Outbreak of invasive meningococcal disease caused by a meningococcus serogroup B in a nursery school, Wallonia, Belgium, 2018.

Although most invasive meningococcal disease (IMD) cases are sporadic without identified transmission links, outbreaks can occur. We report three cases caused by meningococcus B (MenB) at a Belgian nursery school over 9 months. The first two cases of IMD occurred in spring and summer 2018 in healthy children (aged 3-5 years) attending the same classroom. Chemoprophylaxis was given to close contacts of both cases following regional guidelines. The third case, a healthy child of similar age in the same class as a sibling of one case, developed disease in late 2018. Microbiological analyses revealed MenB with identical finetype clonal complex 269 for Case 1 and 3 (unavailable for Case 2). Antimicrobial susceptibility testing revealed no antibiotic resistance. Following Case 3, after multidisciplinary discussion, chemoprophylaxis and 4CMenB (Bexsero) vaccination were offered to close contacts. In the 12-month follow-up of Case 3, no additional cases were reported by the school. IMD outbreaks are difficult to manage and generate public anxiety, particularly in the case of an ongoing cluster, despite contact tracing and management. This outbreak resulted in the addition of MenB vaccination to close contacts in Wallonian regional guidelines, highlighting the potential need and added value of vaccination in outbreak management.

The burden of legionnaires' disease in Belgium, 2013 to 2017.

BACKGROUND: Legionnaires' disease (LD) is a severe bacterial infection causing pneumonia. Surveillance commonly underestimates the true incidence as not all cases are laboratory confirmed and reported to public health authorities. The aim of this study was to present indicators for the impact of LD in Belgium between 2013 and 2017 and to estimate its true burden in the Belgian population in 2017, the most recent year for which the necessary data were available. METHODS: Belgian hospital discharge data, data from three infectious disease surveillance systems (mandatory notification, sentinel laboratories and the national reference center), information on reimbursed diagnostic tests from the Belgian National Institute for Health and Disability Insurance and mortality data from the Belgian statistical office were used. To arrive at an estimate of the total number of symptomatic cases in Belgium, we defined a surveillance pyramid and estimated a multiplication factor to account for LD cases not captured by surveillance. The multiplication factor was then applied to the pooled number of LD cases reported by the three surveillance systems. This estimate was the basis for our hazard- and incidence-based Disability-Adjusted Life Years (DALYs) calculation. To account for uncertainty in the estimations of the DALYs and the true incidence, we used Monte Carlo simulations with 10,000 iterations. RESULTS: We found an average of 184 LD cases reported by Belgian hospitals annually (2013-2017), the majority of which were male (72%). The surveillance databases reported 215 LD cases per year on average, 11% of which were fatal within 90 days after diagnosis. The estimation of the true incidence in the community yielded 2674 (95% Uncertainty Interval [UI]: 2425-2965) cases in 2017. LD caused 3.05 DALYs per case (95%UI: 1.67-4.65) and 8147 (95%UI: 4453-12,426) total DALYs in Belgium in 2017, which corresponds to 71.96 (95%UI: 39.33-109.75) DALYs per 100,000 persons. CONCLUSIONS: This analysis revealed a considerable burden of LD in Belgium that is vastly underestimated by surveillance data. Comparison with other European DALY estimates underlines the impact of the used data sources and methodological approaches on burden estimates, illustrating that national burden of disease studies remain essential.

Impact of solid cancer on in-hospital mortality overall and among different subgroups of patients with COVID-19: a nationwide, population-based analysis.

BACKGROUND: Cancer seems to have an independent adverse prognostic effect on COVID-19-related mortality, but uncertainty exists regarding its effect across different patient subgroups. We report a population-based analysis of patients hospitalised with COVID-19 with prior or current solid cancer versus those without cancer. METHODS: We analysed data of adult patients registered until 24 May 2020 in the Belgian nationwide database of Sciensano. The primary objective was in-hospital mortality within 30 days of COVID-19 diagnosis among patients with solid cancer versus patients without cancer. Severe event occurrence, a composite of intensive care unit admission, invasive ventilation and/or death, was a secondary objective. These endpoints were analysed across different patient subgroups. Multivariable logistic regression models were used to analyse the association between cancer and clinical characteristics (baseline analysis) and the effect of cancer on in-hospital mortality and on severe event occurrence, adjusting for clinical characteristics (in-hospital analysis). RESULTS: A total of 13 594 patients (of whom 1187 with solid cancer (8.7%)) were evaluable for the baseline analysis and 10 486 (892 with solid cancer (8.5%)) for the in-hospital analysis. Patients with cancer were older and presented with less symptoms/signs and lung imaging alterations. The 30-day in-hospital mortality was higher in patients with solid cancer compared with patients without cancer (31.7% vs 20.0%, respectively; adjusted OR (aOR) 1.34; 95% CI 1.13 to 1.58). The aOR was 3.84 (95% CI 1.94 to 7.59) among younger patients (<60 years) and 2.27 (95% CI 1.41 to 3.64) among patients without other comorbidities. Severe event occurrence was similar in both groups (36.7% vs 28.8%; aOR 1.10; 95% CI 0.95 to 1.29). CONCLUSIONS: This population-based analysis demonstrates that solid cancer is an independent adverse prognostic factor for in-hospital mortality among patients with COVID-19. This adverse effect was more pronounced among younger patients and those without other comorbidities. Patients with solid cancer should be prioritised in vaccination campaigns and in tailored containment measurements.

Ongoing measles outbreak in Wallonia, Belgium, December 2016 to March 2017: characteristics and challenges.

We describe characteristics of an ongoing measles outbreak in Wallonia, Belgium, and difficulties in control measures implementation. As at 12 March 2017, 177 measles cases were notified, of which 50% were 15 years and older, 49% female. Atypical clinical presentation and severe complications, mainly among adults, in combination with late notification, low or unknown vaccination coverage of contacts, infected healthcare workers and increased workload due to contact tracing, are the main concerns for outbreak management.

Correction: Capture-Recapture Estimators in Epidemiology with Applications to Pertussis and Pneumococcal Invasive Disease Surveillance.

[This corrects the article DOI: 10.1371/journal.pone.0159832.].

Different measles outbreaks in Belgium, January to June 2016 - a challenge for public health.

During the first half of 2016, several outbreaks of measles were reported in the three regions of Belgium. Main challenges for public health were severe complications occurring in adults, nosocomial transmission and infection in healthcare workers. Here, we describe those outbreaks and lessons learnt for public health.

Capture-Recapture Estimators in Epidemiology with Applications to Pertussis and Pneumococcal Invasive Disease Surveillance.

INTRODUCTION: Surveillance networks are often not exhaustive nor completely complementary. In such situations, capture-recapture methods can be used for incidence estimation. The choice of estimator and their robustness with respect to the homogeneity and independence assumptions are however not well documented. METHODS: We investigated the performance of five different capture-recapture estimators in a simulation study. Eight different scenarios were used to detect and combine case-information. The scenarios increasingly violated assumptions of independence of samples and homogeneity of detection probabilities. Belgian datasets on invasive pneumococcal disease (IPD) and pertussis provided motivating examples. RESULTS: No estimator was unbiased in all scenarios. Performance of the parametric estimators depended on how much of the dependency and heterogeneity were correctly modelled. Model building was limited by parameter estimability, availability of additional information (e.g. covariates) and the possibilities inherent to the method. In the most complex scenario, methods that allowed for detection probabilities conditional on previous detections estimated the total population size within a 20-30% error-range. Parametric estimators remained stable if individual data sources lost up to 50% of their data. The investigated non-parametric methods were more susceptible to data loss and their performance was linked to the dependence between samples; overestimating in scenarios with little dependence, underestimating in others. Issues with parameter estimability made it impossible to model all suggested relations between samples for the IPD and pertussis datasets. For IPD, the estimates for the Belgian incidence for cases aged 50 years and older ranged from 44 to58/100,000 in 2010. The estimates for pertussis (all ages, Belgium, 2014) ranged from 24.2 to30.8/100,000. CONCLUSION: We encourage the use of capture-recapture methods, but epidemiologists should preferably include datasets for which the underlying dependency structure is not too complex, a priori investigate this structure, compensate for it within the model and interpret the results with the remaining unmodelled heterogeneity in mind.

Legionnaires' disease: overview of the situation concerning notification in Wallonia (Belgium) in 2012, a retrospective descriptive study based on a capture-recapture method.

BACKGROUND: Legionnaires' disease is a severe form of pneumonia, and although public health medical inspectors must be notified, it is often under-reported. The objectives of this study were to determine the completeness rate of notification of Legionnaires' disease and to estimate the incidence of this disease in Wallonia, the southern part of Belgium, in 2012. METHOD: This retrospective, transversal descriptive study was based on a capture-recapture method using two sources. An estimation of the total number of Legionnaires' disease cases was calculated using Chapman and Seber's estimators for small numbers, thereby allowing us to estimate the real incidence of this disease in Wallonia as well as the completeness rate of notification. RESULTS: The total number of estimated Legionella cases for 2012 was 45 (IC 95%:41-48) and the completeness rate was 65% (IC 95%:61-70%). The estimated incidence of Legionnaires' disease in Wallonia was 1.27/100,000 inhabitants. CONCLUSIONS: The notification rate of Legionella must be improved in Wallonia. Doctors should be made aware of the importance of diagnosing and reporting Legionnaires' disease.

INTRODUCTION: Malgré une mortalité et morbidité non négligeables, la maladie du légionnaire est une maladie à déclaration obligatoire auprès des médecins inspecteurs qui est fréquemment sous rapportée. Les objectifs de cette étude furent le calcul de l'exhaustivité de la déclaration obligatoire de la maladie du légionnaire et l'estimation de son incidence en Wallonie, la partie sud de la Belgique, pour l'année 2012. MÉTHODOLOGIE: Cette étude descriptive transversale rétrospective s'est basée sur une méthode capture-recapture à 2 sources. Une estimation du nombre total de cas de maladie du légionnaire a été réalisée en utilisant les estimateurs de Chapman et Seber pour effectifs faibles. Ensuite, l'incidence réelle de la maladie du légionnaire en Wallonie ainsi que l'exhaustivité de la déclaration ont pu être calculées. RÉSULTATS: Le nombre total de cas estimés de maladie du légionnaire pour l'année 2012 est de 45 (IC 95% : 41­48) et le taux d'exhaustivité de la déclaration obligatoire est de 65% (IC 95% : 61-70%). L'incidence estimée de maladie du légionnaire en région wallonne est de 1,27/100.000 habitants. CONCLUSION: Le taux de notification de la maladie du légionnaire doit être amélioré en Wallonie. Les médecins devraient être mieux sensibilisés à la déclaration et au diagnostic de la maladie du légionnaire.

[Stakeholder representations of the role of the intermediate level of the DRC health system]. / Rôles exercés par le Niveau intermédiaire du système sanitaire en République démocratique du Congo: représentations des acteurs.

INTRODUCTION: Intermediate health care structures in the DRC were designed during the setting-up of primary health care in a perspective of health district support. This study was designed to describe stakeholder representations of the intermediate level of the DRC health system during the first 30 years of the primary health care system. METHODS: This case study was based on inductive analysis of data from 27 key informant interviews.. RESULTS: The intermediate level of the health system, lacking sufficient expertise and funding during the 1980s, was confined to inspection and control functions, answering to the central level of the Ministry of health and provincial authorities. Since the 1990s, faced with the pressing demand for support from health district teams, whose self-management had to deal with humanitarian emergencies, the need to integrate vertical programmes, and cope with the logistics of many different actors, the intermediate heath system developed methods and tools to support heath districts. This resulted in a subsidiary model of the intermediate level, the perceived efficacy of which varies according to the province over recent years. CONCLUSION: The "subsidiary" model of the intermediary health system level seems a good alternative to the "control" model in DRC.

[Reorganization of the provincial health system in the Democratic Republic of the Congo]. / Réforme des structures intermédiaires de santé en République démocratique du Congo.

INTRODUCTION: In the framework of implementation of health system reform in the Democratic Republic of the Congo (DRC), and in a context of decentralization dictated by the National Constitution, this study presents the process and results obtained in terms of the provincial level of health care organization in DRC. METHODS: A two-year multidisciplinary interventional research protocol was elaborated with two phases and 9 steps including organizational analysis, team building, and organizational learning. It resulted in transformational actions and improved knowledge, allowing the development of an innovative organizational model of the intermediate level of the health care system in the Democratic Republic of the Congo. RESULTS: This interventional research gave rise to function plans set up by the provincial health division (PHD) in order to develop a more participative management and to compensate for the weaknesses of the current structural organization. Experts provided support to PHD for implementation of a new structure in order to institutionalize this new participative management. The new organizational structure of the PHD is based on 4 professions: i) health district support; ii) control and inspection; iii) information, communication and research and iv) resources management. PHD and experts defined these professions and described the required skills. RESULTS were integrated into the new national health plan. CONCLUSIONS: Apart from the concrete results obtained, two major challenges need to be addressed: i) support the transformation of PHD from the current situation to the new model and ii) extend this new model to the other provinces, according to the same participative approach, a necessary condition to adjust the organization flow-chart to the context.

[Supporting the intermediate level of health care in urban health areas in Kinshasa (1995-2005), DR Congo]. / Soutien du niveau intermédiaire au district sanitaire urbain à Kinshasa (1995-2005), RD Congo.

As a result of the decentralization of health systems, some countries have introduced intermediate (provincial) levels in their public health system. This paper presents the results of a case study conducted in Kinshasa on health system decentralization. The study identified a shift from a focus on regulation compliance assessment to an emphasis on health system coordination and health district support. It also highlighted the emergence of a?managerial (as opposed to a bureaucratic) approach to health district support. The performance of health districts in terms of health care coverage and health service use were also found to have improved. The results highlight the importance of intermediate levels in?the health care system and the value of a more organic and managerial rationality in supporting health districts faced with the complexity of urban environments and the integration of specialized multi-partner programs and interventions.

Community volunteers can improve breastfeeding among children under six months of age in the Democratic Republic of Congo crisis.

BACKGROUND: Malnutrition is a major public health problem in developing countries and exclusive breastfeeding is an efficient strategy that can be used to prevent malnutrition and reduce child mortality. The objective of this study is to evaluate the effectiveness of community volunteers in promoting exclusive breastfeeding from birth in an area of endemic malnutrition. METHODS: This evaluation analyzed the impact of the community-based nutrition project in Katana health district of the Democratic Republic of Congo from 2004 to 2006. Each of the villages in this sector had a nutritional village committee made up of five members responsible for continuously working to raise awareness of the importance of exclusive breastfeeding from birth among pregnant women and community leaders in their respective villages. The program worked with community volunteers with a mean age of 37 years, most of whom were married (86%). Eighty percent of the community volunteers had completed secondary school or a higher level of education. Data related to the period of exclusive breastfeeding and to the number of visits made to the health services for 208 children. The data were compared with data from 178 infants collected from another health sector, which had never developed a community-based nutrition program. RESULTS: The duration of exclusive breastfeeding from birth (median, range) was 6 months (2 to 7) in the intervention area compared with 4 months (1 to 6) in the comparison area (p < 0.001). The proportion of infants receiving exclusive breastfeeding at six months of age was higher in the intervention area than in the comparison area: 57.7% (95% Confidence Interval, CI, 50.9 to 64.5) versus 2.7% (95%CI, 1.1 to 6.6) (p < 0.001). The intervention group had a higher mean weight at 12 months (standard deviation): 8.42 kg (1.41) compared to 7.97 kg (1.02), although this difference was not statistically significant (p = 0.055). CONCLUSIONS: The promotion of breastfeeding by community volunteers in an area of endemic malnutrition in rural Democratic Republic of Congo increased the duration of exclusive breastfeeding from birth.

Microbiologic and clinical features of Salmonella species isolated from bacteremic children in eastern Democratic Republic of Congo.

BACKGROUND: The morbidity of Salmonella bloodstream infections is unacceptably high in Africa. In 2000, the WHO Global Salmonella-Surveillance (GSS) program was founded to reduce the health burden of foodborne diseases. The incorporation, in 2002, of the Democratic Republic of Congo (DRC) in this program allowed the improvement of laboratory capacities. In this retrospective study, we describe the first signs of impact the GSS program has had in DRC in the management of bacteremia. METHODS: Between 2002 and 2006, we evaluated, in one pediatric hospital, the microbiologic and clinical features of Salmonella isolated from children suspected of having bacteremia. A random selection of isolates was typed by pulsed field gel electrophoresis (PFGE). RESULTS: Among the 1528 children included in the study, 26.8% were bacteremic. Salmonella accounted for 59% of all bloodstream infections. Salmonella typhimurium (60.5%) and Salmonella enteritidis (22.3%) were the most common Salmonella serotypes. In total, 92.4% were resistant to at least 3 antimicrobials with the following proportion of strains resistant to: ampicillin (86%), chloramphenicol (92%), trimethoprim/sulfamethoxazole (95%), and tetracycline (34%). In 2002, 32.1% of children received an appropriate empiric antimicrobial treatment. In 2006, with the restoration of the confidence in the results provided by the laboratory, we observed an increase of the proportion of patients appropriately (82.9%) treated with antimicrobials (P < 0.01) without any decrease in the overall mortality rates associated with salmonellae bacteremia. CONCLUSIONS: Our findings indicate the benefit to strengthen laboratory capacities in Africa, allowing the development of management guidelines of bloodstream infection.

[Factors associated with malnutrition in children aged under five years in Lubumbashi (DRC)]. / Facteurs prédictifs de la malnutrition chez les enfants âgés de moins de cinq ans à Lubumbashi (RDC).

Nutritional status of children is a global indicator of children's well-being and, indirectly, of the community's well-being. The first objective of this work is to assess the nutritional status of children under five years-old living in a suburb of the city of Lubumbashi, DR Congo, at the end of the 1998-2003 armed conflict. The second objective aims to identify some predictors of malnutrition. A multivariate logistic regression was applied to the results of a cross-sectional survey of 1963 children from selected households. In addition to the anthropometric variables, living conditions were also used. We observed 33.5% stunted growth and 3.8% emaciation. After logistic regression, a low maternal educational level (less than 7 years), the absence of a drinking water tap available in the house or yard, male gender, and age of children ( > 11 months) were all significantly associated with increased risk of stunted growth. Moreover, decreased appetite, diarrhea and age of children ( < 12 months) were significant predictors of emaciation. Compared to the classification of the World Health Organization, our results indicate that the prevalence of stunting is high and the prevalence of emaciation is low. Interventions against malnutrition should consider the various predictors discussed in this study in order to reduce mortality and morbidity in children and contribute to their well-being.

Nutritional monitoring of preschool-age children by community volunteers during armed conflict in the Democratic Republic of the Congo.

BACKGROUND: The coverage of preschool preventive medical visits in developing countries is still low. Consequently, very few children benefit from continuous monitoring during the first 5 years of life. OBJECTIVE: To assess community volunteers' effectiveness in monitoring the growth of preschool-age children in a context of endemic malnutrition and armed conflict. METHODS: Community volunteers were selected by village committees and trained to monitor children's growth in their respective villages. Community volunteers monitored 5479 children under 5 years of age in the Lwiro Health Sector of the Democratic Republic of the Congo from January 2004 to December 2005 under the supervision of the district health office. Children's weight was interpreted according to weight-for-age curves drawn on the growth sheet proposed by the World Health Organization and adopted by the Democratic Republic of the Congo. RESULTS: During the 2-year program, the volunteers weighed children under 5 years of age monthly. The median percentage of children weighed per village varied between 80% and 90% for children of 12-59 months, and 80% and 100% for children of less than 12 months even during the conflict period. The median percentage of children between 12 and 59 months of age per village ranked as highly susceptible to malnutrition by the volunteers decreased from 4.2% (range, 0% to 35.3%) in 2004 to 2.8% (range, 0.0% to 18.9%) in 2005. CONCLUSIONS: The decentralization of weighing of children to the community level could be an alternative for improving growth monitoring of preschool-age children in situations of armed conflict or political instability. This option also offers an opportunity to involve the community in malnutrition care and can be an entry point for other public health activities.

[Intra-hospital mortality of children in central Africa: looking at the impact of a training programme and increased supervision]. / Impact d'un programme de formation et de supervision de la qualité des soins sur la mortalité intra-hospitalière des enfants en Afrique centrale.

The study's aim was to evaluate the impact of an in-service training course and supervision of physicians and nurses in terms of quality of care on intra-hospital mortality. The study included 2 cohorts of children. Cohort 1 included 414 children from 0 to 15-years-old who were followed in the paediatric wards of the provincial hospital of Goma (HPG) between April 1, 2003 and March 31, 2004. Cohort 2 included 996 children from 0 to 15-years-old where were treated and followed in the same service between January 1, 2005 and December 31, 2005. General and specific mortalities occurring before and after an intervention were compared, as were the ratios of the observed deaths to the predicted deaths through the application of the Goma1 model to cohort 2. Overall mortality decreased by 15,9% (before the intervention) to 4,6% (after the intervention), translating to a total reduction of 71,1%. The ratios between the observed deaths and the predicted deaths were lower than 1, globally and when stratified. The risk of death in the cohort 1 (before the intervention) is 6,8 times higher than in cohort 2 (after the intervention). This shows an improvement of child survival after the intervention.