Mainstreaming of Health Equity in Infectious Disease Control Policy During the COVID-19 Pandemic Era.

The Korean government's strategy to combat coronavirus disease 2019 (COVID-19) has focused on non-pharmaceutical interventions, such as social distancing and wearing masks, along with testing, tracing, and treatment; overall, its performance has been relatively good compared to that of many other countries heavily affected by COVID-19. However, little attention has been paid to health equity in measures to control the COVID-19 pandemic. The study aimed to examine the unequal impacts of COVID-19 across socioeconomic groups and to suggest potential solutions to tackle these inequalities. The pathways linking social determinants and health could be entry points to tackle the unequal consequences of this public health emergency. It is crucial for infectious disease policy to consider social determinants of health including poor housing, precarious working conditions, disrupted healthcare services, and suspension of social services. Moreover, the high levels of uncertainty and complexity inherent in this public health emergency, as well as the health and socioeconomic inequalities caused by the pandemic, underscore the need for good governance other than top-down measures by the government. We emphasize that a people-centered perspective is a key approach during the pandemic era. Mutual trust between the state and civil society, strong accountability of the government, and civic participation are essential components of cooperative disaster governance.

A model of HBV infection with intervention strategies: dynamics analysis and numerical simulations.

In this paper, we analyze the effect of environment noise on the transmission dynamics of a stochastic hepatitis B virus (HBV) infection model with intervention strategies. By using the Markov semigroups theory, we define the stochastic basic reproduction number and find it can be used to govern disease extinction or persistence. When it is less than one, under a mild extra condition, the stochastic system has a disease-free equilibrium and the disease is predicted to die out with probability one. When it is greater than one, under mild extra conditions, the model admits a stationary distribution which means the persistence of the disease. Thus, we observe that larger intensity of noise (resulting in a smaller stochastic basic reproduction number) can suppress the emergence of hepatitis B outbreak. Numerical simulations are also carried out to investigate the influence of information intervention strategies that may change individual behavior and protect the susceptible from infection. Our analysis shows that the environmental noise can greatly a ect the long-term behavior of the system, highlighting the importance of the role of intervention strategies in the control of hepatitis B.

Formalization of a Specialty-Specific Military Unique Curriculum: A Joint United States Army and United States Air Force Infectious Disease Fellowship Program.

INTRODUCTION: There are many unique aspects to the practice of military Infectious Diseases (ID). San Antonio Uniformed Services Health Consortium Infectious Disease (ID) Fellowship is a combined Army and Air Force active duty program. Program leadership thought ID military unique curriculum (MUC) was well integrated into the program. We sought to verify this assumption to guide the decision to formalize the ID MUC. This study describes our strategy for the refinement and implementation of ID specific MUC, assesses the fellow and faculty response to these changes, and provides an example for other programs to follow. METHODS: We identified important ID areas through lessons learned from personal military experience, data from the ID Army Knowledge Online e-mail consult service, input from military ID physicians, and the Army and Air Force ID consultants to the Surgeons General. The consultants provided feedback on perceived gaps, appropriateness, and strategy. Due to restrictions in available curricular time, we devised a three-pronged strategy for revision: adapt current curricular practices to include MUC content, develop new learning activities targeted at the key content area, and sustain existing, effective MUC experiences.Learners were assessed by multiple choice question correct answer rate, performance during the simulation exercise, and burn rotation evaluation. Data on correct answer rate were analyzed according to level of training by using Mann-Whitney U test. Program assessment was conducted through anonymous feedback at midyear and end of year program evaluations. RESULTS: Twelve military unique ID content areas were identified. Diseases of pandemic potential and blood borne pathogen management were added after consultant input. Five experiences were adapted to include military content: core and noon conference series, simulation exercises, multiple choice quizzes, and infection control essay questions. A burn intensive care unit (ICU) rotation, Transport Isolation System exercise, and tour of trainee health facilities were the new learning activities introduced. The formal tropical medicine course, infection prevention in the deployed environment course, research opportunities and participation in trainee health outbreak investigations were sustained activities. Ten fellows participated in the military-unique spaced-education multiple-choice question series. Twenty-seven questions were attempted 814 times. 50.37% of questions were answered correctly the first time, increasing to 100% correct by the end of the activity. No difference was seen in the initial correct answer rate between the four senior fellows (median 55% [IQR 49.75, 63.25]) and the six first-year fellows (median 44% [IQR 39.25, 53]) (p = 0.114). Six fellows participated in the simulated deployment scenario. No failure of material synthesis was noted during the simulation exercise and all of the fellows satisfied the stated objectives. One fellow successfully completed the piloted burn ICU rotation. Fellows and faculty reported high satisfaction with the new curriculum. CONCLUSIONS: Military GME programs are required by congress to address the unique aspects of military medicine. Senior fellow knowledge using the spaced interval multiple-choice quizzes did not differ from junior fellow rate, supporting our concern that the ID MUC needed to be enhanced. Enhancement of the MUC experience can be accomplished with minimal increases to curricular and faculty time.

Hospitalist Infectious Disease Service in Academic Medical Centers: A Win-Win for Hospitalists and Fellows.

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Three-level global resource allocation model for hiv control: A hierarchical decision system approach.

Funds from various global organizations, such as, The Global Fund, The World Bank, etc. are not directly distributed to the targeted risk groups. Especially in the so-called third-world-countries, the major part of the fund in HIV prevention programs comes from these global funding organizations. The allocations of these funds usually pass through several levels of decision making bodies that have their own specific parameters to control and specific objectives to achieve. However, these decisions are made mostly in a heuristic manner and this may lead to a non-optimal allocation of the scarce resources. In this paper, a hierarchical mathematical optimization model is proposed to solve such a problem. Combining existing epidemiological models with the kind of interventions being on practice, a 3-level hierarchical decision making model in optimally allocating such resources has been developed and analyzed. When the impact of antiretroviral therapy (ART) is included in the model, it has been shown that the objective function of the lower level decision making structure is a non-convex minimization problem in the allocation variables even if all the production functions for the intervention programs are assumed to be linear.

Optimal time to intervene: The case of measles child immunization.

The recent measles outbreaks in US and Germany emphasize the importance of sustaining and increasing vaccination rates. In Slovakia, despite mandatory vaccination scheme, decrease in the vaccination rates against measles has been observed in recent years. Different kinds of intervention at the state level, like a law making vaccination a requirement for school entry or education and advertising seem to be the only strategies to improve vaccination coverage. This study aims to analyze the economic effectiveness of intervention in Slovakia. Using real options techniques we determine the level of vaccination rate at which it is optimal to perform intervention. We represent immunization rate of newborns as a stochastic process and intervention as a one-period jump of this process. Sensitivity analysis shows the importance of early intervention in the population with high initial average vaccination coverage. Furthermore, our numerical results demonstrate that the less certain we are about the future development of the immunization rate of newborns, the more valuable is the option to intervene.

Monitoring latent tuberculosis infection diagnosis and management in the Netherlands.

Targeted diagnosis and treatment of latent tuberculosis (TB) infection (LTBI) among persons with a high risk of exposure to TB or of developing TB when infected has been performed and monitored routinely in the Netherlands since 1993. We describe trends in target groups, diagnostic methods and treatment regimens, and explore determinants for treatment initiation, treatment completion and adverse events.In total, 37 729 persons were registered with LTBI from 1993 to 2013, of whom 28 931 (77%) started preventive treatment; 82% of those completed preventive treatment and 8% stopped preventive treatment due to adverse events. Two-thirds of the notified cases were detected through contact investigation.Increasing numbers of persons with immunosuppressive disorders, elderly persons and foreign-born persons were notified in recent years, due to policy changes and the introduction of the interferon-γ release assay. Children (96%) and the immunosuppressed (95%) were more likely to start preventive treatment. Children (93%) were also more likely to complete preventive treatment, as were persons treated with rifampicin or rifampicin/isoniazid regimens (91% and 92%, respectively). The latter groups were also 40% less likely to stop preventive treatment due to adverse events.Under these operational conditions, the estimated risk reduction on incident TB in the target population for LTBI management is 40-60%.

[What place and what future for the pathology of infectious and tropical diseases in France?]. / Quelle place et quel avenir pour l'anatomo-cyto-pathologie des maladies infectieuses et tropicales en France?

The management of tissues and cellular samples by the pathologists in the infectious and tropical diseases pathology field in 2014 needs a strong knowledge of both morphological and molecular domains which includes the good control: (i) of the taxonomy of infectious and tropical diseases pathology leading to the pathogens identification and (ii) of the ancillary methods which can be used in fixed samples in order to detect or better identify these pathogens. There is a recent paradox in France concerning the frequency of infectious diseases to be diagnosed in pathology laboratories and the progressive loss of pathologist's expertise in this domain. Different reasons could explain this statement including the omnipresence of the tumour lesions to be managed in a pathology laboratory as well as the recent constraints associated with the different biomarkers that are mandatory to be detected by immunohistochemistry and/or by molecular biology. Even if the microbiologists play a pivotal role for identifying the different pathogens as well as for the assessment of their sensitivity to the anti-microbial drugs, a large number of infectious diseases can be diagnosed only on fixed tissue and/or cells by the pathologists. The purpose of this review is to describe the current and future issues of infectious and tropical diseases diagnoses in pathology laboratories, in particular in France.

Intrinsic noise induces critical behavior in leaky Markovian networks leading to avalanching.

The role intrinsic statistical fluctuations play in creating avalanches--patterns of complex bursting activity with scale-free properties--is examined in leaky Markovian networks. Using this broad class of models, we develop a probabilistic approach that employs a potential energy landscape perspective coupled with a macroscopic description based on statistical thermodynamics. We identify six important thermodynamic quantities essential for characterizing system behavior as a function of network size: the internal potential energy, entropy, free potential energy, internal pressure, pressure, and bulk modulus. In agreement with classical phase transitions, these quantities evolve smoothly as a function of the network size until a critical value is reached. At that value, a discontinuity in pressure is observed that leads to a spike in the bulk modulus demarcating loss of thermodynamic robustness. We attribute this novel result to a reallocation of the ground states (global minima) of the system's stationary potential energy landscape caused by a noise-induced deformation of its topographic surface. Further analysis demonstrates that appreciable levels of intrinsic noise can cause avalanching, a complex mode of operation that dominates system dynamics at near-critical or subcritical network sizes. Illustrative examples are provided using an epidemiological model of bacterial infection, where avalanching has not been characterized before, and a previously studied model of computational neuroscience, where avalanching was erroneously attributed to specific neural architectures. The general methods developed here can be used to study the emergence of avalanching (and other complex phenomena) in many biological, physical and man-made interaction networks.

Harnessing the theoretical foundations of the exponential and beta-Poisson dose-response models to quantify parameter uncertainty using Markov Chain Monte Carlo.

Dose-response models are the essential link between exposure assessment and computed risk values in quantitative microbial risk assessment, yet the uncertainty that is inherent to computed risks because the dose-response model parameters are estimated using limited epidemiological data is rarely quantified. Second-order risk characterization approaches incorporating uncertainty in dose-response model parameters can provide more complete information to decisionmakers by separating variability and uncertainty to quantify the uncertainty in computed risks. Therefore, the objective of this work is to develop procedures to sample from posterior distributions describing uncertainty in the parameters of exponential and beta-Poisson dose-response models using Bayes's theorem and Markov Chain Monte Carlo (in OpenBUGS). The theoretical origins of the beta-Poisson dose-response model are used to identify a decomposed version of the model that enables Bayesian analysis without the need to evaluate Kummer confluent hypergeometric functions. Herein, it is also established that the beta distribution in the beta-Poisson dose-response model cannot address variation among individual pathogens, criteria to validate use of the conventional approximation to the beta-Poisson model are proposed, and simple algorithms to evaluate actual beta-Poisson probabilities of infection are investigated. The developed MCMC procedures are applied to analysis of a case study data set, and it is demonstrated that an important region of the posterior distribution of the beta-Poisson dose-response model parameters is attributable to the absence of low-dose data. This region includes beta-Poisson models for which the conventional approximation is especially invalid and in which many beta distributions have an extreme shape with questionable plausibility.

Use of a United States-based laboratory as a hematopathology reference center for a developing country: logistics and results.

INTRODUCTION: With proper logistical support and sponsorship, a laboratory in an industrialized nation might be able to act as a reference laboratory for clinicians based in a developing country. METHODS: We built on previous experience in the clinical laboratory to see whether a specialized histopathology service (hematopathology) could be provided to a developing country without the expertise or experience to do it in country. RESULTS: Over an 13-year period, 582 cases from 579 individuals were analyzed. Principal pathologic findings included acute leukemia in 84 cases (14%), dyspoiesis in one or more of the hematopoietic lineages in 65 cases (11%, including three cases with high-grade myelodysplasia), 23 cases (4%) with findings suspicious for a chronic myeloproliferative disorder, 35 cases (6%) with findings suspicious for a lymphoproliferative disorder, and infectious organisms (presumably Leishmania in most instances) in 9 (1%) of cases. Specimens from 45 cases (8%) were unsatisfactory owing to extreme hemodilution and/or specimen degeneration. CONCLUSION: With proper support, a medical laboratory in an industrialized nation may serve as a reference facility for a developing nation. The use of existing infrastructure may be remarkably effective to achieve optimal turnaround time. Although the lack of ancillary studies and follow-up biopsies limit the ability to achieve a definitive diagnosis in many cases, this must be viewed in the context of the limited ability to diagnose or manage hematopoietic neoplasia in developing nations.

Exploring short-term responses to changes in the control strategy for Chlamydia trachomatis.

Chlamydia has a significant impact on public health provision in the developed world. Using pair approximation equations we investigate the efficacy of control programmes for chlamydia on short time scales that are relevant to policy makers. We use output from the model to estimate critical measures, namely, prevalence, incidence, and positivity in those screened and their partners. We combine these measures with a costing tool to estimate the economic impact of different public health strategies. Increasing screening coverage significantly increases the annual programme costs whereas an increase in tracing efficiency initially increases annual costs but over time reduces costs below baseline, with tracing accounting for around 10% of intervention costs. We found that partner positivity is insensitive to changes in prevalence due to screening, remaining at around 33%. Whether increases occur in screening or tracing levels, the cost per treated infection increases from the baseline because of reduced prevalence.

Operational scores in the diagnosis of chronic hepatitis. A semi-quantitative assessment.

Starting from the quantification of the specific lesions for chronic hepatitis B and C, our study focused on (i) the correspondence between the necroinflammatory activity and the fibrosis stage ascertained through the Ishak scoring system, (ii) the classification overlaps and differences of Ishak vs. METAVIR score. The study group consisted of 202 cases with chronic hepatitis B and 751 cases with chronic hepatitis C, diagnosed based on liver biopsies. The fragments of hepatic tissue were routinely processed and stained with Hematoxylin-Eosin, trichrome Szekely, Gordon-Sweet silver impregnation, and Periodic Acid-Schiff. A semiquantitative evaluation was performed using the Ishak (for hepatitis B and C) and the METAVIR (for hepatitis C) scoring systems. Our results revealed that the comparison between hepatitis B and C, based on the necroinflammatory activity and fibrosis, is able to offer through the numeric values of the Ishak scoring system accurate proofs, which support the aggressivity of hepatitis C, because it develops fibrosis more quickly, even on the background of mild necroinflammatory activity. Also, our data showed that the necroinflammatory activity and the fibrosis are not processes which progress in a consistent pattern. The application of the METAVIR scoring system for the cases with chronic hepatitis C confirmed that there is not a direct correlation between necroinflammation and fibrosis. The Ishak scoring system provides through the wide range of numeric values attributed for the evaluation of necroinflammatory activity and fibrosis far more precise criteria for the appraisal of the degree of damage to the hepatic parenchyma at the time of the diagnosis. Supplementary, the METAVIR scoring system allows for the hepatitis C an assessment of the entire histologic activity, including the interface hepatitis and the associated lobular necrosis components. The scoring systems have unavoidably strengths and weaknesses, but the choice of a specific one must reflect the consensus between the pathologists and the clinicians, relying on their experience.