Filovirus outbreak detection and surveillance: lessons from Bundibugyo.

The first outbreak of Ebola hemorrhagic fever (EHF) due to Bundibugyo ebolavirus occurred in Uganda from August to December 2007. During outbreak response and assessment, we identified 131 EHF cases (44 suspect, 31 probable, and 56 confirmed). Consistent with previous large filovirus outbreaks, a long temporal lag (approximately 3 months) occurred between initial EHF cases and the subsequent identification of Ebola virus and outbreak response, which allowed for prolonged person-to-person transmission of the virus. Although effective control measures for filovirus outbreaks, such as patient isolation and contact tracing, are well established, our observations from the Bundibugyo EHF outbreak demonstrate the need for improved filovirus surveillance, reporting, and diagnostics, in endemic locations in Africa.

Evaluation of a standardized morbidity surveillance form for use during disasters caused by natural hazards.

INTRODUCTION: Surveillance for health outcomes is critical for rapid responses and timely prevention of disaster-related illnesses and injuries after a disaster-causing event. The Disaster Surveillance Workgroup (DSWG) of the US Centers for Disease Control and Prevention developed a standardized, single-page, morbidity surveillance form, called the Natural Disaster Morbidity Surveillance Individual Form (Morbidity Surveillance Form), to describe the distribution of injuries and illnesses, detect outbreaks, and guide timely interventions during a disaster. PROBLEM: Traditional data sources can be used during a disaster; however, supplemental active surveillance may be required because traditional systems often are disrupted, and many persons will seek care outside of typical acute care settings. Generally, these alternative settings lack health surveillance and reporting protocols. The need for standardized data collection was demonstrated during Hurricane Katrina, as the multiple surveillance instruments that were developed and deployed led to varied and uncoordinated data collection methods, analyses, and morbidity data reporting. Active, post-event surveillance of affected populations is critical for rapid responses to minimize and prevent morbidity and mortality, allocate resources, and target public health messaging. METHODS: The CDC and the Georgia Department of Public Health (GDPH) conducted a study to evaluate a Morbidity Surveillance Form to determine its ability to capture clinical presentations. The form was completed for each patient evaluated in an emergency department (ED) during triage from 01 August, 2007 through 07 August, 2007. Data from the form were compared with the ED discharge diagnoses from electronic medical records, and kappa statistics were calculated to assess agreement. RESULTS: Nine hundred forty-nine patients were evaluated, 41% were male and 57% were Caucasian. According to the forms, the most common reasons for seeking treatment were acute illness, other (29%); pain (12%); and gastrointestinal illness (8%). The frequency of agreement between discharge diagnoses and the form ranged from 3 to 100%. Kappa values ranged from 0.23-1.0, with nine of the 12 categories having very good or good agreement. CONCLUSION: With modifications to increase sensitivity for capturing certain clinical presentations, the Morbidity Surveillance Form can be a useful tool for capturing data needed to guide public health interventions during a disaster. A validated collection instrument for a post-disaster event facilitates rapid and standardized comparison and aggregation of data across multiple jurisdictions, thus, improving the coordination, timeliness, and accuracy of public health responses. The DSWG revised the Morbidity Surveillance Form based on information from this study.

Episodic illness, chronic disease, and health care use among homeless persons in Metropolitan Atlanta, Georgia, 2007.

BACKGROUND: Homeless persons are at higher risk for morbidity and mortality from both chronic and episodic illness than the general population. Few data are available on the prevalence of these conditions and uptake of vaccination for prevention. METHODS: In March 2007, we administered a cross-sectional survey to a convenience sample of homeless persons in Atlanta. RESULTS: Approximately half (46.2%) of the survey participants reported at least one chronic medical condition. Acute respiratory symptoms within the previous 30 days were reported by up to 57.7% of survey participants. Receipt of influenza vaccination was reported by 31.9% of survey participants, receipt of pneumococcal vaccine by 18.7%. Vaccination rates varied by age and risk group. DISCUSSION: The survey demonstrated high rates of morbidity in this population. Influenza and pneumococcal vaccination rates were suboptimal. Culturally appropriate interventions must be developed to prevent respiratory and other diseases in this important group.

International outbreak of severe botulism with prolonged toxemia caused by commercial carrot juice.

BACKGROUND: On 8 September 2006, 3 Georgia residents presented with symptoms of food-borne botulism, a potentially fatal illness caused by Clostridium botulinum neurotoxins. METHODS: Investigators reviewed medical records and interviewed patients and family members. Foods from patients' homes and samples of the implicated commercial beverage were tested for botulinum toxin and C. botulinum by standard methods. RESULTS: The patients presented with cranial neuropathies and flaccid paralysis; all patients required mechanical ventilation. The 3 Georgia patients had consumed carrot juice from the same bottle before illness onset. An additional case in Florida and 2 in Ontario, Canada, were subsequently identified in patients who had consumed carrot juice. Serum samples obtained from 5 patients tested positive for botulinum toxin type A-in one patient, 12 days after illness onset, and in another patient, 25 days after illness onset. Carrot juice produced by 1 manufacturer, recovered from patients' homes in Georgia, Florida, and Ontario, yielded type A toxin. The juice contained no added sugar, salt, or preservative; inappropriate refrigeration likely resulted in botulinum toxin production. CONCLUSION: This outbreak was caused by commercially produced, internationally distributed carrot juice that was contaminated with botulinum toxin. When toxemia persists, treatment for botulism should be considered even if diagnosed weeks after illness onset. The implicated pasteurized carrot juice had no barriers to growth of C. botulinum other than refrigeration; additional protective measures for carrot juice are needed to prevent future outbreaks. The US Food and Drug Administration has since issued industry guidance to reduce the risk of C. botulinum intoxication from low-acid refrigerated juices.

Establishing a field epidemiology elective for medical students in Kenya: a strategy for increasing public health awareness and workforce capacity.

Medical students have limited exposure to field epidemiology, even though will assume public health roles after graduation. We established a 10-week elective in field epidemiology during medical school. Students attended one-week didactic sessions on epidemiology, and nine weeks in field placement sites. We administered pre- and post-tests to evaluate the training. We enrolled 34 students in 2011 and 2012. In 2011, we enrolled five of 24 applicants from a class of 280 medical students. In 2012, we enrolled 18 of 81 applicants from a class of 360 students; plus 11 who participated in the didactic sessions only. Among the 34 students who completed the didactic sessions, 74% were male, and their median age was 24 years (range: 22-26). The median pre-test score was 64% (range: 47-88%) and the median post-test score was 82% (range: 72-100%). Successful completion of the field projects was 100%. Six (30%) students were not aware of public health as a career option before this elective, 56% rated the field experience as outstanding, and 100% reported it increased their understanding of epidemiology. Implementing an elective in field epidemiology within the medical training is a highly acceptable strategy to increase awareness for public health among medical students.

Catheter-related polymicrobial bloodstream infections among pediatric bone marrow transplant outpatients--Atlanta, Georgia, 2007.

OBJECTIVE: To identify risk factors for polymicrobial bloodstream infections (BSIs) in pediatric bone marrow transplant (BMT) outpatients attending a newly constructed clinic affiliated with a children's hospital. METHODS: All 30 outpatients treated at a new BMT clinic during September 10-21, 2007, were enrolled in a cohort study. The investigation included interviews, medical records review, observations, and bacterial culture and molecular typing of patient and environmental isolates. Data were analyzed using exact conditional logistic regression. RESULTS: Thirteen patients experienced BSIs caused by 16 different, predominantly gram-negative organisms. Presence of a tunneled catheter (odds ratio [OR], 19.9 [95% confidence interval {CI}, 2.4-infinity), catheter access (OR, 13.7 [95% CI, 1.8-infinity]), and flushing of a catheter with predrawn saline (OR, 12.9 [95% CI, 1.0-766.0]) were independently associated with BSI. The odds of experiencing a BSI increased by a factor of 16.8 with each additional injection of predrawn saline (95% CI, 1.8-827.0). Although no environmental source of pathogens was identified, interviews revealed breaches in recommended infection prevention practice and medication handling. Saline flush solutions were predrawn, and multiple doses were obtained from single-dose preservative-free vials to avoid delays in patient care. CONCLUSION: We speculate that infection prevention challenges in the new clinic, combined with successive needle punctures of vials, facilitated extrinsic contamination and transmission of healthcare-associated pathogens. We recommend that preservative-free single-use vials not be punctured more than once. Use of single-use prefilled saline syringes might prevent multiuse of single-use saline vials. Storage of saline outside a medication supply system might be advisable. Before opening new clinic facilities, hospitals should consider conducting a mock patient flow exercise to identify infection control challenges.