Emergency response and the need for collective competence in epidemiological teams.

OBJECTIVE: To determine the challenges met by, and needs of, the epidemiology emergency response workforce, with the aim of informing the development of a larger survey, by conducting key informant interviews of public health experts. METHODS: We defined our study population as public health experts with experience of epidemiology deployment. Using purposive sampling techniques, we applied random number sampling to shortlists of potential interviewees provided by key organizations to obtain 10 study participants; we identified three additional interviewees through snowballing. The same interviewer conducted all key informant interviews during May-August 2019. We thematically analysed de-identified transcripts using a qualitative data analysis computer software package. FINDINGS: Despite our interviewees having a wide range of organizational and field experience, common themes emerged. Interviewees reported a lack of clarity in the definition of an emergency response epidemiologist; the need for a broader range of skills; and inadequate leadership and mentoring in the field. Interviewees identified the lack of interpersonal skills (e.g. communication) and a lack of career progression options as limitations to the effectiveness of emergency response. CONCLUSION: The epidemiology emergency response workforce is currently not achieving collective competence. The lack of a clear definition of the role must be addressed, and leadership is required to develop teams in which complementary skills are harmonized and those less experienced can be mentored. Epidemiology bodies must consider individual professional accreditation to ensure that the required skills are being achieved, as well as enabling continual professional development.

Shaping applied epidemiology workforce training to strengthen emergency response: a global survey of applied epidemiologists, 2019-2020.

BACKGROUND: Rapid and effective emergency response to address health security relies on a competent and suitably trained local and international workforce. The COVID-19 pandemic has highlighted that the health security workforce needs to be well equipped to tackle current and future challenges. In this study, we explored whether training in applied epidemiology was meeting the current needs of the applied epidemiology workforce. METHOD: We conducted a cross-sectional online survey that was available in English and French. We used purposive and snowballing sampling techniques to identify potential survey respondents. An online social media advertisement campaign was used to disseminate a REDCap survey link between October 2019 and February 2020 through field epidemiology networks. Survey questions included demographic details of participants, along with their technical background, level of formal education, topics studied during epidemiology training, and years of experience as an epidemiologist. We used Pearson Chi-squared (Chi2) to test the difference between categorical variables, and content analysis to evaluate responses to open-ended questions. RESULTS: In total, 282 people responded to the survey. Participants had a range of formal public health and epidemiology training backgrounds. Respondents applied epidemiology experience spanned almost 30 years, across 64 countries. Overall, 74% (n = 210) were alumni of Field Epidemiology Training Programs (FETP). Basic outbreak and surveillance training was well reported by respondents, however training in specialised techniques related to emergency response, communication, and leadership was less common. FETP graduates reported higher levels of formal training in all survey topics. CONCLUSION: It is critical for the health security workforce to be well-trained and equipped with skills needed to ensure a rapid and effective response to acute public health events. Leadership, communication, interpersonal skills, and specialist training in emergency response are lacking in current training models. Our study has demonstrated that applied epidemiology workforce training must evolve to remain relevant to current and future public health challenges.

Chikungunya virus outbreak in Sint Maarten, 2013-2014.

This report describes the outbreak of chikungunya virus (CHIKV) in Sint Maarten, a constituent country of Kingdom of the Netherlands comprising the southern part of the Caribbean island of Saint Martin, from 22 December 2013 (first reported case) through 5 December 2014. The outbreak was first reported by the French overseas collectivity of Saint-Martin in the northern part of the island-the first site in the Americas to report autochthonous transmission of CHIKV. By 5 December 2014, Sint Maarten had reported a total of 658 cases-an overall attack rate of 1.76%. Actual prevalence may have been higher, as some cases may have been misdiagnosed as dengue. Fever and arthralgia affected 71% and 69% of reported cases respectively. Of the 390 laboratory-confirmed cases, 61% were female and the majority were 20-59 years old (mean: 42; range: 4-92). The spread of CHIKV to Sint Maarten was inevitable given the ease of movement of people, and the vector, island-wide. Continuing their history of collaboration, the French and Dutch parts of the island coordinated efforts for prevention and control of the disease. These included a formal agreement to exchange epidemiological information on a regular basis and provide alerts in a timely manner; collaboration among personnel through joint island-wide planning of mosquito control activities, especially along borders; notification of all island visitors, upon their arrival at airports and seaports, of preventative measures to avoid being bitten by mosquitoes; dissemination of educational materials to the public; and island-wide public awareness campaigns, particularly in densely populated areas, for both residents and visitors. The information provided in this report could help increase understanding of the epidemiological characteristics of CHIKV and guide other countries dealing with vector-borne epidemics.

First reported enterovirus D68 infection in pediatric patients from the Caribbean region: evidence of spread from the U.S. outbreak.

The 2014 enterovirus D68 (EV-D68) outbreak in the United States raised concerns about the introduction of the virus in the Caribbean region. The objective of this study was to provide rapid evidence of the introduction of EV-D68 strains in the Caribbean region during the 2014 outbreak in the United States, using a relatively simple phylogenetic approach. From October 2014 to May 2015, four EV-D68 cases from two countries (Bermuda and Dominica) were detected at the regional referral laboratory at the Caribbean Public Health Agency (Port of Spain, Trinidad and Tobago) based on molecular testing of respiratory specimens. All cases were children presenting to hospitals with moderate respiratory distress. No cases of acute flaccid paralysis were detected. Phylogenetic analysis of the Caribbean strains showed more than 99% similarity with the 2014 U.S.-outbreak strain, providing evidence of the introduction and circulation of the virus in the region.

Regionalization as an approach to regulatory systems strengthening: a case study in CARICOM member states.

Improving basic capacities for regulation of medicines and health technologies through regulatory systems strengthening is particularly challenging in resource-constrained settings. "Regionalization"-an approach in which countries with common histories, cultural values, languages, and economic conditions work together to establish more efficient systems-may be one answer. This report describes the Caribbean Regulatory System (CRS), a regionalization initiative being implemented in the mostly small countries of the Caribbean Community and Common Market (CARICOM). This initiative is an innovative effort to strengthen regulatory systems in the Caribbean, where capacity is limited compared to other subregions of the Americas. The initiative's concept and design includes a number of features and steps intended to enhance sustainability in resource-constrained contexts. The latter include 1) leveraging existing platforms for centralized cooperation, governance, and infrastructure; 2) strengthening regulatory capacities with the largest potential public health impact; 3) incorporating policies that promote reliance on reference authorities; 4) changing the system to encourage industry to market their products in CARICOM (e.g., using a centralized portal of entry to reduce regulatory burdens); and 5) building human resource capacity. If implemented properly, the CRS will be self-sustaining through user fees. The experience and lessons learned thus far in implementing this initiative, described in this report, can serve as a case study for the development of similar regulatory strengthening initiatives in resource-constrained environments.

Contact tracing for influenza A(H1N1)pdm09 virus-infected passenger on international flight.

In April 2009, influenza A(H1N1)pdm09 virus infection was confirmed in a person who had been symptomatic while traveling on a commercial flight from Mexico to the United Kingdom. Retrospective public health investigation and contact tracing led to the identification of 8 additional confirmed cases among passengers and community contacts of passengers.

Disseminating information on acute public health events globally: experiences from the WHO's Disease Outbreak News.

WHO works, on a daily basis, with countries globally to detect, prepare for and respond to acute public health events. A vital component of a health response is the dissemination of accurate, reliable and authoritative information. The Disease Outbreak News (DON) reports are a key mechanism through which WHO communicates on acute public health events to the public. The decision to produce a DON report is taken on a case-by-case basis after evaluating key criteria, and the subsequent process of producing a DON report is highly standardised to ensure the robustness of information. DON reports have been published since 1996, and up to 2022 over 3000 reports have been published. Between 2018 and 2022, the most frequently published DON reports relate to Ebola virus disease, Middle East respiratory syndrome, yellow fever, polio and cholera. The DON web page is highly visited with a readership of over 2.6 million visits per year, on average. The DON report structure has evolved over time, from a single paragraph in 1996 to a detailed report with seven sections currently. WHO regularly reviews the DON report process and structure for improvements. In the last 25 years, DON reports have played a unique role in rapidly disseminating information on acute public health events to health actors and the public globally. They have become a key information source for the global public health response to the benefit of individuals and communities.

Antibiotic use and resistance in emerging economies: a situation analysis for Viet Nam.

BACKGROUND: Antimicrobial resistance is a major contemporary public health threat. Strategies to contain antimicrobial resistance have been comprehensively set forth, however in developing countries where the need for effective antimicrobials is greatest implementation has proved problematic. A better understanding of patterns and determinants of antibiotic use and resistance in emerging economies may permit more appropriately targeted interventions.Viet Nam, with a large population, high burden of infectious disease and relatively unrestricted access to medication, is an excellent case study of the difficulties faced by emerging economies in controlling antimicrobial resistance. METHODS: Our working group conducted a situation analysis of the current patterns and determinants of antibiotic use and resistance in Viet Nam. International publications and local reports published between 1-1-1990 and 31-8-2012 were reviewed. All stakeholders analyzed the findings at a policy workshop and feasible recommendations were suggested to improve antibiotic use in Viet Nam.Here we report the results of our situation analysis focusing on: the healthcare system, drug regulation and supply; antibiotic resistance and infection control; and agricultural antibiotic use. RESULTS: Market reforms have improved healthcare access in Viet Nam and contributed to better health outcomes. However, increased accessibility has been accompanied by injudicious antibiotic use in hospitals and the community, with predictable escalation in bacterial resistance. Prescribing practices are poor and self-medication is common - often being the most affordable way to access healthcare. Many policies exist to regulate antibiotic use but enforcement is insufficient or lacking.Pneumococcal penicillin-resistance rates are the highest in Asia and carbapenem-resistant bacteria (notably NDM-1) have recently emerged. Hospital acquired infections, predominantly with multi-drug resistant Gram-negative organisms, place additional strain on limited resources. Widespread agricultural antibiotic use further propagates antimicrobial resistance. CONCLUSIONS: Future legislation regarding antibiotic access must alter incentives for purchasers and providers and ensure effective enforcement. The Ministry of Health recently initiated a national action plan and approved a multicenter health improvement project to strengthen national capacity for antimicrobial stewardship in Viet Nam. This analysis provided important input to these initiatives. Our methodologies and findings may be of use to others across the world tackling the growing threat of antibiotic resistance.

Epidemiology of dengue reported in the World Health Organization's Western Pacific Region, 2013-2019.

The global burden of dengue, an emerging and re-emerging mosquito-borne disease, increased during the 20-year period ending in 2019, with approximately 70% of cases estimated to have been in Asia. This report describes the epidemiology of dengue in the World Health Organization's Western Pacific Region during 2013-2019 using regional surveillance data reported from indicator-based surveillance systems from countries and areas in the Region, supplemented by publicly available dengue outbreak situation reports. The total reported annual number of dengue cases in the Region increased from 430 023 in 2013 to 1 050 285 in 2019, surpassing 1 million cases for the first time in 2019. The reported case-fatality ratio ranged from 0.19% (724/376 972 in 2014 and 2030/1 050 285 in 2019) to 0.30% (1380/458 843 in 2016). The introduction or reintroduction of serotypes to specific areas caused several outbreaks and rare occurrences of local transmission in places where dengue was not previously reported. This report reinforces the increased importance of dengue surveillance systems in monitoring dengue across the Region.

Estimation of outbreak severity and transmissibility: Influenza A(H1N1)pdm09 in households.

BACKGROUND: When an outbreak of a novel pathogen occurs, some of the most pressing questions from a public-health point of view relate to its transmissibility, and the probabilities of different clinical outcomes following infection, to allow an informed response. Estimates of these quantities are often based on household data due to the high potential for transmission in this setting, but typically a rich spectrum of individual-level outcomes (from uninfected to serious illness) are simplified to binary data (infected or not). We address the added benefit from retaining the heterogeneous outcome information in the case of the 2009-10 influenza pandemic, which posed particular problems for estimation of key epidemiological characteristics due to its relatively mild nature and hence low case ascertainment rates. METHODS: We use mathematical models of within-household transmission and case ascertainment, together with Bayesian statistics to estimate transmission probabilities stratified by household size, the variability of infectiousness of cases, and a set of probabilities describing case ascertainment. This novel approach was applied to data we collected from the early "containment phase" stage of the epidemic in Birmingham, England. We also conducted a comprehensive review of studies of household transmission of influenza A(H1N1)pdm09. RESULTS: We find large variability in the published estimates of within-household transmissibility of influenza A(H1N1)pdm09 in both model-based studies and those reporting secondary attack rates, finding that these estimates are very sensitive to how an infected case is defined. In particular, we find that reliance on laboratory confirmation alone underestimates the true number of cases, while utilising the heterogeneous range of outcomes (based on case definitions) for household infections allows a far more comprehensive pattern of transmission to be elucidated. CONCLUSIONS: Differences in household sizes and how cases are defined could account for an appreciable proportion of the reported variability of within-household transmissibility of influenza A(H1N1)pdm09. Retaining and statistically analysing the full spectrum of individual-level outcomes (based on case definitions) rather than taking a potentially arbitrary threshold for infection, provides much-needed additional information. In a future pandemic, our approach could be used as a real-time analysis tool to infer the true number of cases, within-household transmission rates and levels of case ascertainment.

Multiple outbreaks of Salmonella braenderup associated with consumption of iceberg lettuce.

The aim of this study was to describe the findings from an outbreak investigation following several apparently unrelated community outbreaks of gastroenteritis. Epidemiological, environmental, laboratory and traceback investigations were used to identify the source of the outbreak. We enrolled 23 (of 29) laboratory confirmed cases and 24 neighbourhood case-nominated controls in a case-control study which revealed that illness was associated with consumption of iceberg lettuce (matched odds ratio 8.0 (95% CI 1.1-355) contaminated with Salmonella braenderup. Several eating establishments were affected and the lettuce was traced back to a single producer in Spain. This is the first UK report implicating S. braenderup in an outbreak due to lettuce. The results highlight the need to increase attention to the various stages in the farm-to-fork process to reduce produce-associated outbreaks related to the global food trade.

Tool for tracking all-cause mortality and estimating excess mortality to support the COVID-19 pandemic response.

Problem: Quantifying mortality from coronavirus disease (COVID-19) is difficult, especially in countries with limited resources. Comparing mortality data between countries is also challenging, owing to differences in methods for reporting mortality. Context: Tracking all-cause mortality (ACM) and comparing it with expected ACM from pre-pandemic data can provide an estimate of the overall burden of mortality related to the COVID-19 pandemic and support public health decision-making. This study validated an ACM calculator to estimate excess mortality during the COVID-19 pandemic. Action: The ACM calculator was developed as a tool for computing expected ACM and excess mortality at national and subnational levels. It was developed using R statistical software, was based on a previously described model that used non-parametric negative binomial regression and was piloted in several countries. Goodness-of-fit was validated by forecasting 2019 mortality from 2015-2018 data. Outcome: Three key lessons were identified from piloting the tool: using the calculator to compare reported provisional ACM with expected ACM can avoid potential false conclusions from comparing with historical averages alone; using disaggregated data at the subnational level can detect excess mortality by avoiding dilution of total numbers at the national level; and interpretation of results should consider system-related performance indicators. Discussion: Timely tracking of ACM to estimate excess mortality is important for the response to COVID-19. The calculator can provide countries with a way to analyse and visualize ACM and excess mortality at national and subnational levels.

An epidemiological overview of human infections with HxNy avian influenza in the Western Pacific Region, 2003-2022.

Avian influenza subtype A(HxNy) viruses are zoonotic and may occasionally infect humans through direct or indirect contact, resulting in mild to severe illness and death. Member States in the Western Pacific Region (WPR) communicate and notify the World Health Organization of any human cases of A(HxNy) through the International Health Regulations (IHR 2005) mechanism. This report includes all notifications in the WPR with illness onset dates from 1 November 2003 to 31 July 2022. During this period, there were 1972 human infections with nine different A(HxNy) subtypes notified in the WPR. Since the last report, an additional 134 human avian influenza infections were notified from 1 October 2017 to 31 July 2022. In recent years there has been a change in the primary subtypes and frequency of reports of human A(HxNy) in the region, with a reduction of A(H7N9) and A(H5N1), and conversely an increase of A(H5N6) and A(H9N2). Furthermore, three new subtypes A(H7N4), A(H10N3) and A(H3N8) notified from the People's Republic of China were the first ever recorded globally. The public health risk from known A(HxNy) viruses remains low as there is no evidence of person-to-person transmission. However, the observed changes in A(HxNy) trends reinforce the need for effective and rapid identification to mitigate the threat of a pandemic from avian influenza if person-to-person transmission were to occur.

Strengthening national, regional and global health capacity through the WHO Western Pacific Region's Field Epidemiology Fellowship Programme.

OBJECTIVE: The World Health Organization's (WHO's) Field Epidemiology Fellowship Programme in the Western Pacific Region aims to strengthen countries' capacities for surveillance and risk assessment and build a workforce to tackle public health emergencies. A survey was conducted to assess the on-the-job training experience of the Regional Fellows, evaluate the strengths of the Programme and gain feedback on areas for improvement. METHODS: Between 25 September and 25 October 2018, an online survey was sent to Regional Fellows who had participated in the Programme between July 2006 and September 2018. The survey was shared with WHO country offices in the Western Pacific Region and directly with graduates of the Programme. Responses were recorded electronically and analysed. RESULTS: A total of 53 former Regional Fellows responded (54% response rate; 53/98). At the time of Programme participation, the Fellows' median age was 35, 62% (33/53) were female and 72% (38/53) were affiliated with a national or subnational health department. Fellows gained experience in event-based surveillance and risk assessment and worked among a diverse group of professionals in various Member States. Altogether, 77% (41/53) of respondents believed that the Programme had helped them move into a better career position with greater responsibility. Ninety-four percent (50/53) would recommend the Programme to their colleagues. DISCUSSION: Alumni from the Western Pacific Region's Field Epidemiology Fellowship Programme perform key health security roles, particularly within governmental systems, and directly contribute to managing health emergencies in their countries, in the Region and globally. The Programme is building a workforce with surge capacity to ensure that public health events in the Region can be addressed. Furthermore, connections developed through the Programme are helping to develop an alumni network, and enhance communications among Member States and between Member States and WHO.

Regional event-based surveillance in WHO's Western Pacific Region.

In the World Health Organization's Western Pacific Region, event-based surveillance has been conducted for more than a decade to rapidly detect and assess public health events. This report describes the establishment and evolution of the Western Pacific Region's event-based surveillance system and presents an analysis of public health events in the Region. Between July 2008 and June 2017, a total of 2396 events were reported in the Western Pacific Region, an average of 266 events per year. Infectious diseases in humans and animals accounted for the largest proportion of events recorded during this period (73%, 1743 events). Maintaining and strengthening this well established system is critical to support the rapid detection, assessment and response to public health events to sustain regional health security.

Study protocol: building an evidence base for epidemiology emergency response, a mixed-methods study.

INTRODUCTION: Determinants and drivers for emergencies, such as political instability, weak health systems, climate change and forcibly displaced populations, are increasing the severity, complexity and frequency of public health emergencies. As emergencies become more complex, it is increasingly important that the required skillset of the emergency response workforce is clearly defined. To enable essential epidemiological activities to be implemented and managed during an emergency, a workforce is required with the right mix of skills, knowledge, experience and local context awareness. This study aims to provide local and international responders with an opportunity to actively contribute to the development of new thinking around emergency response roles and required competencies. In this study, we will develop recommendations using a broad range of evidence to address identified lessons and challenges so that future major emergency responses are culturally and contextually appropriate, and less reliant on long-term international deployments. METHOD AND ANALYSIS: We will conduct a mixed-methods study using an exploratory sequential study design. The integration of four data sources, including key informant interviews, a scoping literature review, survey and semistructured interviews will allow the research questions to be examined in a flexible, semistructured way, from a range of perspectives. The study is unequally weighted, with a qualitative emphasis. We will analyse all activities as individual components, and then together in an integrated analysis. Thematic analysis will be conducted in NVivo V.11 and quantitative analysis will be conducted in Stata V.15. ETHICS AND DISSEMINATION: All activities have been approved by the Science and Medical Delegated Ethics Review Committee at the Australian National University (protocol numbers 2018-521, 2018-641, 2019-068). Findings will be disseminated through international and local deployment partners, peer-reviewed publication, presentation at international conferences and through social media such as Twitter and Facebook.

University undergraduates' knowledge of chlamydia screening services and chlamydia infection following the introduction of a National Chlamydia Screening Programme.

OBJECTIVES: To determine knowledge of sexually transmitted chlamydia infection among university undergraduates following the introduction of a National Chlamydia Screening Programme (NCSP). METHODS: Anonymous self-administered questionnaire on chlamydia knowledge and sexual behaviour provided to a convenience sample of 400 university undergraduates. RESULTS: There were 259 responses (65%) and 17% of respondents were aware of the NCSP. Female students had significantly higher mean knowledge scores than males (p < 0.001), were more likely to be aware of the NCSP (Odds Ratio [OR] 2.70, 95% Confidence Interval [CI] 1.11-7.49) and to have ever attended chlamydia screening (OR 2.98, 95% CI 1.33-6.66). Overall, higher mean knowledge scores did not translate into reduced risk taking sexual behaviour, and female respondents were significantly more likely to attend for a 'general check-up' if they 'had sex without a condom with a person of unknown sexual history' (p = 0.043). Popular sources of chlamydia-related information were friends and the media. The internet was not a major source of information. CONCLUSIONS: Awareness regarding the NCSP, chlamydia infection and screening is limited and perception of personal risk poor. New evidence-based strategies are required to address knowledge gaps and risk-taking behaviour among university students.

Effect of social factors on winter hospital admission for respiratory disease: a case-control study of older people in the UK.

BACKGROUND: Every winter, hospitals in the UK and other developed countries experience a surge in respiratory admissions. Ecological studies suggest that social circumstances may be an important determinant. AIM: To establish the most important factors associated with winter hospital admissions among older people presenting with acute respiratory disease, especially the relative effect of social factors. DESIGN OF STUDY: case-control study. SETTING: Seventy-nine general practices in central England. METHOD: Of a cohort of patients consulting medical services with lower respiratory tract infection or exacerbation of chronic respiratory disease, 157 hospitalised cases were compared to 639 controls. Social, medical, and other factors were examined by interview and GP records. RESULTS: Measures of material deprivation were not significant risk factors for admission at either individual or area level, although social isolation (odds ratio [OR] 4.5; 95% confidence interval [CI] = 1.3 to 15.8) resulted in an increased risk of admission. The most important independent risk factor was the presence of chronic obstructive pulmonary disease (COPD; OR 4.0; 95% CI = 1.4 to 11.4), other chronic disease (OR 2.9; 95% CI = 1.2 to 7.0), or both (OR 6.7; 95% CI = 2.4 to 18.4). Being housebound was also an independent risk factor (OR 2.2; 95% CI = 1.0 to 4.8). CONCLUSION: Socioeconomic factors had little relative effect compared with medical and functional factors. The most important was the presence of long-term medical conditions (especially COPD), being housebound, and having received two or more courses of oral steroid treatment in the previous year. This combination of factors could be used by primary medical services to identify older patients most vulnerable to winter admissions. Clinicians should ensure that patients with COPD are better supported to manage their condition.