Lessons Learned from CDC's Global COVID-19 Early Warning and Response Surveillance System.

Early warning and response surveillance (EWARS) systems were widely used during the early COVID-19 response. Evaluating the effectiveness of EWARS systems is critical to ensuring global health security. We describe the Centers for Disease Control and Prevention (CDC) global COVID-19 EWARS (CDC EWARS) system and the resources CDC used to gather, manage, and analyze publicly available data during the prepandemic period. We evaluated data quality and validity by measuring reporting completeness and compared these with data from Johns Hopkins University, the European Centre for Disease Prevention and Control, and indicator-based data from the World Health Organization. CDC EWARS was integral in guiding CDC's early COVID-19 response but was labor-intensive and became less informative as case-level data decreased and the pandemic evolved. However, CDC EWARS data were similar to those reported by other organizations, confirming the validity of each system and suggesting collaboration could improve EWARS systems during future pandemics.

Using Weibo and WeChat social media channels to assess public awareness and practices related to antimicrobial resistance, China, 2019.

BACKGROUND: Antimicrobial resistance (AMR) is a global healthcare problem, including in China where high rates of resistance to common bacterial infections have been documented. In 2016, the National Health and Family Planning Commission (NHFPC) in China established a comprehensive strategic plan to increase awareness about AMR through education programs. METHODS: We conducted an online survey to assess changes in public knowledge, awareness and practices related to AMR in China since 2016. The survey was administered using China's national and provincial level 12320 Health Hotline Weibo (micro-blog site) and WeChat (text messaging service) social media accounts from April 12, 2019 to May 7, 2019. All persons ≥16 years of age able to read Chinese were eligible to participate. RESULTS: A total of 2773 respondents completed the survey. Of the 2633 respondents indicating recent use of antibiotics, 84% (2223) reported obtaining their course of antibiotics from a hospital or pharmacy, 9% (246) of respondents reported using antibiotics saved from a previous prescription or treatment course, and 42% (1115) of respondents reported that they had stopped taking antibiotics as soon as they started feeling better. Most respondents correctly indicated that antibiotics can effectively treat urinary tract infections (86% [2388]) and skin infections (76% [2119]), but many incorrectly indicated that antibiotics can also treat viral infections such as measles (32% [889]) or a cold or flu (26% [726]). Of all respondents, 95% (2634) had heard of 'antibiotic resistance'. Almost half (47% [1315]) reported using antibiotics within the last 6 months. CONCLUSION: While awareness of AMR was high in this survey of social media users in China, inappropriate antibiotic use remains common, including the believe that antibiotics can effectively treat viral infections. Multiple interventions targeting the correct use of antibiotics and information on the cause AMR are likely needed. The 12320 Health Hotline provides a platform for conducting routine surveys to monitor antibiotic use and knowledge about AMR.

Excess deaths directly and indirectly attributable to COVID-19 using routinely reported mortality data, Bishkek, Kyrgyzstan, 2020: a cross-sectional study.

OBJECTIVES: Studies on excess deaths (ED) show that reported deaths from COVID-19 underestimate death. To understand mortality for improved pandemic preparedness, we estimated ED directly and indirectly attributable to COVID-19 and ED by age groups. DESIGN: Cross-sectional study using routinely reported individual deaths data. SETTINGS: The 21 health facilities in Bishkek that register all city deaths. PARTICIPANTS: Residents of Bishkek who died in the city from 2015 to 2020. OUTCOME MEASURE: We report weekly and cumulative ED by age, sex and causes of death for 2020. EDs are the difference between observed and expected deaths. Expected deaths were calculated using the historical average and the upper bound of the 95% CI from 2015 to 2019. We calculated the percentage of deaths above expected using the upper bound of the 95% CI of expected deaths. COVID-19 deaths were laboratory confirmed (U07.1) or probable (U07.2 or unspecified pneumonia). RESULTS: Of 4660 deaths in 2020, we estimated 840-1042 ED (79-98 ED per 100 000 people). Deaths were 22% greater than expected. EDs were greater for men (28%) than for women (20%). EDs were observed in all age groups, with the highest ED (43%) among people 65-74 years of age. Hospital deaths were 45% higher than expected. During peak mortality (1 July -21 July), weekly ED was 267% above expected, and ED by disease-specific cause of death were above expected: 193% for ischaemic heart diseases, 52% for cerebrovascular diseases and 421% for lower respiratory diseases. COVID-19 was directly attributable to 69% of ED. CONCLUSION: Deaths directly and indirectly associated with the COVID-19 pandemic were markedly higher than reported, especially for older populations, in hospital settings, and during peak weeks of SARS-CoV-2 transmission. These ED estimates can support efforts to prioritise support for persons at greatest risk of dying during surges.

Associations of diabetes, hypertension and obesity with COVID-19 mortality: a systematic review and meta-analysis.

INTRODUCTION: Despite a growing body of scholarly research on the risks of severe COVID-19 associated with diabetes, hypertension and obesity, there is a need for estimating pooled risk estimates with adjustment for confounding effects. We conducted a systematic review and meta-analysis to estimate the pooled adjusted risk ratios of diabetes, hypertension and obesity on COVID-19 mortality. METHODS: We searched 16 literature databases for original studies published between 1 December 2019 and 31 December 2020. We used the adapted Newcastle-Ottawa Scale to assess the risk of bias. Pooled risk ratios were estimated based on the adjusted effect sizes. We applied random-effects meta-analysis to account for the uncertainty in residual heterogeneity. We used contour-funnel plots and Egger's test to assess possible publication bias. RESULTS: We reviewed 34 830 records identified in literature search, of which 145 original studies were included in the meta-analysis. Pooled adjusted risk ratios were 1.43 (95% CI 1.32 to 1.54), 1.19 (95% CI 1.09 to 1.30) and 1.39 (95% CI 1.27 to 1.52) for diabetes, hypertension and obesity (body mass index ≥30 kg/m2) on COVID-19 mortality, respectively. The pooled adjusted risk ratios appeared to be stronger in studies conducted before April 2020, Western Pacific Region, low- and middle-income countries, and countries with low Global Health Security Index scores, when compared with their counterparts. CONCLUSIONS: Diabetes, hypertension and obesity were associated with an increased risk of COVID-19 mortality independent of other known risk factors, particularly in low-resource settings. Addressing these chronic diseases could be important for global pandemic preparedness and mortality prevention. PROSPERO REGISTRATION NUMBER: CRD42021204371.

Diabetes, obesity, hypertension and risk of severe COVID-19: a protocol for systematic review and meta-analysis.

INTRODUCTION: Previous evidence from several countries, including China, Italy, Mexico, UK and the USA, indicates that among patients with confirmed COVID-19 who were hospitalised, diabetes, obesity and hypertension might be important risk factors for severe clinical outcomes. Several preliminary systematic reviews and meta-analyses have been conducted on one or more of these non-communicable diseases, but the findings have not been definitive, and recent evidence has become available from many more populations. Thus, we aim to conduct a systematic review and meta-analysis of observational studies to assess the relationship of diabetes, obesity and hypertension with severe clinical outcomes in patients with COVID-19. METHOD AND ANALYSIS: We will search 16 major databases (MEDLINE, Embase, Global Health, CAB Abstracts, PsycINFO, CINAHL, Academic Research Complete, Africa Wide Information, Scopus, PubMed Central, ProQuest Central, WHO Virtual Health Library, Homeland Security COVID-19 collection, SciFinder, Clinical Trials and Cochrane Library) for articles published between December 2019 and December 2020. We will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2016 guidelines for the design and reporting the results. We will include observational studies that assess the associations of pre-existing diabetes, obesity and hypertension in patients with COVID-19 with risk of severe clinical outcomes such as intensive care unit admission, receiving mechanical ventilation or death. Stata V.16.1 and R-Studio V.1.4.1103 statistical software will be used for statistical analysis. Meta-analysis will be used to estimate the pooled risks and to assess potential heterogeneities in risks. ETHICS AND DISSEMINATION: The study was reviewed for human subjects concerns by the US CDC Center for Global Health and determined to not represent human subjects research because it uses data from published studies. We plan to publish results in a peer-reviewed journal and present at national and international conferences. PROSPERO REGISTRATION NUMBER: CRD42021204371.

The Role of Noncommunicable Diseases in the Pursuit of Global Health Security.

Noncommunicable diseases and their risk factors are important for all aspects of outbreak preparedness and response, affecting a range of factors including host susceptibility, pathogen virulence, and health system capacity. This conceptual analysis has 2 objectives. First, we use the Haddon matrix paradigm to formulate a framework for assessing the relevance of noncommunicable diseases to health security efforts throughout all phases of the disaster life cycle: before, during, and after an event. Second, we build upon this framework to identify 6 technical action areas in global health security programs that are opportune integration points for global health security and noncommunicable disease objectives: surveillance, workforce development, laboratory systems, immunization, risk communication, and sustainable financing. We discuss approaches to integration with the goal of maximizing the reach of global health security where infectious disease threats and chronic disease burdens overlap.

Acute health effects after exposure to chlorine gas released after a train derailment.

In January 2005, a train derailment on the premises of a textile mill in South Carolina released 42 to 60 tons of chlorine gas in the middle of a small town. Medical records and autopsy reports were reviewed to describe the clinical presentation, hospital course, and pathology observed in persons hospitalized or deceased as a result of chlorine gas exposure. Eight persons died before reaching medical care; of the 71 persons hospitalized for acute health effects as a result of chlorine exposure, 1 died in the hospital. The mean age of the hospitalized persons was 40 years (range, 4 months-76 years); 87% were male. The median duration of hospitalization was 4 days (range, 1-29 days). Twenty-five (35%) persons were admitted to the intensive care unit; the median length of stay was 3 days. Many surviving victims developed significant pulmonary signs and severe airway inflammation; 41 (58%) hospitalized persons met PO2/FiO2 criteria for acute respiratory distress syndrome or acute lung injury. During their hospitalization, 40 (57%) developed abnormal x-ray findings, 74% of those within the first day. Hypoxia on room air and PO2/FiO2 ratio predicted severity of outcome as assessed by the duration of hospitalization and the need for intensive care support. This community release of chlorine gas caused widespread exposure and resulted in significant acute health effects and substantial health care requirements. Pulse oximetry and arterial blood gas analysis provided early indications of outcome severity.

Carbon monoxide poisoning in Florida during the 2004 hurricane season.

BACKGROUND: During August-September 2004, four major hurricanes hit Florida, resulting in widespread power outages affecting several million households. Carbon monoxide (CO) poisonings during this period were investigated to identify ways to prevent future poisoning. METHODS: Medical records from ten hospitals (two with hyperbaric oxygen chambers) were reviewed to identify individuals diagnosed with unintentional CO poisoning between August 13 and October 15, 2004. Multiple attempts were made to interview one person from each nonfatal incident. Medical examiner records and reports of investigations conducted by the U.S. Consumer Product Safety Commission of six fatal poisonings from five additional incidents were also reviewed. RESULTS: A total of 167 people treated for nonfatal CO poisoning were identified, representing 51 incidents. A portable, gasoline-powered generator was implicated in nearly all nonfatal incidents and in all fatal poisonings. Generators were most often located outdoors, followed by inside the garage, and inside the home. Telephone interviews with representatives of 35 (69%) incidents revealed that concerns about theft or exhaust most often influenced the choice of location. Twenty-six (74%) households did not own a generator before the hurricanes, and 86% did not have a CO detector at the time of the poisoning. Twenty-one (67%) households reported reading or hearing CO education messages before the incident. CONCLUSIONS: Although exposure to public education messages may have encouraged more appropriate use of generators, a substantial number of people were poisoned even when the devices were operated outdoors. Additional educational efforts and engineering solutions that reduce CO emission from generators should be the focus of public health activities.

An outbreak of hepatitis C virus infections among outpatients at a hematology/oncology clinic.

BACKGROUND: Approximately 2.7 million persons in the United States have chronic hepatitis C virus (HCV) infection. Health care-associated HCV transmission can occur if aseptic technique is not followed. The authors suspected a health care-associated HCV outbreak after the report of 4 HCV infections among patients at the same hematology/oncology clinic. OBJECTIVE: To determine the extent and mechanism of HCV transmission among clinic patients. DESIGN: Epidemiologic analysis through a cohort study. SETTING: Hematology/oncology clinic in eastern Nebraska. PARTICIPANTS: Patients who visited the clinic from March 2000 through December 2001. MEASUREMENTS: HCV infection status, relevant medical history, and clinic-associated exposures. Bivariate analysis and logistic regression were used to identify risk factors for HCV infection. RESULTS: Of 613 clinic patients contacted, 494 (81%) underwent HCV testing. The authors documented infection in 99 patients who lacked previous evidence of HCV infection; all had begun treatment at the clinic before July 2001. Hepatitis C virus genotype 3a was present in all 95 genotyped samples and presumably originated from a patient with chronic hepatitis C who began treatment in March 2000. Infection with HCV was statistically significantly associated with receipt of saline flushes (P < 0.001). Shared saline bags were probably contaminated when syringes used to draw blood from venous catheters were reused to withdraw saline solution. The clinic corrected this procedure in July 2001. LIMITATION: The delay between outbreak and investigation (>1 year) may have contributed to an underestimate of cases. CONCLUSIONS: This large health care-associated HCV outbreak was related to shared saline bags contaminated through syringe reuse. Effective infection-control programs are needed to ensure high standards of care in outpatient care facilities, such as hematology/oncology clinics.

A large nosocomial outbreak of hepatitis C and hepatitis B among patients receiving pain remediation treatments.

BACKGROUND AND OBJECTIVE: In August 2002, the Oklahoma State Department of Health received a report of six patients with unexplained hepatitis C virus (HCV) infection treated in the same pain remediation clinic. We investigated the outbreak's extent and etiology. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective cohort study of clinic patients, including a serologic survey, interviews of infected patients, and reviews of medical records and staff infection control practices. Patients received outpatient pain remediation treatments one afternoon a week in a clinic within a hospital. Cases were defined as HCV or hepatitis B virus (HBV) infections among patients who reported no prior diagnosis or risk factors for disease or reported previous risk factors but had evidence of acute infection. RESULTS: Of 908 patients, 795 (87.6%) were tested, and 71 HCV-infected patients (8.9%) and 31 HBV-infected patients (3.9%) met the case definition. Multiple HCV genotypes were identified. Significantly higher HCV infection rates were found among individuals treated after an HCV-infected patient during the same visit (adjusted odds ratio [AOR], 6.2; 95% confidence interval [CI95], 2.4-15.8); a similar association was observed for HBV (AOR, 2.9; CI95, 1.3-6.5). Review of staff practices revealed the nurse anesthetist had been using the same syringe-needle to sequentially administer sedation medications to every treated patient each clinic day. CONCLUSIONS: Reuse of needles-syringes was the mechanism for patient-to-patient transmission of HCV and HBV in this large nosocomial outbreak. Further education and stricter oversight of infection control practices may prevent future outbreaks.

Evaluation of field training in the epidemic intelligence service: publications and job choices.

BACKGROUND: Since 1951, the Centers for Disease Control and Prevention's Epidemic Intelligence Service (EIS) has provided training in applied epidemiology to physicians, nurses, veterinarians, dentists, and doctoral-level health scientists. About one third of these EIS officers have been trained in the setting of state and local health departments (the field). METHODS: To evaluate two specific outcomes of field EIS training, the authors reviewed the published work and career choices of field EIS officers after completing the program. The EIS classes of 1991-1996 were selected for study. A field officer was defined as an EIS Officer who completed at least the second year of a 2-year EIS assignment in a state or local health department position. RESULTS: During this period, 430 EIS officers completed the program; 117 (27.2%) were field officers. Of these, 84 (71.8%) published one or more scientific paper as first author for a total of 202 first authored manuscripts in over 50 different journals, an average of 1.7 (range, 0-8) per officer. Most (71%) were on infectious disease topics; 16% were on environmental health or injury control topics, and 11% were on chronic diseases. Field officers were more likely than headquarters-based officers to choose positions in state or local health departments for their first job after graduating (32/117 [27.4%] versus 22/313 [7.0%]; relative risk = 3.9, 95% confidence interval = 2.4-6.4). CONCLUSIONS: EIS training in the field has contributed to the scientific literature and to the strengthening of public health infrastructure at the state and local level.

A multistate outbreak of Salmonella enterica serotype typhimurium infection linked to raw milk consumption--Ohio, 2003.

In December 2002, the Ohio Department of Health was notified of two children with Salmonella infection. Both had a history of drinking raw milk from a combination dairy-restaurant-petting zoo (dairy). The dairy was the only establishment in Ohio licensed to sell raw milk and reported 1.35 million visitors annually. We investigated to determine the extent of the outbreak and identify illness risk factors. A case patient was any person with pulsed-field gel electrophoresis-matched Salmonella enterica serotype Typhimurium from 30 November 2002 to 18 February 2003. Sixty-two met the confirmed case definition. Forty dairy case patient patrons were included in a case-control study; 56 controls were their well meal companions. Consumption of raw milk was found to be associated with illness (odds ratio, 45.1; 95% confidence interval, 8.8 to 311.9). The dairy discontinued selling raw milk. Because 27 other states still allow the sale of raw milk, awareness of the hazards of its consumption should be raised and relevant regulations carefully reviewed.

Resident cleanup activities, characteristics of flood-damaged homes and airborne microbial concentrations in New Orleans, Louisiana, October 2005.

BACKGROUND: Flooding in the greater New Orleans (GNO) area after the hurricanes caused extensive mold growth in homes resulting in public health concerns. OBJECTIVES: We conducted an environmental assessment of homes to determine the extent and type of microbial growth. METHODS: We randomly selected 112 homes, stratified by water damage, and then visually assessed mold growth. Air samples from a subset of 20 homes were analyzed for culturable fungi, fungal spores, and markers of mold ((1-->3, 1-->6)-beta-D-glucans) and bacteria (endotoxin). RESULTS: Visible mold growth occurred in 49 (44%) homes; 18 (16%) homes had >50% mold coverage. Flood levels were >6 ft at 20 (19%), 3-6 ft at 20 (19%), and <3 ft at 28 (26%) homes out of 107; no flooding at 39 (36%) homes. The residents spent an average of 18 h (range: 1-84) doing heavy cleaning and of those, 22 (38%) reported using an N-95 or other respirator. Visible mold growth was significantly associated with flood height 3 ft and the predominant fungi indoors were Aspergillus and Penicillium species, which were in higher concentrations in homes with a flood level 3 ft. Geometric mean (GM) levels of endotoxin were as high as 40.2 EU/m(3), while GM glucan levels were as high as 3.5 microg/m(3) even when flooding was 3 ft. CONCLUSIONS: Based on our observations of visible mold, we estimated that elevated mold growth was present in 194,000 (44%) homes in the GNO area and 70,000 (16%) homes had heavy mold growth. Concentrations of endotoxin and glucans exceeded those previously associated with health effects. With such high levels of microbial growth following flooding, potentially harmful inhalation exposures can be present for persons entering or cleaning affected homes. Persons exposed to water-damaged homes should follow the CDC recommendations developed following the 2005 hurricanes for appropriate respiratory precautions.

Knowledge, attitudes, and practices related to mold exposure among residents and remediation workers in posthurricane New Orleans.

To assess knowledge, attitudes, and practices related to mold exposure in postflood New Orleans, the authors surveyed 159 residents and 76 remediation workers, using logistic regression to explore associations. Nearly all answered "yes" to the questionnaire item, "Do you think mold can make people sick?" and most knew respirators were recommended for cleaning mold. Residents (87%) and workers (47%) said they believed that television or radio were the best ways to communicate information about mold. Workers (24%) also suggested employers provided the best means for communication of this information. Few participants reliably used all recommended protective equipment. Residents cited respirator discomfort and unavailability as reasons for noncompliance; workers cited discomfort and inadequate training, with 50% reporting respirator fit testing. Spanish-speaking workers relied on employers for information. Self-employed workers used protective equipment infrequently. The authors recommend that information on postflood mold exposure be disseminated through media and employers, that protective equipment be made readily available for residents, and that workers receive better training and fit testing. In addition, they suggest that targeted approaches may benefit Spanish-speaking workers and the self-employed.

The epidemiology and early clinical features of West Nile virus infection.

We studied early clinical features of the West Nile virus (WNV) infection. Case patients were Ohio residents who reported to the Ohio Department of Health from August 14 to December 31, 2002, with a positive serum or cerebrospinal fluid for anti-WNV IgM. Of 441 WNV cases, medical records of 224 (85.5%) hospitalized patients were available for review. Most frequent symptoms were fever at a temperature of 38.0 degrees C or higher (n = 155; 69.2%), headache (n = 114; 50.9%), and mental status changes (n = 113; 50.4%). At least one neurological symptom, one gastrointestinal symptom, and one respiratory symptom was present in 186 (83.0%), 119 (53.1%), and 46 (20.5%) patients, respectively. Using multivariate logistic regression and controlling for age, we found that the initial diagnosis of encephalitis (P = .001) or reporting abdominal pain (P < .001) was associated with death. Because initial symptoms of WNV infection are not specific, physicians should maintain a high index of suspicion during the epidemic season, particularly in elderly patients with compatible symptoms.

Investigation of healthcare-associated transmission of Mycobacterium tuberculosis among patients with malignancies at three hospitals and at a residential facility.

BACKGROUND: Immunocompromised patients have an increased risk of experiencing progression of latent Mycobacterium tuberculosis infection (LTBI) to active tuberculosis (TB) disease. In January 2002, 2 patients with leukemia (Patients 1 and 2) developed pulmonary TB after recent exposure at 3 hospitals (Hospital A, Hospital B, and Hospital C) and at a residential facility for patients with cancer. Neither was known to have LTBI. Within 1 year, 3 other patients with malignancy and TB disease had been identified at these facilities, prompting an investigation of healthcare facility-associated transmission of M. tuberculosis. METHODS: The authors performed genotypic analysis of the five available M. tuberculosis isolates from patients with malignancies at these facilities, reviewed medical records, interviewed individuals who had identical M. tuberculosis genotypic patterns, and performed tuberculin skin testing (TST) and case finding for possible exposed contacts. RESULTS: Only Patients 1 and 2 had identical genotypic patterns. Neither patient had baseline TST results available. Patient 1 had clinical evidence of infectiousness 3 months before the diagnosis of TB was ascertained. Among employee contacts of Patient 1, TST conversions occurred in 1 of 59 (2%), 2 of 34 (6%), 2 of 32 (6%), and 0 of 8 who were tested at Hospitals A, B, and C and at the residential facility, respectively. Among the others who were exposed to Patient 1, 1 of 31 (3%), 1 of 30 (3%), 0 of 40 (0%), and 12 of 136 (9%) who were tested had positive TSTs at Hospitals A, B, and C and at the residential facility, respectively. CONCLUSIONS: Delayed TB diagnosis in 2 patients with leukemia resulted in the transmission of M. tuberculosis to 19 patients and staff at 3 hospitals and a residential facility. Baseline TB screening and earlier clinical recognition of active disease could reduce healthcare facility-associated transmission of M. tuberculosis among patients with malignancy.