Impact of COVID-19 Vaccination Rates and Public Measures on Case Rates at the Provincial Level, Thailand, 2021: Spatial Panel Model Analyses.

The coronavirus disease of 2019 (COVID-19) was a pandemic that caused high morbidity and mortality worldwide. The COVID-19 vaccine was expected to be a game-changer for the pandemic. This study aimed to describe the characteristics of COVID-19 cases and vaccination in Thailand during 2021. An association between vaccination and case rates was estimated with potential confounders at ecological levels (color zones, curfews set by provincial authorities, tourism, and migrant movements) considering time lags at two, four, six, and eight weeks after vaccination. A spatial panel model for bivariate data was used to explore the relationship between case rates and each variable and included only a two-week lag after vaccination for each variable in the multivariate analyses. In 2021, Thailand had 1,965,023 cumulative cases and 45,788,315 total administered first vaccination doses (63.60%). High cases and vaccination rates were found among 31-45-year-olds. Vaccination rates had a slightly positive association with case rates due to the allocation of hot-spot pandemic areas in the early period. The proportion of migrants and color zones measured had positive associations with case rates at the provincial level. The proportion of tourists had a negative association. Vaccinations should be provided to migrants, and collaboration between tourism and public health should prepare for the new era of tourism.

Delivering Modern Global Health Learning Requires New Obligations and Approaches.

Introduction: The COVID-19 pandemic has forced a new look (or modernization) for both the obligations and approaches to achieve best-practices in global health learning. These best-practices have moved beyond traditional, face-to-face (F2F), classroom-based didactics to the use of innovative online, asynchronous and synchronous instructional design and the information and communication technology (ICT) tools to support it. But moving to this higher level of online in-service and pre-service training, key obligations (e.g., stopping neocolonialization, cultural humility, reversing brain drain, gender equity) must guide the modernization of instructional design and the supporting ICT. To positively impact global health training, educators must meet the needs of learners where they are. Purpose: We describe a set of multi-communication methods, e-Learning principles, strategies, and ICT approaches for educators to pivot content delivery from traditional, F2F classroom didactics into the modern era. These best-practices in both the obligations and approaches utilize thoughtful, modern strategies of instructional design and ICT. Approach: We harnessed our collective experiences in global health training to present thoughtful insights on the guiding principles, strategies, and ICT environment central to develop learning curricula that meet trainee needs and how they can be actualized. Specifically, we describe five strategies: 1. Individualized learning; 2. Provide experiential learning; 3. Mentor … Mentor … Mentor; 4. Reinforce learning through assessment; and 5. Information and communication technology and tools to support learning. Discussion: We offer a vision, set of guiding principles, and five strategies for successful curricula delivery in the modern era so that global health training can be made available to a wider audience more efficiently and effectively.

Nosocomial outbreak of the Middle East Respiratory Syndrome coronavirus: A phylogenetic, epidemiological, clinical and infection control analysis.

BACKGROUND: Middle East Respiratory Syndrome coronavirus (MERS-CoV) continues to cause intermittent community and nosocomial outbreaks. Obtaining data on specific source(s) and transmission dynamics of MERS-CoV during nosocomial outbreaks has been challenging. We performed a clinical, epidemiological and phylogenetic investigation of an outbreak of MERS-CoV at a University Hospital in Riyadh, Kingdom of Saudi Arabia. METHODS: Clinical, epidemiological and infection control data were obtained from patients and Healthcare workers (HCWs). Full genome sequencing was conducted on nucleic acid extracted directly from MERS-CoV PCR-confirmed clinical samples and phylogenetic analysis performed. Phylogenetic analysis combined with published MERS-CoV genomes was performed. HCWs compliance with infection control practices was also assessed. RESULTS: Of 235 persons investigated, there were 23 laboratory confirmed MERS cases, 10 were inpatients and 13 HCWs. Eight of 10 MERS inpatients died (80% mortality). There were no deaths among HCWs. The primary index case assumed from epidemiological investigation was not substantiated phylogenetically. 17/18 MERS cases were linked both phylogenetically and epidemiologically. One asymptomatic HCW yielded a MERS-CoV genome not directly linked to any other case in the investigation. Five HCWs with mild symptoms yielded >75% full MERS-CoV genome sequences. HCW compliance with use of gowns was 62.1%, gloves 69.7%, and masks 57.6%. CONCLUSIONS: Several factors and sources, including a HCW MERS-CoV 'carrier phenomenon', occur during nosocomial MERS-CoV outbreaks. Phylogenetic analyses of MERS-CoV linked to clinical and epidemiological information is essential for outbreak investigation. The specific role of apparently healthy HCWs in causing nosocomial outbreaks requires further definition.

Innovative Approaches to Improve Public Health Practice in the Eastern Mediterranean Region: Findings From the Sixth Eastern Mediterranean Public Health Network Regional Conference.

Public health professionals in the Eastern Mediterranean region (EMR) have limited access to continuing education, including workshops and conferences in public health. Held under the theme Innovative Approaches: Adapting to the Current EMR Context, the Eastern Mediterranean Public Health Network (EMPHNET) organized and conducted the Sixth EMPHNET Regional Conference from March 26 to 29, 2018. This paper summarizes the key activities including workshops, roundtable discussions, oral and poster presentations, keynote speeches, and side meetings. Before the opening, 5 preconference workshops were held: "Field Epidemiology Training Program (FETP) Accreditation," "Innovative Public Health Surveillance," "Human and Animal Brucellosis," "Rapid Response Teams," and "Polio Transition and Routine Immunization." The conference hosted 6 roundtable discussions: "Consolidation of the FETP Network," "One Health to Achieve Global Health Security," "Polio Eradication Efforts and Transition Planning for Measles Elimination," "Mobile Data Collection and Other Innovative Tools to Enhance Decision Making," "Confronting Candida auris: An Emerging Multidrug-resistant Global Pathogen," and "Functioning and Sustainable Country Public Health Emergency Response Operation Framework." One of the conference's key objectives was to provide a space for FETP residents, graduates, and public health professionals to showcase achievements. A total of 421 abstracts were submitted and after professional review, 34.9% (147/421) were accepted (111 for oral presentations and 36 for poster presentations) and published by Iproceeding. The conference met the primary objectives of showcasing the public health accomplishments and contributions of the EMR, encouraging the exchange of ideas and coordination among stakeholders, and engaging cross-sectoral workforce in producing recommendations for approaching regional and global health concerns. Moreover, the conference presented a unique opportunity for FETPs and other public health professionals from the Mediterranean region to present their significant scientific work and also facilitated networking among professionals. EMPHNET strives to continue to present similar exchange opportunities for public health professionals in the region.

Dynamics of allergy development during the first 5 years of life.

Allergic diseases have increased in developed countries during the past decades. A cohort of Slovak children was followed from birth to track allergic symptoms dynamics in early childhood. Information on allergic symptoms (atopic dermatitis = AD, rhino conjunctivitis = RC, wheezing = Wh, urticaria = Ur) and food allergies among children was based on clinical evaluation of children by allergists at three developmental stages (infant, toddler, preschool). Out of 320 cases of allergies, 64 infants, 145 toddlers, and 195 preschool children suffered from AD, RC, Wh, Ur, or their combinations (i.e., significant increase with age, p < 0.001). AD first appeared in infants, Wh and/or RC rose mainly in toddlers, and Ur among preschool children. AD in infants or toddlers disappeared in the subsequent developmental stage in approximately one third of all cases. Single AD persistence without remission or extension was not common and accounted only for 6.9% of AD infants' allergic manifestations. In addition to single-symptom allergic diseases, this study also identified several combinations of atopic symptoms.Conclusions: The proportion of multi-symptom allergies increased while single-symptom forms decreased. The observed temporal trends of allergic symptoms correspond to the atopic march. What is Known: • The observed temporal trends of allergic symptoms correspond to the atopic march. What is New: • Allergic diseases in children were first manifested as single forms, with atopic dermatitis (AD) commonly functioning as the "entry point" to allergies. • The overall proportion of single-symptom allergic disorders decreased over time while the proportion of multi-symptom allergies increased.

Distribution and determinants of tuberculosis in the Kingdom of Saudi Arabia from 2005 to 2012.

Tuberculosis (TB) remains a public health threat in the Kingdom of Saudi Arabia (KSA) with many challenges that limit its prevention and control. To understand how to meet these challenges, this study calculated the TB incidence rates (IRs) in KSA from 2005 to 2012, which were stratified by nationality, sex, and administrative regions. Furthermore, laboratory capabilities were assessed by determining the proportion of laboratory-confirmed TB cases. The overall TB IRs decreased from 15.80/100,000 population in 2005 [95% confidence interval (CI)=15.29-16.31] to 13.16/100,000 population in 2012 (95% CI=12.74-13.58). The IRs were greater for males than for females from 2009 to 2012. The IRs of non-Saudis were approximately two times those of Saudis during the study period. Mecca had greater IR during the study period compared with other regions [25.13/100,000 (95% CI=24.7-25.56)]. Among non-Saudis, those from Indonesia and Yemen had the greatest proportion of TB cases (15.4% and 12.9%, respectively). Individuals <15years of age comprised 14.2% of the TB cases. Employed non-Saudis had the greatest proportion of TB (32%), followed by unemployed Saudis (22.38%). The proportion of laboratory-confirmed cases of reported TB was 57% from 2005 to 2012. For effective prevention and control, TB screening should be implemented for non-Saudi workers at ports of entry and laboratory-screening capacity for TB should be evaluated.

Device-associated nosocomial infection in general hospitals, Kingdom of Saudi Arabia, 2013-2016.

Healthcare-associated infections (HAIs) including device-associated HAI (DA-HAI) are a serious patient safety issue in hospitals worldwide, affecting 5-10% of hospitalized patients and deadly for patients in intensive care units (ICUs). (Vincent, 2003; Al-Tawfiq et al., 2013; Hu et al., 2013). DA-HAIs account for up to 23% of HAIs in ICUs and about 40% of all hospital infections (i.e. central line-associated blood stream infections [CLABSI], ventilator-associated pneumonia [VAP], and catheter-associated urinary tract infections [CAUTI]). This study aims to identify DA-HAI rates among a group of selected hospitals in the Kingdom of Saudi Arabia (KSA), 2013-2016. Secondary data was analyzed from 12 medical/surgical intensive care units (M/SICUs) and two cardiac care units (CCUs) from 12 Ministry of Health (MoH) hospitals from different regions in KSA. These data were reported by infection control practitioners to the MoH via electronic International Nosocomial Infection Control Consortium (INICC) systems in each hospital. Among 6178 ICU patients with 13,492 DA-HAIs during 2013-2016, the average length of stay (LOS) was 10.7 days (range 0-379 days). VAP was the most common DA-HAI (57.4%), followed by CAUTI (28.4%), and CLABSI (14.2%). In CCUs there were no CLABSI cases; CAUTI was reported from 1 to 2.6 per 1000 device-days; and VAP did not occur in Hospital B but occurred 8.1 times per 1000 device-days in the CCU in Hospital A. In M/SICUs, variations occurred among time periods, hospitals, and KSA provinces. CLABSI varied between hospitals from 2.2 to 10.5 per 1000 device-days. CAUTI occurred from 2.3 to 4.4 per 1000 device-days, while VAP had the highest rates, from 8.9 to 39.6 per 1000 device-days. Most hospitals had high device-utilization ratios (DURs) (from the 75th to 90th percentile of National Healthcare Safety Network (NHSN)'s standard and the 50th to 75th percentile of INICC's). This study showed higher device-associated infection rates and higher device-utilization ratios in the study's CCUs and M/SICUs than NHSN benchmarks. To reduce the rates of infection, ongoing monitoring of infection control practices and comprehensive education are required. Furthermore, a sensitive and specific national healthcare safety network is needed in KSA.

Impact of mobile teams on tuberculosis treatment outcomes, Riyadh Region, Kingdom of Saudi Arabia, 2013-2015.

The objective of this study was to evaluate the impact of the tuberculosis (TB) mobile teams on treatment outcomes in Riyadh Region by comparing patients who received treatment under mobile teams and those who did not, from 2013 to 2015. This was a retrospective descriptive study using National TB Control and Prevention Program data from 2013 to 2015 from Riyadh, Kingdom of Saudi Arabia. Descriptive analyses were used to summarize characteristics of TB case-patients served by mobile teams and those who were not served. The χ2 test measured the significant differences between mobile-served and non-mobile-served case-patients. Exposure was whether or not the TB case-patient was under the care of the mobile team; the outcome of interest was whether or not treatment was successful, defined as treatment completed and cured. We found that the ratio of treatment success among mobile team case-patients was 1.28 greater than among those not served by mobile teams. The χ2 test showed a statistically significant finding (probability ratio=1.28; 95% confidence interval=1.21-1.35, p<0.01). Mobile teams increased the treatment success rate to 92%, compared to 71.77% among those not served by mobile teams. This study shows that community mobilization of mobile teams is an effective strategy to enhance TB treatment, reduced mortality and loss to follow-up and improve TB treatment outcomes.

Meningitis outbreak investigation in Nkoranza South Municipality in Brong Ahafo Region, Ghana, February, 2016.

The occurrence of communicable diseases highlights the need to have well-trained field epidemiologists at the forefront in the fight against these diseases, especially during an outbreak. Training for outbreak investigation is most effective when participants can develop their competencies in a practical exercise. This is a simulation of the steps in meningitis outbreak investigation conducted in Ghana in February 2016 by Ghana Field Epidemiology Training Programme (FELTP) residents and the public health technical team of the Nkoranza South Municipality as a field epidemiologist. This case study is suited to reinforce principles and skills already covered in a lecture or in background reading by providing a practical training beyond the scope of theoretical learning. It is primarily intended for training novice public health practitioners who should be able to complete the exercises in 3 hours.

Outbreak of pertussis at community A in Dormaa Municipality, Ghana, August 2016.

Pertussis is a vaccine preventable disease (VPD) monitored by the World Health Organization (WHO). Despite a long-established Pertussis immunization system, the re-emergence of the disease in some countries stressed the need to have well-trained field epidemiologists at the forefront in the fight against these VPDs, especially during an outbreak. Practical, hands-on training is useful for clearer understanding of the principles and development of competencies relevant to outbreak investigation, which will enhance field practice; case method training using realistic public health scenarios helps trainees put into practice learned theory. As such, this case study was adopted from a real Pertussis outbreak investigation that was conducted by Ghana's Field Epidemiology Training Program residents, together with the rapid response team members of Dormaa Municipal health directorate in August 2016. It was primarily designed for training novice public health practitioners in a facilitated classroom setting. Participants should be able to complete the exercises in approximately 3 hours.

Evaluation of home respiratory therapy delivered to patients in the Ministry of Health's Home Medical Program (HMP) and administered through the Madinah HMP Center, Kingdom of Saudi Arabia, 2013.

This was an evaluation of home respiratory therapy (HRT) services administered through the Madinah Home Medical Program (MHMP) Center of the Ministry of Health (MoH), Kingdom of Saudi Arabia (KSA). Using a retrospective design and descriptive analyses, we analyzed 83 patient records for the clinical care received, outcomes, and patient satisfaction. We also assessed a subset from an economic perspective. Demographically, 72% were >60 years of age, 80% were female, and 90% were Saudi. Asthma accounted for 34% of the diagnosed respiratory diseases, followed by chronic obstructive pulmonary disease (11%). Most patients (71%) required two or three respiratory modalities: 94% used oxygen therapy and 14% were on mechanical ventilation. A full 90% of HMP patients expressed a high level of satisfaction with the HMP overall care, and 43% saw an improvement in their condition. The MHMP lowered healthcare costs for HRT-receiving patients by decreasing the frequency of emergency room (ER) and outpatient visits by 50.8% from 59 to 30 visits. HRT administered through the MHMP Center improved clinical outcomes and increased patient satisfaction while reducing hospital utilization and associated costs. A prospective study is recommended to assess HMP services in comparison with hospitalization.

Trends of reported human cases of brucellosis, Kingdom of Saudi Arabia, 2004-2012.

Human brucellosis is an important zoonotic disease and is especially concerning in the Kingdom of Saudi Arabia (KSA), where livestock importation is significant. We analyzed reported human brucellosis disease trends in KSA over time to help policymakers understand the magnitude of the disease and guide the design of prevention and control measures. By using data from the national registry from 2004 to 2012, we calculated the cumulative numbers by age group and months. Trends of incidence rates (IRs) by gender, nationality, and region were also calculated. We found that there was a greater number of cases (19,130) in the 15-44 years age group than in any other age group. The IRs significantly decreased from 22.9 in 2004 [95% confidence interval (CI)=22.3, 23.5] to 12.5 in 2012 (95% CI=12.1, 13). Males had a significantly greater IR than females. Most cases were reported during spring and summer seasons. The IR of Saudi citizens was significantly greater than that of non-Saudis, but this difference reduced over time. The IRs of Al-Qassim, Aseer, and Hail were in the highest 25th percentile. Young, male Saudi citizens living in highly endemic areas were at greatest risk of acquiring brucellosis. We recommend vaccinating susceptible animals against brucellosis and increasing the public's awareness of preventive measures.

Evaluation of tuberculosis public health surveillance, Al-Madinah province, Kingdom of Saudi Arabia, 2012.

The objective of the study is to evaluate the quality of the data, the sensitivity of the surveillance, and the completeness of identification and investigation of tuberculosis (TB) patient's contacts. The study covered the TB surveillance program in Al-Madinah province in 2011. First, we reviewed all the notifications, treatment cards, and register books, as well as monthly and quarterly reports, for completeness and accuracy of data. Then, we searched for the missed cases that were not reported. Finally, we reviewed all the patients' household contacts' reports to assess the degree of completion of identification and investigation. There were 444 cases detected during the study period; only 200 cases were reported. The sensitivity of the TB surveillance system was 45%. Among the 200 reported cases, the results revealed high completeness rates for demographic and disease data and low completeness rates for the test result fields. The contact identification and investigation showed that 34.4% of smear-positive cases' contacts were not identified. Only 67% of identified contacts were investigated. The review of hospital records and lab registers showed that 244 cases were not reported. In conclusion, the TB surveillance system has several areas that need improvement.

Disruptive Innovation Can Prevent the Next Pandemic.

Public health surveillance (PHS) is at a tipping point, where the application of novel processes, technologies, and tools promise to vastly improve efficiency and effectiveness. Yet twentieth century, entrenched ideology and lack of training results in slow uptake and resistance to change. The term disruptive innovation - used to describe advances in technology and processes that change existing markets - is useful to describe the transformation of PHS. Past disruptive innovations used in PHS, such as distance learning, the smart phone, and field-based laboratory testing have outpaced older services, practices, and technologies used in the traditional classroom, governmental offices, and personal communication, respectively. Arguably, the greatest of these is the Internet - an infrastructural innovation that continues to enable exponential benefits in seemingly limitless ways. Considering the Global Health Security Agenda and facing emerging and reemerging infectious disease threats, evolving environmental and behavioral risks, and ever changing epidemiologic trends, PHS must transform. Embracing disruptive innovation in the structures and processes of PHS can be unpredictable. However, it is necessary to strengthen and unlock the potential to prevent, detect, and respond.

Compliance with postexposure screening and treatment of latent tuberculosis infection among healthcare workers in a tertiary care hospital in Saudi Arabia.

BACKGROUND: Controlling tuberculosis (TB) infection among occupationally exposed healthcare workers (HCWs) may be challenging. METHODS: We retrospectively reviewed clinical records of HCWs who were exposed to patients diagnosed with infectious TB at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between 2008 and 2010. The collected data included baseline tuberculin skin test (TST) status, potential predictors of TST positivity, postexposure diagnosis of latent TB infection (LTBI), and postexposure compliance with LTBI therapy. RESULTS: Thirteen patients were diagnosed with infectious pulmonary TB during the study period. A total of 298 HCWs met our definition for exposure. Exposed HCWs tended to be female (62.9%), non-Saudi (83.9%), nurses (68.6%), or respiratory therapists (24.0%) working in critical care locations (72.8%). Baseline (preemployment) TST documentation existed for 41.3% (123/298). Among those with documented baseline TSTs, 51.2% (63/123) were positive, representing 21.1% (63/298) of all HCWs. Only 48.9% (115/235) of exposed HCWs who had negative or unknown preexposure TST status had their TST tested after exposure. Approximately 46.1% (53/115) of them were diagnosed with postexposure LTBI, and 92.5% (49/53) of them were prescribed LTBI therapy. Among those, 93.9% (46/49) started LTBI therapy; however, 82.6% (38/46) failed to complete the recommended course. CONCLUSIONS: We found low rates of baseline TST documentation and postexposure screening among exposed HCWs. Compliance with initiating postexposure isoniazid prophylaxis among HCWs was fair, but only a small fraction of those who started prophylaxis completed the recommended course of therapy. These findings suggest substantial opportunities to implement administrative measures to enhance LTBI management among HCWs.