Progress Toward Measles and Rubella Elimination - Indonesia, 2013-2022.

In 2019, Indonesia and the other countries in the World Health Organization South-East Asia Region adopted the goal of measles and rubella elimination by 2023. This report describes Indonesia's progress toward measles and rubella elimination during 2013-2022. During this period, coverage with a first dose of measles-containing vaccine (MCV) decreased from 87% to 84%, and coverage with a second MCV dose decreased from 76% to 67%. After rubella vaccine was introduced in 2017, coverage with the first dose of rubella-containing vaccine increased approximately fivefold, from 15% in 2017 to 84% in 2022. During 2013-2021, annual reported measles incidence decreased by 95%, from 33.2 to 1.4 cases per million population; reported rubella incidence decreased 89%, from 9.3 to 1.0 cases per million population. However, a large surge in measles and rubella cases occurred in 2022, with a reported measles incidence of 29 cases per million and a reported rubella incidence of 3 per million, primarily related to disruption in immunization services caused by the COVID-19 pandemic. In 2022, approximately 26 million children (an estimated 73% of the target population) received a combined measles- and rubella-containing vaccine during supplementary immunization activities completed in 32 provinces. Progress toward measles and rubella elimination in Indonesia has been made; however, continued and urgent efforts are needed to restore routine immunization services that were adversely affected by the COVID-19 pandemic and close immunity gaps to accelerate progress toward measles and rubella elimination.

Using Population Mobility Patterns to Adapt COVID-19 Response Strategies in 3 East Africa Countries.

The COVID-19 pandemic spread between neighboring countries through land, water, and air travel. Since May 2020, ministries of health for the Democratic Republic of the Congo, Tanzania, and Uganda have sought to clarify population movement patterns to improve their disease surveillance and pandemic response efforts. Ministry of Health-led teams completed focus group discussions with participatory mapping using country-adapted Population Connectivity Across Borders toolkits. They analyzed the qualitative and spatial data to prioritize locations for enhanced COVID-19 surveillance, community outreach, and cross-border collaboration. Each country employed varying toolkit strategies, but all countries applied the results to adapt their national and binational communicable disease response strategies during the pandemic, although the Democratic Republic of the Congo used only the raw data rather than generating datasets and digitized products. This 3-country comparison highlights how governments create preparedness and response strategies adapted to their unique sociocultural and cross-border dynamics to strengthen global health security.

Planning and implementing a targeted polio vaccination campaign for Somali mobile populations in Northeastern Kenya based on migration and settlement patterns.

Supporting the global eradication of wildpoliovrisu (WPV), this project aimed to provide polio and measles vaccines to a population frequenty missed by immunization services and campaigns, ethnic Somali children living among mobile populations within Kenya's Northeastern Region. Additionally, nutritional support, albendazole (for treatment of intestinal parasites) and vitamin A were provided to improve children's health and in accordance with regional vaccination campaign practices. To better understand movement patterns and healthcare-seeking behaviors within this population, we trained community-based data collectors in qualitative and geospatial data collection methods. Data collectors conducted focus group and participatory mapping discussions with ethnic Somalis living in the region. Qualitative and geospatial data indicated movement patterns that followed partially definable routes and temporary settlement patterns with an influx of ethnic Somali migrants into Kenya at the start of the long rainy season (April-June). Community members also reported concerns about receiving healthcare services in regional health facilities. Using these data, an 8-week vaccination campaign was planned and implemented: 2196 children aged 0-59 months received polio vaccine (9% had not previously received polio vaccine), 2524 children aged 9-59 months received measles vaccine (27% had not previously received measles vaccine), 113 were referred for the treatment of severe acute malnourishment, 150 were referred to a supplementary feeding program due to moderate acute malnourishment, 1636 children aged 12-59 months were provided albendazole and 2008 children aged 6-59 months were provided with vitamin A. This project serves as an example for how community-based data collectors and local knowledge can help adapt public health programming to the local context and could aid disease eradication in at-risk populations.

Countries with delayed COVID-19 introduction - characteristics, drivers, gaps, and opportunities.

BACKGROUND: Three months after the first reported cases, COVID-19 had spread to nearly 90% of World Health Organization (WHO) member states and only 24 countries had not reported cases as of 30 March 2020. This analysis aimed to 1) assess characteristics, capability to detect and monitor COVID-19, and disease control measures in these 24 countries, 2) understand potential factors for the reported delayed COVID-19 introduction, and 3) identify gaps and opportunities for outbreak preparedness, particularly in low and middle-income countries (LMICs). We collected and analyzed publicly available information on country characteristics, COVID-19 testing, influenza surveillance, border measures, and preparedness activities in these countries. We also assessed the association between the temporal spread of COVID-19 in all countries with reported cases with globalization indicator and geographic location. RESULTS: Temporal spreading of COVID-19 was strongly associated with countries' globalization indicator and geographic location. Most of the 24 countries with delayed COVID-19 introduction were LMICs; 88% were small island or landlocked developing countries. As of 30 March 2020, only 38% of these countries reported in-country COVID-19 testing capability, and 71% reported conducting influenza surveillance during the past year. All had implemented two or more border measures, (e.g., travel restrictions and border closures) and multiple preparedness activities (e.g., national preparedness plans and school closing). CONCLUSIONS: Limited testing capacity suggests that most of the 24 delayed countries may have lacked the capability to detect and identify cases early through sentinel and case-based surveillance. Low global connectedness, geographic isolation, and border measures were common among these countries and may have contributed to the delayed introduction of COVID-19 into these countries. This paper contributes to identifying opportunities for pandemic preparedness, such as increasing disease detection, surveillance, and international collaborations. As the global situation continues to evolve, it is essential for countries to improve and prioritize their capacities to rapidly prevent, detect, and respond, not only for COVID-19, but also for future outbreaks.

Population Movement Patterns Among the Democratic Republic of the Congo, Rwanda, and Uganda During an Outbreak of Ebola Virus Disease: Results from Community Engagement in Two Districts - Uganda, March 2019.

Tailoring communicable disease preparedness and response strategies to unique population movement patterns between an outbreak area and neighboring countries can help limit the international spread of disease. Global recognition of the value of addressing community connectivity in preparedness and response, through field work and visualizing the identified movement patterns, is reflected in the World Health Organization's declaration on July 17, 2019, that the 10th Ebola virus disease (Ebola) outbreak in the Democratic Republic of the Congo (DRC) was a Public Health Emergency of International Concern (1). In March 2019, the Infectious Diseases Institute (IDI), Uganda, in collaboration with the Ministry of Health (MOH) Uganda and CDC, had previously identified areas at increased risk for Ebola importation by facilitating community engagement with participatory mapping to characterize cross-border population connectivity patterns. Multisectoral participants identified 31 locations and associated movement pathways with high levels of connectivity to the Ebola outbreak areas. They described a major shift in the movement pattern between Goma (DRC) and Kisoro (Uganda), mainly through Rwanda, when Rwanda closed the Cyanika ground crossing with Uganda. This closure led some travelers to use a potentially less secure route within DRC. District and national leadership used these results to bolster preparedness at identified points of entry and health care facilities and prioritized locations at high risk further into Uganda, especially markets and transportation hubs, for enhanced preparedness. Strategies to forecast, identify, and rapidly respond to the international spread of disease require adapting to complex, dynamic, multisectoral cross-border population movement, which can be influenced by border control and public health measures of neighboring countries.

Responding to Communicable Diseases in Internationally Mobile Populations at Points of Entry and along Porous Borders, Nigeria, Benin, and Togo.

Recent multinational disease outbreaks demonstrate the risk of disease spreading globally before public health systems can respond to an event. To ensure global health security, countries need robust multisectoral systems to rapidly detect and respond to domestic or imported communicable diseases. The US Centers for Disease Control and Prevention International Border Team works with the governments of Nigeria, Togo, and Benin, along with Pro-Health International and the Abidjan-Lagos Corridor Organization, to build sustainable International Health Regulations capacities at points of entry (POEs) and along border regions. Together, we strengthen comprehensive national and regional border health systems by developing public health emergency response plans for POEs, conducting qualitative assessments of public health preparedness and response capacities at ground crossings, integrating internationally mobile populations into national health surveillance systems, and formalizing cross-border public health coordination. Achieving comprehensive national and regional border health capacity, which advances overall global health security, necessitates multisectoral dedication to the aforementioned components.

Arsenic exposure and hepatitis E virus infection during pregnancy.

BACKGROUND: Arsenic has immunomodulatory properties and may have the potential to alter susceptibility to infection in humans. OBJECTIVES: We aimed to assess the relation of arsenic exposure during pregnancy with immune function and hepatitis E virus (HEV) infection, defined as seroconversion during pregnancy and postpartum. METHODS: We assessed IgG seroconversion to HEV between 1st and 3rd trimester (TM) and 3 months postpartum (PP) among 1100 pregnancies in a multiple micronutrient supplementation trial in rural Bangladesh. Forty women seroconverted to HEV and were matched with 40 non-seroconverting women (controls) by age, parity and intervention. We assessed urinary inorganic arsenic plus methylated species (∑As) (µg/L) at 1st and 3rd TM and plasma cytokines (pg/mL) at 1st and 3rd TM and 3 months PP. RESULTS: HEV seroconverters' urinary ∑As was elevated throughout pregnancy. Non-seroconverters' urinary ∑As was similar to HEV seroconverters at 1st TM but declined at 3rd TM. The adjusted odds ratio (95% confidence interval) of HEV seroconversion was 2.17 (1.07, 4.39) per interquartile range (IQR) increase in average-pregnancy urinary ∑As. Increased urinary ∑As was associated with increased concentrations of IL-2 during the 1st and 3rd TM and 3 months PP among HEV seroconverters but not non-seroconverters. CONCLUSIONS: The relation of urinary arsenic during pregnancy with incident HEV seroconversion and with IL-2 levels among HEV-seroconverting pregnant women suggests arsenic exposure during pregnancy may enhance susceptibility to HEV infection.

Low-birthweight rates higher among Bangladeshi neonates measured during active birth surveillance compared to national survey data.

Birth size is an important gauge of fetal and neonatal health. Birth size measurements were collected within 72 h of life for 16 290 live born, singleton infants in rural Bangladesh from 2004 to 2007. Gestational age was calculated based on the date of last menstrual period. Newborns were classified as small-for-gestational age (SGA) based on a birthweight below the 10th percentile for gestational age, using three sets of US reference data. Birth size distributions were explored based on raw values as well as after z-score standardisation in reference to World Health Organization (WHO) 2006 growth standards. Mean (SD) birthweight (g), length (cm) and head circumference (cm) measurements, completed within [median (25th, 75th percentile)] 15 (8, 23) h of life, were 2433 (425), 46.4 (2.4) and 32.4 (1.6), respectively. Twenty-two per cent were born preterm. Over one-half (55.3%) of infants were born low birthweight; 46.6%, 37.0% and 33.6% had a weight, length and head circumference below -2 z-scores of the WHO growth standard at birth; and 70.9%, 72.2% and 59.8% were SGA for weight based on Alexander et al., Oken et al. and Olsen et al. references, respectively. Infants in this typical rural Bangladesh setting were commonly born small, reflecting a high burden of fetal growth restriction and preterm birth. Our findings, produced by active birth surveillance, suggest that low birthweight is far more common than suggested by cross-sectional survey estimates. Interventions that improve fetal growth during pregnancy may have the largest impact on reducing SGA rates.

Preferred delivery method and acceptability of Wheat-Soy Blend (WSB++) as a daily complementary food supplement in northwest Bangladesh.

Fortified blended foods (FBFs) are widely used to prevent undernutrition in early childhood in food-insecure settings. We field tested enhanced Wheat Soy Blend (WSB++)-a FBF fortified with micronutrients, milk powder, sugar, and oil-in preparation for a complementary food supplement (CFS) trial in rural northwestern Bangladesh. Formative work was conducted to determine the optimal delivery method (cooked vs. not) for this CFS, to examine mothers' child feeding practices with and acceptance of the WSB++, and to identify potential barriers to adherence. Our results suggest WSB++ is an acceptable CFS in rural Bangladesh and the requirement for mothers to cook WSB++ at home is unlikely to be a barrier to its daily use as a CFS in this population.

Plasma zinc, vitamin B(12) and α-tocopherol are positively and plasma γ-tocopherol is negatively associated with Hb concentration in early pregnancy in north-west Bangladesh.

OBJECTIVE: The objective of the current analysis was to explore the association of multiple micronutrients with Hb concentration among pregnant women in a South Asian setting, a topic that has not been adequately explored. DESIGN: Sociodemographic, anthropometric and micronutrient status (plasma ferritin, transferrin receptor, retinol, a- and g-tocopherol, folate, vitamin B12, Zn) and Hb concentration were assessed at early pregnancy. SETTING: The biochemical sub-study was nested within a double-blind, placebo-controlled, community-based vitamin A and b-carotene supplementation trial in rural north-western Bangladesh (JiVitA). All assessments were conducted before trial supplementation was initiated. SUBJECTS: A systematic sample of 285 women was selected from those enrolled in the biochemical sub-study. RESULTS: Seventeen per cent of women were mildly anaemic; moderate and severe anaemia was uncommon (2.1 %). a-Tocopherol, vitamin B12 and Zn deficiencies were common (43.5%, 19.7% and 14.7%, respectively); however, vitamin A, folate and Fe deficiencies were comparatively rare (7.4%, 2.8% and ,1%,respectively). Plasma Zn, vitamin B12 and a-tocopherol were positively associated and plasma g-tocopherol was negatively associated with Hb (P < 0.05) after adjustment for gestational age, inflammation status, season and nutritional status measured by mid-upper arm circumference. CONCLUSIONS: Among pregnant women in rural Bangladesh with minimal Fe deficiency, plasma Zn, vitamin B12, and a- and g-tocopherol concentrations were associated with Hb concentration. Appreciating the influence on Hb of micronutrients in addition to those with known associations with anaemia, such as Fe, folate, and vitamin A, is important when addressing anaemia in similar settings.

Using spatial and population mobility models to inform outbreak response approaches in the Ebola affected area, Democratic Republic of the Congo, 2018-2020.

The Democratic Republic of the Congo's (DRC) 10th known Ebola virus disease (EVD) outbreak occurred between August 1, 2018 and June 25, 2020, and was the largest EVD outbreak in the country's history. During this outbreak, the DRC Ministry of Health initiated traveller health screening at points of control (POC, locations not on the border) and points of entry (POE) to minimize disease translocation via ground and air travel. We sought to develop a model-based approach that could be applied in future outbreaks to inform decisions for optimizing POC and POE placement, and allocation of resources more broadly, to mitigate the risk of disease translocation associated with ground-level population mobility. We applied a parameter-free mobility model, the radiation model, to estimate likelihood of ground travel between selected origin locations (including Beni, DRC) and surrounding population centres, based on population size and drive-time. We then performed a road network route analysis and included estimated population movement results to calculate the proportionate volume of travellers who would move along each road segment; this reflects the proportion of travellers that could be screened at a POC or POE. For Beni, the road segments estimated to have the highest proportion of travellers that could be screened were part of routes into Uganda and Rwanda. Conversely, road segments that were part of routes to other population centres within the DRC were estimated to have relatively lower proportions. We observed a posteriori that, in many instances, our results aligned with locations that were selected for actual POC or POE placement through more time-consuming methods. This study has demonstrated that mobility models and simple spatial techniques can help identify potential locations for health screening at newly placed POC or existing POE during public health emergencies based on expected movement patterns. Importantly, we have provided methods to estimate the proportionate volume of travellers that POC or POE screening measures would assess based on their location. This is critical information in outbreak situations when timely decisions must be made to implement public health interventions that reach the most individuals across a network.

Groundwater iron assessment and consumption by women in rural northwestern Bangladesh.

In Bangladesh, approximately 97 % of the rural population uses groundwater as a drinking source. In many areas of the country this water is known to have elevated levels of iron. The contribution to iron intake that this exposure provides, and the impact on health, are unknown. In the pre- and post-monsoon seasons of 2008, we measured iron content of household tube well water, explored local water collection methods, and estimated iron intake through consumption of groundwater for 276 women of reproductive age in a rural setting in northwestern Bangladesh. Groundwater samples were analyzed for total iron (mg/L), arsenic (category of µg/L), pH, temperature (°C), and oxidation-reduction potential (Eh). Participants drank [mean (SD); 2.7 (0.8) L] of water per day, all of which was collected from domestic tube wells. Total iron concentration in groundwater was high, [median (IQR) 16.3 (6.9, 28.2) mg/L], and variable throughout the area. Using this value, estimated daily iron intake [median (IQR)] was 41.1 (16.0, 71.0) mg from drinking water alone. The amount of water consumed was unrelated to its iron concentration (r = - 0.06; p = 0.33) despite potentially unpleasant organoleptic qualities of high iron content in water. Groundwater contributes substantially to daily iron intake of rural Bangladeshi women and currently represents an under-assessed potential source of dietary iron.

Iron status of women is associated with the iron concentration of potable groundwater in rural Bangladesh.

Women of reproductive age are at a high risk of iron deficiency, often as a result of diets low in bioavailable iron. In some settings, the iron content of domestic groundwater sources is high, yet its contribution to iron intake and status has not been examined. In a rural Bangladeshi population of women deficient in dietary iron, we evaluated the association between groundwater iron intake and iron status. In 2008, participants (n = 209 with complete data) were visited to collect data on 7-d food frequency, 7-d morbidity history, 24-h drinking water intake, and rice preparation, and to measure the groundwater iron concentration. Blood was collected to assess iron and infection status. Plasma ferritin (µg/L) and body iron (mg/kg) concentrations were [median (IQR)] 67 (46, 99) and 10.4 ± 2.6, respectively, and the prevalence of iron deficiency (ferritin < 12 µg/L) was 0%. Daily iron intake from water [42 mg (18, 71)] was positively correlated with plasma ferritin (r = 0.36) and total body iron (r = 0.35) (P < 0.001 for both). In adjusted linear regression analyses, plasma ferritin increased by 6.1% (95% CI: 3.8, 8.4%) and body iron by 0.3 mg/kg (0.2, 0.4) for every 10-mg increase in iron intake from water (P < 0.001). In this rural area of northern Bangladesh, women of reproductive age had no iron deficiency likely attributable to iron consumed from drinking groundwater, which contributed substantially to dietary intake. These findings suggest that iron intake from water should be included in dietary assessments in such settings.

Refugee Settlements and Cholera Risks in Uganda, 2016-2019.

During 2016 to 2019, cholera outbreaks were reported commonly to the Ministry of Health from refugee settlements. To further understand the risks cholera posed to refugees, a review of surveillance data on cholera in Uganda for the period 2016-2019 was carried out. During this 4-year period, there were seven such outbreaks with 1,495 cases and 30 deaths in five refugee settlements and one refugee reception center. Most deaths occurred early in the outbreak, often in the settlements or before arrival at a treatment center rather than after arrival at a treatment center. During the different years, these outbreaks occurred during different times of the year but simultaneously in settlements that were geographically separated and affected all ages and genders. Some outbreaks spread to the local populations within Uganda. Cholera control prevention measures are currently being implemented; however, additional measures are needed to reduce the risk of cholera among refugees including oral cholera vaccination and a water, sanitation and hygiene package during the refugee registration process. A standardized protocol is needed to quickly conduct case-control studies to generate information to guide future cholera outbreak prevention in refugees and the host population.

An approach to integrate population mobility patterns and sociocultural factors in communicable disease preparedness and response.

Complex human movement patterns driven by a range of economic, health, social, and environmental factors influence communicable disease spread. Further, cross-border movement impacts disparate public health systems of neighboring countries, making an effective response to disease importation or exportation more challenging. Despite the array of quantitative techniques and social science approaches available to analyze movement patterns, there continues to be a dearth of methods within the applied public health setting to gather and use information about community-level mobility dynamics. Population Connectivity Across Borders (PopCAB) is a rapidly-deployable toolkit to characterize multisectoral movement patterns through community engagement using focus group discussions or key informant interviews, each with participatory mapping, and apply the results to tailor preparedness and response strategies. The Togo and Benin Ministries of Health (MOH), in collaboration with the Abidjan Lagos Corridor Organization and the US Centers for Disease Control and Prevention, adapted and applied PopCAB to inform cross-border preparedness and response strategies for multinational Lassa fever outbreaks. Initially, the team implemented binational, national-level PopCAB activities in March 2017, highlighting details about a circular migration pathway across northern Togo, Benin, and Nigeria. After applying those results to respond to a cross-border Lassa fever outbreak in February 2018, the team designed an expanded PopCAB initiative in April 2018. In eight days, they trained 54 MOH staff who implemented 21 PopCAB focus group discussions in 14 cities with 224 community-level participants representing six stakeholder groups. Using the newly-identified 167 points of interest and 176 routes associated with a circular migration pathway across Togo, Benin, and Nigeria, the Togo and Benin MOH refined their cross-border information sharing and collaboration processes for Lassa fever and other communicable diseases, selected health facilities with increased community connectivity for enhanced training, and identified techniques to better integrate traditional healers in surveillance and community education strategies. They also integrated the final toolkit in national- and district-level public health preparedness plans. Integrating PopCAB in public health practice to better understand and accommodate population movement patterns can help countries mitigate the international spread of disease in support of improved global health security and International Health Regulations requirements.

Elevated and variable groundwater iron in rural northwestern Bangladesh.

Over the past 30 years, tubewells have become a ubiquitous source of potable groundwater in South Asia. Considered safer than surface water, groundwater naturally contains minerals that may impact human health; however, few data exist on tubewell water mineral content or its association with human nutritional or health conditions. We surveyed iron concentration in tubewell water across a 435 km2, contiguous, rural area in northwestern Bangladesh to map and quantify levels of iron in drinking water. One tubewell was randomly sampled from each of 948 adjacent grid cells 675 m2 in size. Water sampling was standardized and iron concentration measured using a field-based colorimetric kit. The median (interquartile range) concentration of iron in tubewell water was 7.6 (1.6, 17.6) mg l(-1). There was high geographic variation (range of 0-46.5 mg l(-1)), and iron in only 3% of surveyed tubewells fell below the WHO aesthetic cut-off of 0.3 mg l(-1) suggesting elevated levels of iron throughout the area. Villagers accurately perceived groundwater iron concentration, based on a 4-point ('none', 'a little', 'medium', 'a lot') scale (p<0.001). Water source iron content can be readily quantified in population settings offering the potential to evaluate the health relevance of groundwater iron exposure in rural communities.

Ebola Virus Disease Preparedness Assessment and Risk Mapping in Uganda, August-September 2018.

Uganda's proximity to the tenth Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo (DRC) presents a high risk of cross-border EVD transmission. Uganda conducted preparedness and risk-mapping activities to strengthen capacity to prevent EVD importation and spread from cross-border transmission. We adapted the World Health Organization (WHO) EVD Consolidated Preparedness Checklist to assess preparedness in 11 International Health Regulations domains at the district level, health facilities, and points of entry; the US Centers for Disease Control and Prevention (CDC) Border Health Capacity Discussion Guide to describe public health capacity; and the CDC Population Connectivity Across Borders tool kit to characterize movement and connectivity patterns. We identified 40 ground crossings (13 official, 27 unofficial), 80 health facilities, and more than 500 locations in 12 high-risk districts along the DRC border with increased connectivity to the EVD epicenter. The team also identified routes and congregation hubs, including origins and destinations for cross-border travelers to specified locations. Ten of the 12 districts scored less than 50% on the preparedness assessment. Using these results, Uganda developed a national EVD preparedness and response plan, including tailored interventions to enhance EVD surveillance, laboratory capacity, healthcare professional capacity, provision of supplies to priority locations, building treatment units in strategic locations, and enhancing EVD risk communication. We identified priority interventions to address risk of EVD importation and spread into Uganda. Lessons learned from this process will inform strategies to strengthen public health emergency systems in their response to public health events in similar settings.

Improving Cross-Border Preparedness and Response: Lessons Learned from 3 Lassa Fever Outbreaks Across Benin, Nigeria, and Togo, 2017-2019.

Long-standing cultural, economic, and political relationships among Benin, Nigeria, and Togo contribute to the complexity of their cross-border connectivity. The associated human movement increases the risk of international spread of communicable disease. The Benin and Togo ministries of health and the Nigeria Centre for Disease Control, in collaboration with the Abidjan Lagos Corridor Organization (a 5-country intergovernmental organization) and the US Centers for Disease Control and Prevention, sought to minimize the risk of cross-border outbreaks by defining and implementing procedures for binational and multinational public health collaboration. Through 2 multinational meetings, regular district-level binational meetings, and fieldwork to characterize population movement and connectivity patterns, the countries improved cross-border public health coordination. Across 3 sequential cross-border Lassa fever outbreaks identified in Benin or Togo between February 2017 and March 2019, the 3 countries improved their collection and sharing of patients' cross-border travel histories, shortened the time between case identification and cross-border information sharing, and streamlined multinational coordination during response efforts. Notably, they refined collaborative efforts using lessons learned from the January to March 2018 Benin outbreak, which had a 100% case fatality rate among the 5 laboratory-confirmed cases, 3 of whom migrated from Nigeria across porous borders when ill. Aligning countries' expectations for sharing public health information would assist in reducing the international spread of communicable diseases by facilitating coordinated preparedness and responses strategies. Additionally, these binational and multinational strategies could be made more effective by tailoring them to the unique cultural connections and population movement patterns in the region.

Validation of two portable instruments to measure iron concentration in groundwater in rural Bangladesh.

Iron is ubiquitous in natural water sources used around the world for drinking and cooking. The health impact of chronic exposure to iron through water, which in groundwater sources can reach well above the World Health Organization's defined aesthetic limit of 0.3 mg/L, is not currently understood. To quantify the impact of consumption of iron in groundwater on nutritional status, it is important to accurately assess naturally-occurring exposure levels among populations. In this study, the validity of iron quantification in water was evaluated using two portable instruments: the HACH DR/890 portable colorimeter (colorimeter) and HACH Iron test-kit, Model IR-18B (test-kit), by comparing field-based iron estimates for 25 tubewells located in northwestern Bangladesh with gold standard atomic absorption spectrophotometry analysis. Results of the study suggest that the HACH test-kit delivers more accurate point-of-use results across a wide range of iron concentrations under challenging field conditions.