the hospitalized severe acute respiratory illness (SARI) incidence for children <5 years old and persons ≥5 years old from population-based surveillance in one province. This base rate of SARI is then adjusted for each province based on the prevalence of risk factors and healthcare-seeking behavior. The percentage of SARI with influenza virus detected is determined from provincial-level sentinel surveillance and applied to the adjusted provincial rates of hospitalized SARI. Healthcare-seeking data from healthcare utilization surveys is used to estimate non-hospitalized influenza-associated SARI. Rates of hospitalized and non-hospitalized influenza-associated SARI are applied to census data to calculate the national number of cases. The method was field-tested in Kenya, and validated in Guatemala, using data from August 2009-July 2011. In Kenya (2009 population 38.6 million persons), the annual number of hospitalized influenza-associated SARI cases ranged from 17,129-27,659 for children <5 years old (2.9-4.7 per 1,000 persons) and 6,882-7,836 for persons ≥5 years old (0.21-0.24 per 1,000 persons), depending on year and base rate used. In Guatemala (2011 population 14.7 million persons), the annual number of hospitalized cases of influenza-associated pneumonia ranged from 1,065-2,259 (0.5-1.0 per 1,000 persons) among children <5 years old and 779-2,252 cases (0.1-0.2 per 1,000 persons) for persons ≥5 years old, depending on year and base rate used. In both countries, the number of non-hospitalized influenza-associated cases was several-fold higher than the hospitalized cases. CONCLUSIONS: Influenza virus was associated with a substantial amount of severe disease in Kenya and Guatemala. This method can be performed in most low and lower-middle income countries.