Surveillance To Track Progress Toward Poliomyelitis Eradication - Worldwide, 2021-2022.

Since the Global Polio Eradication Initiative (GPEI) was established in 1988, the number of wild poliovirus (WPV) cases has declined by >99.9%, and WPV serotypes 2 and 3 have been declared eradicated (1). By the end of 2022, WPV type 1 (WPV1) transmission remained endemic only in Afghanistan and Pakistan (2,3). However, during 2021-2022, Malawi and Mozambique reported nine WPV1 cases that were genetically linked to Pakistan (4,5), and circulating vaccine-derived poliovirus (cVDPV) outbreaks were detected in 42 countries (6). cVDPVs are oral poliovirus vaccine-derived viruses that can emerge after prolonged circulation in populations with low immunity allowing reversion to neurovirulence and can cause paralysis. Polioviruses are detected primarily through surveillance for acute flaccid paralysis (AFP), and poliovirus is confirmed through stool specimen testing. Environmental surveillance, the systematic sampling of sewage and testing for the presence of poliovirus, supplements AFP surveillance. Both surveillance systems were affected by the COVID-19 pandemic's effects on public health activities during 2020 (7,8) but improved in 2021 (9). This report updates previous reports (7,9) to describe surveillance performance during 2021-2022 in 34 priority countries.* In 2022, a total of 26 (76.5%) priority countries met the two key AFP surveillance performance indicator targets nationally compared with 24 (70.6%) countries in 2021; however, substantial gaps remain in subnational areas. Environmental surveillance expanded to 725 sites in priority countries, a 31.1% increase from the 553 sites reported in 2021. High-quality surveillance is critical to rapidly detect poliovirus transmission and enable prompt poliovirus outbreak response to stop circulation. Frequent monitoring of surveillance guides improvements to achieve progress toward polio eradication.

Stopping a polio outbreak in the midst of war: Lessons from Syria.

BACKGROUND: Outbreaks of circulating vaccine-derived polioviruses (cVDPVs) pose a threat to the eventual eradication of all polioviruses. In 2017, an outbreak of cVDPV type 2 (cVDPV2) occurred in the midst of a war in Syria. We describe vaccination-based risk factors for and the successful response to the outbreak. METHODS: We performed a descriptive analysis of cVDPV2 cases and key indicators of poliovirus surveillance and vaccination activities during 2016-2018. In the absence of reliable subnational coverage data, we used the caregiver-reported vaccination status of children with non-polio acute flaccid paralysis (AFP) as a proxy for vaccination coverage. We then estimated the relative odds of being unvaccinated against polio, comparing children in areas affected by the outbreak to children in other parts of Syria in order to establish the presence of poliovirus immunity gaps in outbreak affected areas. FINDINGS: A total of 74 cVDPV2 cases were reported, with paralysis onset ranging from 3 March to 21 September 2017. All but three cases were reported from Deir-ez-Zor governorate and 84% had received < 3 doses of oral poliovirus vaccine (OPV). After adjusting for age and sex, non-polio AFP case-patients aged 6-59 months in outbreak-affected areas had 2.5 (95% CI: 1.1-5.7) increased odds of being unvaccinated with OPV compared with non-polio AFP case-patients in the same age group in other parts of Syria. Three outbreak response rounds of monovalent OPV type 2 (mOPV2) vaccination were conducted, with governorate-level coverage mostly exceeding 80%. INTERPRETATION: Significant declines in both national and subnational polio vaccination coverage, precipitated by war and a humanitarian crisis, led to a cVDPV2 outbreak in Syria that was successfully contained following three rounds of mOPV2 vaccination.

Testing early warning and response systems through a full-scale exercise in Vietnam.

BACKGROUND: Simulation exercises can functionally validate World Health Organization (WHO) International Health Regulations (IHR 2005) core capacities. In 2018, the Vietnam Ministry of Health (MOH) conducted a full-scale exercise (FSX) in response to cases of severe viral pneumonia with subsequent laboratory confirmation for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) to evaluate the country's early warning and response capabilities for high-risk events. METHODS: An exercise planning team designed a complex fictitious scenario beginning with one case of severe viral pneumonia presenting at the hospital level and developed all the materials required for the exercise. Actors, controllers and evaluators were trained. In August 2018, a 3-day exercise was conducted in Quang Ninh province and Hanoi city, with participation of public health partners at the community, district, province, regional and national levels. Immediate debriefings and an after-action review were conducted after all exercise activities. Participants assessed overall exercise design, conduction and usefulness. RESULTS: FSX findings demonstrated that the event-based surveillance component of the MOH surveillance system worked optimally at different administrative levels. Detection and reporting of signals at the community and health facility levels were appropriate. Triage, verification and risk assessment were successfully implemented to identify a high-risk event and trigger timely response. The FSX identified infection control, coordination with internal and external response partners and process documentation as response challenges. Participants positively evaluated the exercise training and design. CONCLUSIONS: This exercise documents the value of exercising surveillance capabilities as part of a real-time operational scenario before facing a true emergency. The timing of this exercise and choice of disease scenario was particularly fortuitous given the subsequent appearance of COVID-19. As a result of this exercise and subsequent improvements made by the MOH, the country may have been better able to deal with the emergence of SARS-CoV-2 and contain it.

Challenges in Public Health Rapid Response Team Management.

The International Health Regulations (2005) dictate the need for states parties to establish capacity to respond promptly and effectively to public health risks. Public health rapid response teams (RRTs) can fulfill this need as a component of a larger public health emergency response infrastructure. However, lack of a standardized approach to establishing and managing RRTs can lead to substantial delays in effective response measures. As part of the Global Health Security Agenda, national governments have sought to develop and more formally institute their RRTs. RRT challenges were identified from 21 countries spanning 4 continents from 2016 to 2018 through direct observation of RRTs deployed during public health emergencies, discussions with RRT managers involved in outbreak response, and during formal RRT management training workshops. One major challenge identified is the development and maintenance of an RRT roster to ensure deployable surge staff identification, selection, and availability. Another challenge is ensuring that RRT members are trained and have the relevant competencies to be effective in the field. Finally, the lack of defined RRT standard operating procedures covering both nonemergency maintenance measures and the multistage emergency response processes required for RRT function can delay the RRT's response time and effectiveness. These findings highlight the importance of planning to preemptively address these challenges to ensure rapid and effective response measures, ultimately strengthening global health security.

Strategic Response to an Outbreak of Circulating Vaccine-Derived Poliovirus Type 2 - Syria, 2017-2018.

Since the 1988 inception of the Global Polio Eradication Initiative (GPEI), progress toward interruption of wild poliovirus (WPV) transmission has occurred mostly through extensive use of oral poliovirus vaccine (OPV) in mass vaccination campaigns and through routine immunization services (1,2). However, because OPV contains live, attenuated virus, it carries the rare risk for reversion to neurovirulence. In areas with very low OPV coverage, prolonged transmission of vaccine-associated viruses can lead to the emergence of vaccine-derived polioviruses (VDPVs), which can cause outbreaks of paralytic poliomyelitis. Although WPV type 2 has not been detected since 1999, and was declared eradicated in 2015,* most VDPV outbreaks have been attributable to VDPV serotype 2 (VDPV2) (3,4). After the synchronized global switch from trivalent OPV (tOPV) (containing vaccine virus types 1, 2, and 3) to bivalent OPV (bOPV) (types 1 and 3) in April 2016 (5), GPEI regards any VDPV2 emergence as a public health emergency (6,7). During May-June 2017, VDPV2 was isolated from stool specimens from two children with acute flaccid paralysis (AFP) in Deir-ez-Zor governorate, Syria. The first isolate differed from Sabin vaccine virus by 22 nucleotides in the VP1 coding region (903 nucleotides). Genetic sequence analysis linked the two cases, confirming an outbreak of circulating VDPV2 (cVDPV2). Poliovirus surveillance activities were intensified, and three rounds of vaccination campaigns, aimed at children aged <5 years, were conducted using monovalent OPV type 2 (mOPV2). During the outbreak, 74 cVDPV2 cases were identified; the most recent occurred in September 2017. Evidence indicates that enhanced surveillance measures coupled with vaccination activities using mOPV2 have interrupted cVDPV2 transmission in Syria.

Are Children or Adolescents More at Risk for Posttraumatic Stress Reactions Following Exposure to Violence?: Evidence From Post-Genocide Rwanda.

Whether children or adolescents exhibit higher levels of posttraumatic stress symptoms (PTSS) in response to violence is an unresolved research question. We examine this issue in UNICEF's 1995 National Trauma Survey (NTS) of 8-19-year-olds (n = 942) who survived the Rwandan Genocide and lived and attended schools in the community. PTSS were assessed with a symptom checklist based on DSM-IV indexed using an overall score comprising the sum of scores on all items and mean item scores of each of five distinct factors identified in a factor analysis within this sample. Eighty percent of the sample had witnessed massacres; 25%, rape/sexual mutilation. The overall symptom score among children was significantly (p < 0.05) lower than among adolescents. Among the five separate factors, this direct association of age with symptom levels held for two: re-experiencing (p < 0.001) and dysphoric arousal (p < 0.05), but not for the remaining three: avoidance, numbing, and anxious arousal. This discordance in factorial response to violence may help explain prevailing inconsistencies in the age-PTSS association reported to date.

Establishment of CDC Global Rapid Response Team to Ensure Global Health Security.

The 2014-2016 Ebola virus disease epidemic in West Africa highlighted challenges faced by the global response to a large public health emergency. Consequently, the US Centers for Disease Control and Prevention established the Global Rapid Response Team (GRRT) to strengthen emergency response capacity to global health threats, thereby ensuring global health security. Dedicated GRRT staff can be rapidly mobilized for extended missions, improving partner coordination and the continuity of response operations. A large, agencywide roster of surge staff enables rapid mobilization of qualified responders with wide-ranging experience and expertise. Team members are offered emergency response training, technical training, foreign language training, and responder readiness support. Recent response missions illustrate the breadth of support the team provides. GRRT serves as a model for other countries and is committed to strengthening emergency response capacity to respond to outbreaks and emergencies worldwide, thereby enhancing global health security.

The impact of active surveillance and health education on an Ebola virus disease cluster - Kono District, Sierra Leone, 2014-2015.

BACKGROUND: During December 2014-February 2015, an Ebola outbreak in a village in Kono district, Sierra Leone, began following unsafe funeral practices after the death of a person later confirmed to be infected with Ebola virus. In response, disease surveillance officers and community health workers, in collaboration with local leadership and international partners, conducted 1 day of active surveillance and health education for all households in the village followed by ongoing outreach. This study investigated the impact of these interventions on the outbreak. METHODS: Fifty confirmed Ebola cases were identified in the village between December 1, 2014 and February 28, 2015. Data from case investigations, treatment facility and laboratory records were analyzed to characterize the outbreak. The reproduction number (R) was estimated by fitting to the observed distribution of secondary cases. The impact of the active surveillance and health education was evaluated by comparing two outcomes before and after the day of the interventions: 1) the number of days from symptom onset to case-patient isolation or death and 2) a reported epidemiologic link to a prior Ebola case. RESULTS: The case fatality ratio among the 50 confirmed Ebola cases was 64.0 %. Twenty-three cases occurred among females (46.0 %); the mean age was 39 years (median: 37 years; range: 5 months to 75 years). Forty-three (87.8 %) cases were linked to the index case; 30 (61.2 %) were either at the funeral of Patient 1 or had contact with him while he was ill. R was 0.93 (95 % CI: 0.15-2.3); excluding the funeral, R was 0.29 (95 % CI: 0.11-0.53). The mean number of days in the community after onset of Ebola symptoms decreased from 4.0 days (median: 3 days; 95 % CI: 3.2-4.7) before the interventions to 2.9 days (median: 2 days; 95 % CI: 1.6-4.3) afterward. An epidemiologic link was reported in 47.6 % of case investigations prior to and 100 % after the interventions. CONCLUSIONS: Initial case investigation and contact tracing were hindered by delayed reporting and under-reporting of symptomatic individuals from the community. Active surveillance and health education contributed to quicker identification of suspected cases, interrupting further transmission.

Monitoring of Persons with Risk for Exposure to Ebola Virus Disease - United States, November 3, 2014-March 8, 2015.

On October 27, 2014, CDC released guidance for monitoring and movement of persons with potential Ebola virus disease (Ebola) exposure in the United States. For persons with possible exposure to Ebola, this guidance recommended risk categorization, daily monitoring during the 21-day incubation period, and, for persons in selected risk categories, movement restrictions. The purpose of the guidance was to delineate methods for early identification of symptoms among persons at potential risk for Ebola so that they could be isolated, tested, and if necessary, treated to improve their chance of survival and reduce transmission. Within 7 days, all 50 states and two local jurisdictions (New York City [NYC] and the District of Columbia [DC]) had implemented the guidelines. During November 3, 2014-March 8, 2015, a total of 10,344 persons were monitored for up to 21 days with >99% complete monitoring. This public health response demonstrated the ability of state, territorial, and local health agencies to rapidly implement systems to effectively monitor thousands of persons over a sustained period.

Measuring the impact of Hurricane Katrina on access to a personal healthcare provider: the use of the National Survey of Children's Health for an external comparison group.

This paper examined the effect of Hurricane Katrina on children's access to personal healthcare providers and evaluated the use of propensity score methods to compare a nationally representative sample of children, as a proxy for an unexposed group, with a smaller exposed sample. 2007 data from the Gulf Coast Child and Family Health (G-CAFH) Study, a longitudinal cohort of households displaced or greatly impacted by Hurricane Katrina, were matched with 2007 National Survey of Children's Health (NSCH) data using propensity score techniques. Propensity scores were created using poverty level, household educational attainment, and race/ethnicity, with and without the addition of child age and gender. The outcome was defined as having a personal healthcare provider. Additional confounders (household structure, neighborhood safety, health and insurance status) were also examined. All covariates except gender differed significantly between the exposed (G-CAFH) and unexposed (NSCH) samples. Fewer G-CAFH children had a personal healthcare provider (65 %) compared to those from NSCH (90 %). Adjusting for all covariates, the propensity score analysis showed exposed children were 20 % less likely to have a personal healthcare provider compared to unexposed children in the US (OR = 0.80, 95 % CI 0.76, 0.84), whereas the logistic regression analysis estimated a stronger effect (OR = 0.28, 95 % CI 0.21, 0.39). Two years after Hurricane Katrina, children exposed to the storm had significantly lower odds of having a personal health care provider compared to unexposed children. Propensity score matching techniques may be useful for combining separate data samples when no clear unexposed group exists.

Children as bellwethers of recovery: dysfunctional systems and the effects of parents, households, and neighborhoods on serious emotional disturbance in children after Hurricane Katrina.

BACKGROUND: Over 160,000 children were displaced from their homes after Hurricane Katrina. Tens of thousands of these children experienced the ongoing chaos and uncertainty of displacement and transiency, as well as significant social disruptions in their lives. The objectives of this study were to estimate the long-term mental health effects of such exposure among children, and to elucidate the systemic pathways through which the disaster effect operates. METHODS: The prevalence of serious emotional disturbance was assessed among 283 school-aged children in Louisiana and Mississippi. These children are part of the Gulf Coast Child & Family Health Study, involving a longitudinal cohort of 1079 randomly sampled households in the two states, encompassing a total of 427 children, who have been interviewed in 4 annual waves of data collection since January 2006. The majority of data for this analysis was drawn from the fourth round of data. RESULTS: Although access to medical care for children has expanded considerably since 2005 in the region affected by Hurricane Katrina, more than 37% of children have received a clinical mental health diagnosis of depression, anxiety, or behavior disorder, according to parent reports. Children exposed to Hurricane Katrina were nearly 5 times as likely as a pre-Katrina cohort to exhibit serious emotional disturbance. Path analyses confirm the roles played by neighborhood social disorder, household stressors, and parental limitations on children's emotional and behavioral functioning. CONCLUSIONS: Children and youth are particularly vulnerable to the effects of disasters. They have limited capacity to independently mobilize resources to help them adapt to stressful postdisaster circumstances, and are instead dependent upon others to make choices that will influence their household, neighborhood, school, and larger social environment. Children's mental health recovery in a postdisaster setting can serve as a bellwether indicator of successful recovery or as a lagging indicator of system dysfunction and failed recovery.

Measuring individual disaster recovery: a socioecological framework.

BACKGROUND: Disaster recovery is a complex phenomenon. Too often, recovery is measured in singular fashion, such as quantifying rebuilt infrastructure or lifelines, without taking in to account the affected population's individual and community recovery. A comprehensive framework is needed that encompasses a much broader and far-reaching construct with multiple underlying dimensions and numerous causal pathways; without the consideration of a comprehensive framework that investigates relationships between these factors, an accurate measurement of recovery may not be valid. This study proposes a model that encapsulates these ideas into a single framework, the Socio-Ecological Model of Recovery. METHODS: Using confirmatory factor analysis, an operational measure of recovery was developed and validated using the five measures of housing stability, economic stability, physical health, mental health, and social role adaptation. The data were drawn from a sample of displaced households following Hurricane Katrina. Measures of psychological strength, risk, disaster exposure, neighborhood contextual effects, and formal and informal help were modeled to examine their direct and indirect effects on recovery using a structural equation model. FINDINGS: All five elements of the recovery measure were positively correlated with a latent measure of recovery, although mental health and social role adaptation displayed the strongest associations. An individual's psychological strength had the greatest association with positive recovery, followed by having a household income greater than $20,000 and having informal social support. Those factors most strongly associated with an absence of recovery included the time displaced since the hurricane, being disabled, and living in a community with substantial social disorder. DISCUSSION: The socio-ecological framework provides a robust means for measuring recovery, and for testing those factors associated with the presence or absence of recovery.

Post-traumatic stress reactions among Rwandan children and adolescents in the early aftermath of genocide.

BACKGROUND: Epidemiological investigations of post-traumatic stress reactions in Sub-Saharan Africa, where atrocious violence against civilians is endemic, are rare. This article is the first complete report of the key community-based findings of a 1995 psychiatric epidemiological survey of young survivors of the 1994 Rwandan Genocide. METHODS: The National Trauma Survey (NTS) of Rwandans aged 8-19 measured traumatic exposures using an inventory of possible war time experiences and post-traumatic stress reactions with a checklist of symptoms of Post-traumatic stress disorder (PTSD). Individuals meeting assessed PTSD diagnostic criteria are classified as cases of 'probable PTSD'. The NTS interviewed youth residing in the community and others institutionalized in unaccompanied children's centres; the former (n = 1547) are the subject of the present report. Instrument change midway into the study divides respondents into two samples. RESULTS: Among respondents, over 90% witnessed killings and had their lives threatened; 35% lost immediate family members; 30% witnessed rape or sexual mutilation; 15% hid under corpses. In Sample 1, 95% of respondents reported one or more re-experiencing symptom, 95% reported three or more avoidance/blunting symptoms and 63% reported two or more arousal symptoms; in Sample 2, these figures were 96%, 95% and 56%, respectively. The overall rate of 'probable PTSD' was 62% and 54% in Samples 1 and 2, respectively, and exhibited a dose-response relationship with exposure. Among the most heavily exposed individuals the rate was 100%. Rates of 'probable PTSD' were higher among females than among males. Results for age were inconsistent. CONCLUSION: In industrialized societies, most survivors of traumatizing violence experience symptoms only transiently. In the Rwanda survey, symptom levels and rates of 'probable PTSD' were exceptionally elevated, suggesting that at the limits of catastrophic man-made violence, psychological resilience among youth is all but extinguished.

Prevalence and predictors of mental health distress post-Katrina: findings from the Gulf Coast Child and Family Health Study.

BACKGROUND: Catastrophic disasters often are associated with massive structural, economic, and population devastation; less understood are the long-term mental health consequences. This study measures the prevalence and predictors of mental health distress and disability of hurricane survivors over an extended period of recovery in a postdisaster setting. METHODS: A representative sample of 1077 displaced or greatly affected households was drawn in 2006 using a stratified cluster sampling of federally subsidized emergency housing settings in Louisiana and Mississippi, and of Mississippi census tracts designated as having experienced major damage from Hurricane Katrina in 2005. Two rounds of data collection were conducted: a baseline face-to-face interview at 6 to 12 months post-Katrina, and a telephone follow-up at 20 to 23 months after the disaster. Mental health disability was measured using the Medical Outcome Study Short Form 12, version 2 mental component summary score. Bivariate and multivariate analyses were conducted examining socioeconomic, demographic, situational, and attitudinal factors associated with mental health distress and disability. RESULTS: More than half of the cohort at both baseline and follow-up reported significant mental health distress. Self-reported poor health and safety concerns were persistently associated with poorer mental health. Nearly 2 years after the disaster, the greatest predictors of poor mental health included situational characteristics such as greater numbers of children in a household and attitudinal characteristics such as fatalistic sentiments and poor self-efficacy. Informal social support networks were associated significantly with better mental health status. Housing and economic circumstances were not independently associated with poorer mental health. CONCLUSIONS: Mental health distress and disability are pervasive issues among the US Gulf Coast adults and children who experienced long-term displacement or other serious effects as a result of Hurricanes Katrina and Rita. As time progresses postdisaster, social and psychological factors may play greater roles in accelerating or impeding recovery among affected populations. Efforts to expand disaster recovery and preparedness policies to include long-term social re-engagement efforts postdisaster should be considered as a means of reducing mental health sequelae.