Assessment of core activities and supportive functions for the communicable diseases surveillance system in Khartoum state, Sudan, 2005-2007.

We conducted a descriptive, retrospective, cross-sectional study to assess the core activities and supportive functions of the communicable diseases surveillance system (CDSS) in Khartoum state, Sudan, for the period 2005-2007. This is the first assessment conducted for CDSS in Khartoum state. The CDSS was studied in terms of core activities and supportive functions. We found that knowledge of the system was 100% at all levels. Data reporting was over the recommended standard of 80% at all levels. Data analysis, epidemic preparedness and feedback were below the recommended standard. All assigned CDSS staff members were trained. Lower levels lacked modern technologies for data reporting and analysis. The CDSS system in Khartoum state is centralized; moreover, the system has not been updated, it is poorly documented and has a shortage of staff at lower levels.

Familial factors and suicide: an adoption study in a Swedish National Cohort.

BACKGROUND: Parental characteristics influence the risk of offspring suicide. In this study we wanted to separate the hereditary from the environmental influence of such factors by comparing their effects in the adopted versus non-adopted. METHOD: A register study was conducted in a national cohort of 2,471,496 individuals born between 1946 and 1968, including 27,600 national adoptees, followed-up for suicide during 1987-2001. Cox regression was used to calculate hazard ratios (HR) for suicide of socio-economic indicators of the childhood household and biological parents' suicide, alcohol abuse and psychiatric morbidity separately in the adopted and non-adopted. Differences in effects were tested in interaction analyses. RESULTS: Suicide and indicators of severe psychiatric disorder in the biological parents had similar effects on offspring suicide in the non-adopted and adopted (HR 1.5-2.3). Biological parents' alcohol abuse was a risk factor for suicide in the non-adopted group only (HR 1.8 v. 0.8, interaction effect: p=0.03). The effects of childhood household socio-economic factors on suicide were similar in adopted and non-adopted individuals, with growing up in a single parent household [HR 1.5 (95% confidence interval 1.4-1.5)] as the most important socio-economic risk factor for the non-adopted. CONCLUSIONS: The main familial effects of parental suicide and psychiatric morbidity on offspring suicide are not mediated by the post-natal environment or imitation, in contrast to effects of parental alcohol abuse that are primarily mediated by the post-natal environment. Social drift over generations because of psychiatric disorders does not seem likely to explain the association of socio-economic living conditions in childhood to suicide.

Staff views about the quality of the Communicable Diseases Surveillance System in Khartoum State, Sudan, 2005-2007: a qualitative study.

Surveillance staff are vital to the success of surveillance of infectious diseases. In this study, we interviewed staff of the Communicable Diseases Surveillance System (CDSS) in Khartoum state individually and in focus groups to assess their views about the quality of the system for the years 2005-07. The quality of CDSS was considered poor because the system was not representative as it included neither the private nor military sectors nor the important teaching hospitals. It also lacked timeliness due to poor documentation, was inflexible since it did not rapidly respond to emerging and re-emerging diseases such as SARS and avian flu in its notification lists, and it did not use the data collected to apply interventions for control and prevention of communicable diseases on a routine basis. While staff were committed to the surveillance system and felt they worked hard, they were also demotivated and in the long run this might affect their performance.

Effects of a Brief Web-Based "Social Norms"-Intervention on Alcohol, Tobacco and Cannabis Use Among German University Students: Results of a Cluster-Controlled Trial Conducted at Eight Universities.

Background and Aim: "Social norms" (SN)-interventions are aimed at changing existing misperceptions regarding peer substance use by providing feedback on actual norms, thereby affecting personal substance use. It is unknown whether SN-intervention effects previously demonstrated in US students can be replicated in German students. The aim of the INSIST-study was to examine the effects of a web-based SN-intervention on substance use. Design: Cluster-controlled trial. Setting: Eight Universities in Germany. Participants and Measurements: Students were recruited at four intervention vs. four delayed intervention control Universities. 4,463 students completed baseline, 1,255 students (59% female) completed both baseline and 5-months follow-up web-based surveys on personal and perceived peer substance use. Intervention participants received feedback contrasting personal and perceived peer use with previously assessed use and perceptions of same-sex, same-university peers. Intervention effects were assessed via multivariable mixed logistic regression models. Findings: Relative to controls, reception of SN-feedback was associated with higher odds for decreased alcohol use (OR: 1.91, 95% CI 1.42-2.56). This effect was most pronounced in students overestimating peer use at baseline and under or accurately estimating it at follow-up (OR: 6.28, 95% CI 2.00-19.8). The OR was 1.33 (95% CI 0.67-2.65) for decreased cannabis use in students at intervention Universities and was statistically significant at 1.70 (95% CI 1.13-2.55) when contrasting unchanged and decreased with increased use. Regarding tobacco use and episodes of drunkenness, no intervention effects were found. Conclusions: This study was the first cluster-controlled trial suggesting beneficial effects of web-based SN-intervention on alcohol and cannabis use in a large sample of German University students. Clinical Trial Registration: The trial registration number of the INSIST-study is DRKS00007635 at the "German Clinical Trials Register."

[Prevention and control of infectious diseases with pandemic potential: the EU-project SARSControl]. / Prävention und Kontrolle von pandemischen Infektionskrankheiten: Das EU-Projekt SARSControl.

INTRODUCTION: The influenza pandemics of the 20th century, the SARS epidemic in 2002/03 and the growing number of human cases infected with the H5N1 avian influenza virus clearly demonstrate that the threat of new pandemics is very real. These events have intensified pandemic prevention and control activities worldwide. "SARSControl" is a three-year project funded by the European Commission with the objective to aid European member states in the public health management of new emerging infections. This article summarises the main research results and recommendations arising from this project. METHOD: The reports and papers published in the SARSControl project form the basis of this article. In addition, a literature search for SARS and pandemic influenza was conducted and information on pandemic planning and management guidelines obtained from the WHO and EU websites. The project results are discussed in this context. RESULTS: A lack of knowledge and delayed international communication resulted in the rapid spread of SARS, highlighting the importance of a global system for rapid and transparent information transfer. Epidemiological and economic modelling studies have shown that, in comparison to travel restrictions, applying intervention measures to interrupt local transmission within a country and investing into vaccine research and anti-viral stockpiling, is a more cost-effective and efficient use of resources for the containment of pandemics. A study investigating the perceived threat associated with pandemics showed that the subjective risk perception of people varies among countries. This influences human behaviour and should hence be considered during risk communication and implementation of pandemic control measures. DISCUSSION: The basic prerequisites of an efficient pandemic management are operationalisable pandemic plans, subjected to regular exercises, backed by adequate resources and a sound health-care infrastructure. At international level cross-border co-operation and information exchange on infection control is the key to pandemic mitigation and containment. Strengthening surveillance systems at the international level, to allow the timely monitoring of infectious agents and outbreaks is essential. Transferring such outbreak information in real time into mathematical models and the resulting essential epidemiological information to policy makers would facilitate a more efficient use of scarce resources. Involvement of the public in decisions regarding the implementation of restrictive control measures which often curtail individual liberty is necessary for the acceptance and ultimate success of pandemic control.

Longitudinal study of meningococcal carrier rates in teenagers.

To gain actual information concerning the oropharyngeal carriage of Neisseria meningitidis among teenagers aged 15-18 years in Germany especially in a region with increased incidence of meningococal-related diseases prompted the study. Each teenager was swabbed three times with an interval of 2 months between the examinations. The 901 recovered N. meningitidis strains were characterized using serological (serogrouping, serotyping/serosubtyping) and molecular methods (PCR, PFGE) each. The results of the study demonstrate an overall average carrier rate of 18.8% for the three collection periods. There were, however, significant differences between the carrier rates within a given school and of different towns and counties. Of all isolates, 60.6% were not serogroupable. Serogroup B dominated (12.3%), followed by serogroup Y (9.0%) and serogroup C (3.6%). After PCR-based serogrouping of not serogroupable strains the percentages for serogroups enhanced to 18.8% for B, 10.8% for Y and 4.1% for C. Serotyping led to 305 different phenotypes with the most common being 29E:NT:P1.2,5 followed by Y:14:NST. In the 6 study towns the number of different N. meningitidis clones (PFGE types) isolated, varied between 30 and 87. In Wenden, where a prolonged outbreak had taken place, serogroup C (14.8%) was predominant. Only in this town C:2a isolates were found, all belonging to the ST-11/ET-37 complex and 12/13 matched identically to the ET-15 clone. Of the colonized teenagers, 26.7% were carriers over at least 23 weeks, 22.6% with the same strain, 36.0% were carrier for at least 15 weeks. Over all three collection periods 36.7% of the adolescents acquired a new strain. The highest acquisition rate was related to PFGE type 12.

Community-wide outbreak of enteroviral illness caused by echovirus 30: a cross-sectional survey and a case-control study.

BACKGROUND: In June, 1997, 21 children from a single community in Germany were hospitalized with aseptic meningitis. An epidemiologic investigation was conducted to determine the extent of the outbreak and risk factors for illness. METHOD: The extent of the outbreak was assessed with a cross-sectional survey of every 10th child listed in the town register among the 2240 town children < 16 years old. A case-control study determined risk factors for illness. Sixty-two cases were identified through the cross-sectional survey from hospitalized persons and from persons seen by local physicians. Controls were 114 asymptomatic persons identified from the cross-sectional survey. RESULTS: The overall attack rate was 16%, with the highest attack rates (24%) among the 6- to 8-year olds. Onsets occurred during a 37-day period. Among the 2240 town children <16 years of age, an estimated 353 met the case definition for enteroviral illness, 168 visited a doctor and 21 were hospitalized. Data from the case-control study indicated that contact with an ill household member [odds ratio (OR) = 6.3; 95% confidence interval (CI) 2.6 to 15.5], day-care attendance (OR = 2.6; 95% CI 1.1 to 6.2) and playground use, either two to three times per week (OR = 3.7; 95% CI 1.3 to 10.2) or daily (OR = 4.3; 95% CI 1.6 to 11.3), were risk factors for illness. CONCLUSION: Echovirus 30 caused substantial morbidity during this community outbreak caused by person-to-person spread. Household contacts, day-care centers and playgrounds were prominent risk factors for transmission.

Age, neurofibrillary changes, A beta-amyloid and the onset of Alzheimer's disease.

Intraneuronal neurofibrillary changes and extracellular A beta-amyloid deposits are neuropathologic hallmarks of Alzheimer's disease. Examination of numerous non-selected autopsy cases demonstrates that they are by no means normal concomitants of brain aging. Rather, the initial neurofibrillary changes indicate the beginning of Alzheimer's disease. A small proportion of cases displays particularly early development of the intraneuronal changes, indicating that advanced age is not a prerequisite for the evolution of the lesions. However, the mean of stages in the development of the specific neurofibrillary pathology increases with age. Alzheimer's disease is thus an age-related, not an age-dependent disease.

Meningococcal carriage in relation to an outbreak of invasive disease due to Neisseria meningitidis serogroup C in the Netherlands.

BACKGROUND: a cross-sectional study on meningococcal carriage was performed in Putten, a small rural town in the Netherlands where an unusual high incidence of invasive meningococcal disease (IMD) due to Neisseria meningitidis C:2a:P1.5 occurred. The outbreak was controlled by mass vaccination of all inhabitants aged 2 to 20 years. METHODS: meningococcal carriage was studied in three groups: (1) a systematic age-specific sample of 2-20 year olds who visited the immunization clinic in Putten (January 1998: n=411); (2) children and adolescents in the same age range recruited through a kindergarten and schools in Venlo, a town where the causative strain of IMD had not been encountered (February 1998; n=374); (3) all initial carriers in Putten and a sample of non-carriers in that town (March 1998: n=145). Oropharyngeal swabs were taken for the purpose of isolating N. menigitidis. RESULTS: the prevalence of carriage was 12.4% in Putten and 18.2%, in Venlo, but the prevalence of group C meningococci was higher in Putten (1.7%) than Venlo (0.5%). N. meningitidis C:2a:P1.5 was isolated twice in Putten and not at all in Venlo. A second examination in Putten showed that 18 of the 22 repeatedly tested carriers were still carriers, and six new carriers were found among the 55 initial non-carriers. Of the two known carriers of C:2a:P1.5, one was still carrying the same strain, and the other did not participate in the second investigation. Carriage was associated with increasing family size, discotheque visits and visits to youth clubs and sports clubs. In contrast, visits to the swimming pool appeared to be related to a lower risk, as was recent antibiotic use. CONCLUSION: the prevalence of carriage with the invasive strain C:2a:P1.5 was low in the population that experienced a community-wide outbreak recently: the specific strain was not found in the reference population. This indicates a relatively high risk of developing the invasive disease for those who become infected with such strains.

Infectious disease surveillance in North Rhine-Westphalia: first steps in the development of an early warning system.

It is often difficult to detect warning signals on infectious disease outbreaks from raw surveillance data. Data need to be used for a timely generation and distribution of information on the current state of infectious diseases. This offers the opportunity to detect outbreaks and to initiate preventive measures. To improve the surveillance system in North Rhine-Westphalia we have introduced an infectious disease barometer, a simple tool based on weekly notification data. The aim of this tool is not to provide in depth data analysis, but to help to detect clusters or outbreaks. This can be the first step in the development of an early warning system and can support epidemiological investigation and policy making.

Descriptive epidemiology of exanthems in the Rotterdam region January 1997 to June 1998.

The European Advisory Group on Immunisation has recommended that measles should be eliminated from Europe by the year 2007, a target accepted by National Immunisation Programme Managers for the World Health Organization (WHO) European Region countries. I

An outbreak of Norwalk like virus gastroenteritis in a nursing home in Rotterdam.

Sixty-two per cent of elderly and disabled residents of a Dutch nursing home (74/120) and 32% of staff (33/102) became ill in an outbreak of Norwalk-like viral gastroenteritis. The outbreak spread from person to person was supported by temporal clustering

[Screening policy for travellers from Rotterdam for hepatitis A antibodies prior to eventual immunization: favourable cost-benefit ratio]. / Beleid bij screening van reizigers uit Rotterdam op antistoffen tegen hepatitis A voorafgaand aan eventuele immunisatie: gunstige kosten-batenverhouding.

OBJECTIVE: To evaluate costs and benefits of the screening and immunisation policy for hepatitis A virus (HAV) infection among travellers from Rotterdam. DESIGN: Descriptive and cost-benefit analysis. METHOD: From the data of the Municipal Health Service Rotterdam (GGD), the Netherlands, the details were collected on individuals travelling frequently to HAV endemic countries, who were born before 1950, or had lived for more than 10 years in an HAV endemic country or had ever suffered jaundice. Persons to whom these criteria applied were screened for HAV antibodies at the GGD before immunisation for HAV in the period January 1st 1996-June 30th 1998. Screening and vaccination policies were compared with a cost analysis. RESULTS: Antibodies against HAV were found in 79% of 1466 screened people. The lowest prevalence of antibodies was found among Dutch nationals (67%). A significantly higher prevalence was found amongst individuals from Turkey/Morocco (96%) and from the Cape-Verde Islands (97%). In the cost analysis the break even point, the prevalence level of HAV antibodies in the population at which screening cost as much as blind prophylaxis, lay for passive immunisation between 69% and 93%. For active immunisation this point lay around 17%. CONCLUSION: The selection criteria for prevaccination screening are effective in identifying individuals with a high probability of being immune against HAV infections. The current screening policy for antibodies against HAV is cost effective.

[Surveillance of communicable diseases in the European Union]. / Surveillance van infectieziekten in de Europese Unie.

Important developments are taking place in the Public Health framework in the European Union (EU). A number of international surveillance networks have been developed between the countries of the EU. The European Commission has initiated horizontal and disease specific programmes in the field of infectious disease surveillance. These have stimulated European co-operation for prevention and control of infectious diseases. Much topical information can be found on several Internet pages. The challenge is to set up networks for all public health relevant infectious diseases.

Feasibility of implementing recommendations to improve communicable diseases surveillance--a modified Delphi study.

BACKGROUND: Effective control of communicable diseases requires an effective disease surveillance system (CDSS) which provides information for action on priority communicable diseases. It is the basis for public health decision-making worldwide. Implementation of any public health recommendations for improving a disease surveillance system depends on the acceptability of such recommendations by the relevant stakeholders and the feasibility of implementing the recommendations in practice. OBJECTIVES: The aim of this study was to assess the acceptability and the feasibility of recommended improvements in CDSS among relevant stakeholders in Khartoum state. METHODS: A Delphi consensus process was used in the form of three analytical written rounds and individual face-to-face discussions among relevant stakeholders in Khartoum state to study the feasibility of the recommended improvements in CDSS in Khartoum state. RESULTS: The stakeholders in Khartoum state agreed with most of our statements to improve the CDSS core activities, supportive functions and quality in Khartoum State, and that the existing CDSS in Khartoum state needs to be strengthened with more effective coordination at different levels. Regarding the feasibility of implementing our recommendations, the results of our Delphi survey suggest neither expanding CDSS system, nor including vertical programmes; formulation of updated objectives; improving data management and feedback; strengthening epidemic management, as well as the quality of the system in terms of timeliness, completeness and acceptability. CONCLUSION: This study added strength to our recommendations, based on two previous studies assessing the CDSS in Khartoum state. The Ministry of Health in Khartoum state can implement our consensus recommendations to improve the CDSS system in the future in order to achieve its targeted goals.

Developing policy options for SARS and SARS-like diseases - a Delphi study.

The objective of the SARSControl Delphi study was to develop options for national and international emerging infectious diseases policies. The aim of this paper is to present the results of the study, which gathered expert opinions on gaps and inconsistencies concerning preparedness and response planning for Severe Acute Respiratory Syndrome (SARS) and SARS-like diseases. The Delphi technique was employed, which comprised a pilot round, two written rounds and a face-to-face meeting. The Delphi panel consisted of 38 experts from 22 countries, who highlighted the necessity to test plans and stressed the importance of surveillance measures for the swift containment of communicable disease outbreaks and the inclusion of detailed triage plans in national pandemic plans. The experts also suggested a need to define criteria for testing pandemic preparedness plans at different regional levels. New policy alternatives were identified, such as the need for generic plans on pandemics and universal access to healthcare during an outbreak. The usefulness of some non-medical interventions, such as bans on travel, could not be established and need further research. Dissemination of the findings will help to bridge gaps and rectify inconsistencies in current pandemic planning and response strategies for SARS and SARS-like diseases, as well as add valuable knowledge towards the development of national and international emerging infectious disease policies.