Piloting wastewater-based surveillance of norovirus in England.

Wastewater-based epidemiology (WBE) gained widespread use as a tool for supporting clinical disease surveillance during the COVID-19 pandemic. There is now significant interest in the continued development of WBE for other pathogens of clinical significance. In this study, approximately 3,200 samples of wastewater from across England, previously collected for quantification of SARS-CoV-2, were re-analysed for the quantification of norovirus genogroup I (GI) and II (GII). Overall, GI and GII were detected in 93% and 98% of samples respectively, and at least one of the genogroups was detected in 99% of samples. GI was found at significantly lower concentrations than GII, but the proportion of each genogroup varied over time, with GI becoming more prevalent than GII in some areas towards the end of the study period (May 2021 - March 2022). Using relative strength indices (RSI), it was possible to study the trends of each genogroup, and total norovirus over time. Increases in norovirus levels appeared to coincide with the removal of COVID-19 related lockdown restrictions within England. Local Moran's I analyses indicated several localised outbreaks of both GI and GII across England, notably the possible GI outbreak in the north of England in early 2022. Comparisons of national average norovirus concentrations in wastewater against concomitant norovirus reported case numbers showed a significant linear relationship. This highlights the potential for wastewater-based monitoring of norovirus as a valuable approach to support surveillance of norovirus in communities.

A survey of the representativeness and usefulness of wastewater-based surveillance systems in 10 countries across Europe in 2023.

Wastewater-based surveillance (WBS) has become a widespread method to monitor transmission of SARS-CoV-2 and other human pathogens in Europe. We conducted a survey about WBS systems' objectives, approaches, representativeness and usefulness in 10 invited European countries in 2023, i.e. Austria, Belgium, Denmark, Finland, Greece, Hungary, Italy, Luxembourg, the Netherlands and Norway. All countries completed the study questionnaire about their SARS-CoV-2 WBS systems, and shared information about WBS of other pathogens as deemed relevant. SARS-CoV-2 WBS systems primarily monitored national and subnational trends (population coverage: 25-99%), and a majority (8/10) also tracked variant distribution. Nine of 10 countries reported that their SARS-CoV-2 WBS systems were representative of their population and all countries remarked that the findings were valuable for public health decision-making. Results were shared with relevant public health authorities and published via dedicated websites and/or dashboards. WBS systems of other pathogens were mostly in the early stages, with some countries implementing pilots. Notable exceptions were the well-established poliovirus surveillance systems in Finland, Italy and the Netherlands. This study brings understanding the diverse landscape of WBS in Europe, offering insights for future developments and collaborations. Furthermore, it highlights the need for further integration of WBS into other European surveillance systems.

[Continuous SARS-CoV-2 monitoring in day care centers: A qualitative interview study on the experiences of childcare workers and parents with different self-sampling methods in the home environment]. / Kontinuierliche Überwachung von SARS-CoV-2 Infektionen in Kindertagesstätten: eine qualitative Interviewstudie über die Erfahrungen von Betreuer*innen und Eltern mit verschiedenen Testverfahren im häuslichen Umfeld.

BACKGROUND: Since the beginning of the corona pandemic in Germany in January 2020, day care centres (DCC) have faced the challenge of reliably detecting cases of SARS-CoV-2 infection as early and reliably as possible in order to avoid major outbreaks and closures. Conducting regular virological screening tests for asymptomatic DCC children and childcare workers requires a high level of acceptance among participants and should be as easy as possible to implement. The present study aimed to evaluate childcare workers' and parents' attitudes and experiences regarding the acceptance and feasibility of various screening methods. This assessment was conducted using additional qualitative interviews designed for home-based screening in the context of a screening study in DCCs. METHOD: From May to July 2021, childcare workers and parents of children in nine DCCs in Wuerzburg independently carried out screening tests for SARS-CoV-2 at home twice a week as part of the "Würzburg Child Care Study in the COVID-19 Pandemic 2.0". The participants were offered two self-sampling methods (mouth-rinsing fluid for pooled PCR tests and/or nasal rapid antigen self-tests). Before and after the 12-week test phase, telephone interviews were conducted with a selected sample of childcare workers and parents in order to ascertain initial attitudes and further experiences with the two self-sampling methods and their implementation. The interviews were fully transcribed for analysis and subjected to a qualitative content analysis according to Kuckartz. RESULTS: Of the 1,026 eligible participants, 591 individuals, including 139 childcare workers and the parents of 452 children, agreed to take part in the screening tests. A total of 49 interviews were conducted with a specifically selected sample (20 before the start of the test, 29 after the end of the test). In the qualitative content analysis, three overarching topics emerged: 'aspects of the test performance', 'aspects of the perception of safety' and 'aspects of the testing in children'. Regardless of the fact that the various test methods and test features were perceived very differently, conducting the tests at home was found to be feasible. DISCUSSION: The differentiated insights into the participants' perspectives provide valuable information about factors that influence the acceptance of self-testing. These should be taken into account before such a measure is introduced in DCCs if necessary. CONCLUSION: The assessment of test procedures is strongly influenced by individual preferences. Test concepts should be implemented with as little time and organisational effort as possible in order to promote willingness to participate. Clear study information and quick feedback on test results can enhance the sense of security among parents and childcare workers.

Trends in HIV Prevalence, Sexual Behavior, and Pre-Exposure Prophylaxis Willingness Among Transgender Women: An Analysis of Three Cross-Sectional Studies Conducted Mainly in Shenyang, China, 2014-2019.

Purpose: Although transgender women (TGW) bear the highest HIV burden worldwide, routine surveillance of this group is rare. We aimed to evaluate the trends in health characteristics of Chinese TGW. Methods: Three cross-sectional studies using snowball sampling were conducted in 2014, 2017, and 2019, primarily in Shenyang, China. A questionnaire and voluntary HIV testing were used to obtain information on background characteristics, sexual behaviors, pre-exposure prophylaxis (PrEP) willingness, and HIV status. Results: There were 220 respondents in 2014, 198 in 2017, and 247 in 2019 (average age 31.1±7.6 to 33.5±9.6 years). HIV prevalence significantly decreased from 29.5% (95% confidence interval [CI]: 25.3-38.4%) in 2014 to 19.4% (95% CI: 14.7-24.9%) in 2019 (p<0.05). The proportion of participants reporting condomless anal intercourse (CAI) with any partner fluctuated from 30.8% (95% CI: 25.1-36.1%) to 53.0% (95% CI: 45.8-60.1%). The proportion of participants willing to use PrEP decreased from 86.4% (95% CI: 81.1-90.6%) in 2014 to 62.8% (95% CI: 56.4-68.8%) in 2019. Factors significantly associated with HIV infection were CAI with any partner (multivariate odds ratio [ORm]: 3.58, 95% CI: 1.55-8.29 in 2017; ORm: 3.18, 95% CI: 1.56-6.46 in 2019) and PrEP willingness (ORm: 0.26, 95% CI: 0.12-0.58 in 2017). Conclusion: HIV prevalence and associated risk factors remain substantial among Chinese TGW. There is an urgent need to strengthen HIV surveillance in this population, and develop trans-friendly and effective interventions to minimize HIV prevalence and transmission.

Clinical Significance, Species Distribution, and Temporal Trends of Nontuberculous Mycobacteria, Denmark, 1991-2022.

Nontuberculous mycobacteria (NTM) are emerging as notable causative agents of opportunistic infections. To examine clinical significance, species distribution, and temporal trends of NTM in Denmark, we performed a nationwide register-based study of all unique persons with NTM isolated in the country during 1991-2022. We categorized patients as having definite disease, possible disease, or isolation by using a previously validated method. The incidence of pulmonary NTM increased throughout the study period, in contrast to earlier findings. Mycobacterium malmoense, M. kansasii, M. szulgai, and M. avium complex were the most clinically significant species based on microbiologic findings; M. avium dominated in incidence. This study shows the need for surveillance for an emerging infection that is not notifiable in most countries, provides evidence to support clinical decision-making, and highlights the importance of not considering NTM as a single entity.

Opportunities for Enhanced Public Health Surveillance via Molecular Detection and Sequencing of Diverse Respiratory Viruses From Self-collected SARS-CoV-2 Antigen Test Swabs.

We sequenced and genotyped severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), influenza, adenovirus, and respiratory syncytial virus, among other pathogens, from residual anterior nasal swabs self-collected for rapid SARS-CoV-2 antigen testing at the US Naval Academy. This is a key proof-of-concept for an acute respiratory infection surveillance approach, which could leverage prevalent SARS-CoV-2 antigen self-testing.

Linking Maternal and Child Health Data to Enhance Public Health Surveillance and Implement Sustainable Interventions.

Our initiative aims to enhance the public health informatics infrastructure for surveillance of maternal and child health (MCH) using data captured from electronic health records (EHRs), public health information systems, and administrative health data. Our work includes development, validation, and application of linkage algorithms across records for mothers and children; integration of data across myriad sources; design of routine surveillance reports; and design of longitudinal studies to examine determinants and outcomes in MCH populations. Our work is conducted in partnership with governmental public health agencies, health care providers, academic institutions, and community-based organizations. Future work will build on the enhanced informatics infrastructure to draw from additional public health data sources and/or expand surveillance efforts to include prioritized MCH outcomes. We will further translate knowledge gained from surveillance into action, working with our partners to improve and sustain better MCH equitably in our population.

Surveillance of Disease Outbreaks Using Unsupervised Uni-Multivariate Anomaly Detection of Time-Series Symptoms.

Effectively identifying deviations in real-world medical time-series data is a critical endeavor, essential for early surveillance of disease outbreaks. This paper demonstrates the integration of time-series anomaly detection techniques to develop surveillance systems for disease outbreaks. Utilizing data from Sweden's telephone counseling service (1177), we first illustrate the trends in physical and mental symptoms recorded as contact reasons, offering valuable insights for outbreak detection. Subsequently, an advanced anomaly detection technique is applied incrementally to these time-series symptoms as univariate and multivariate approaches to assess the effectiveness of a machine learning-based method on early detection of the COVID-19 outbreak.

Longitudinal screening adherence in the Australian National Bowel Cancer Screening Program from 2006 to 2022.

OBJECTIVE: Australia's National Bowel Cancer Screening Program (NBCSP) offers two-yearly screening to 50-74-year-olds for the prevention and early detection of colorectal cancer (CRC). Internationally, detailed reporting of participation across multiple screening rounds - also known as longitudinal adherence - is becoming more common, but remains limited in Australia. We described the longitudinal screening adherence of individuals by age and sex invited to the NBCSP at least once, and quantified longitudinal adherence among individuals who received four NBCSP invitations. METHODS: We obtained aggregate national data for individuals who received at least one NBCSP invitation between 1 August 2006 and 31 March 2022. We described screening adherence patterns including longitudinal adherence among individuals who received four invitations, and evaluated prior longitudinal adherence and adherence at most recent invitation as predictors of future participation. RESULTS: Over the study period, 8.5 million individuals were invited to screen in the NBCSP; 51.9% of these individuals screened at least once. Of the >2.5 million individuals who received four invitations, 23.3% consistently screened, 38.3% never screened, and 38.3% inconsistently screened. The longitudinal adherence at the fourth invitation round for individuals who previously returned none, one, two, or three of their previous three invitations was 9.5%, 37.4%, 70.1% and 88.8%, respectively. Both longitudinal adherence and adherence at the most recent invitation were significant predictors of future participation. CONCLUSION: Our study is the first detailed report of longitudinal adherence to the NBCSP in >2 screening rounds. These insights into long-term behaviours can inform planning for interventions to improve screening participation.

Assessing real world vaccine effectiveness: A review of Scotland's approach to monitoring human papillomavirus (HPV) vaccine impact on HPV infection and cervical disease.

High-risk human papillomavirus (HPV) infections can progress to cervical cancer which is the fourth most common cancer in women globally. In Scotland, the incidence of cervical cancer has a strong socioeconomic deprivation gradient disproportionately affecting women from more deprived areas. An HPV vaccination programme was initiated in Scotland in 2008 targeting girls aged 12-13 years with a catch-up campaign running for the first three years for girls aged up to 18 years. The programme has evolved over the last 16 years with changes in the type of vaccine, dosing schedules and the extension of the programme to boys and gay, bisexual and other men who have sex with men. Vaccine uptake in Scotland has historically been high but has gradually decreased over time and disparities exist in women from more deprived areas of Scotland. The ability to link national immunisation and screening databases in Scotland has allowed direct monitoring of the impact of the HPV vaccine on virological and histological outcomes. Analyses of this linked data have demonstrated real-world evidence of high vaccine effectiveness against HPV infection, cervical disease, and cervical cancer with evidence of herd immunity in unvaccinated women. Continued monitoring is crucial to assess the duration of protection, the impact of vaccine and dosing schedules changes and the emergence of potential type replacement. With the World Health Organisation's aim to eliminate cervical cancer as a public health problem by the next century addressing the inequalities in cervical cancer incidence will be crucial. This will require targeted interventions for women most at risk of cervical cancer to ensure elimination is achieved timely for all women in Scotland.

Impact of the COVID-19 Pandemic on Influenza Hospital Admissions and Deaths in Wales: Descriptive National Time Series Analysis.

Background: The COVID-19 pandemic and the ensuing implementation of control measures caused widespread societal disruption. These disruptions may also have affected community transmission and seasonal circulation patterns of endemic respiratory viruses. Objective: We aimed to investigate the impact of COVID-19-related disruption on influenza-related emergency hospital admissions and deaths in Wales in the first 2 years of the pandemic. Methods: A descriptive analysis of influenza activity was conducted using anonymized pathology, hospitalization, and mortality data from the Secure Anonymised Information Linkage Databank in Wales. The annual incidence of emergency hospitalizations and deaths with influenza-specific diagnosis codes between January 1, 2015, and December 31, 2021, was estimated. Case definitions of emergency hospitalization and death required laboratory confirmation with a polymerase chain reaction test. Trends of admissions and deaths were analyzed monthly and yearly. We conducted 2 sensitivity analyses by extending case definitions to include acute respiratory illnesses with a positive influenza test and by limiting admissions to those with influenza as the primary diagnosis. We also examined yearly influenza testing trends to understand changes in testing behavior during the pandemic. Results: We studied a population of 3,235,883 Welsh residents in 2020 with a median age of 42.5 (IQR 22.9-61.0) years. Influenza testing in Wales increased notably in the last 2 months of 2020, and particularly in 2021 to 39,720 per 100,000 people, compared to the prepandemic levels (1343 in 2019). The percentage of influenza admissions matched to an influenza polymerase chain reaction test increased from 74.8% (1890/2526) in 2019 to 85.2% (98/115) in 2021. However, admissions with a positive test per 100,000 population decreased from 17.0 in 2019 to 2.7 and 0.6 in 2020 and 2021, respectively. Similarly, deaths due to influenza with a positive influenza test per 100,000 population decreased from 0.4 in 2019 to 0.0 in 2020 and 2021. Sensitivity analyses showed similar patterns of decreasing influenza admissions and deaths in the first 2 years of the COVID-19 pandemic. Conclusions: Nonpharmaceutical interventions to control COVID-19 were associated with a substantial reduction in the transmission of the influenza virus, with associated substantial reductions in hospital cases and deaths observed. Beyond the pandemic context, consideration should be given to the role of nonpharmaceutical community-driven interventions to reduce the burden of influenza.

Clinical effects of non-pharmaceutical interventions for COVID-19 on other nationally notifiable infectious diseases in South Korea.

Background/Aims: This study aimed to assess the impact of non-pharmaceutical interventions (NPIs) implemented during the COVID-19 pandemic on nationally notifiable infectious diseases (NNIDs) in South Korea. Methods: Long-term data on seven NNIDs from 2018 to 2021 were analyzed to identify trends and change points using a change point detection technique. The timings of the NPI implementations were compared to the identified change points to determine their association. Results: Varicella, mumps, and scarlet fever showed a significant decrease in incidence following the implementation of NPIs during the COVID-19 pandemic. These diseases, which are primarily transmitted through respiratory droplets, demonstrated a clear response to NPIs. However, carbapenem-resistant Enterobacterales (CRE) showed an increasing trend unrelated to the timing of NPI implementation, suggesting the complex nature of controlling healthcare-associated infections. Hepatitis A, hepatitis C, and scrub typhus did not show significant changes associated with NPIs, likely due to their non-respiratory route of transmission. Conclusions: NPIs effectively controlled NNIDs, particularly those transmitted through respiratory infections. However, the impact varied depending on the disease. Understanding the effectiveness and limitations of NPIs is crucial for developing comprehensive public health strategies during infectious disease outbreaks.

Use of wastewater from passenger ships to assess the movement of COVID-19 and other pathogenic viruses across maritime international boundaries.

Objective: The worldwide spread of SARS-CoV-2 and the resulting COVID-19 pandemic has been driven by international travel. This has led to the desire to develop surveillance approaches which can estimate the rate of import of pathogenic organisms across international borders. The aim of this study was to investigate the use of wastewater-based approaches for the surveillance of viral pathogens on commercial short-haul (3.5 h transit time) roll-on/roll-off passenger/freight ferries operating between the UK and the Republic of Ireland. Methods: Samples of toilet-derived wastewater (blackwater) were collected from two commercial ships over a 4-week period and analysed for SARS-CoV-2, influenza, enterovirus, norovirus, the faecal-marker virus crAssphage and a range of physical and chemical indicators of wastewater quality. Results: A small proportion of the wastewater samples were positive for SARS-CoV-2 (8% of the total), consistent with theoretical predictions of detection frequency (4%-15% of the total) based on the national COVID-19 Infection Survey and defecation behaviour. In addition, norovirus was detected in wastewater at low frequency. No influenza A/B viruses, enterovirus or enterovirus D68 were detected throughout the study period. Conclusion: We conclude that testing of wastewater from ships that cross international maritime boundaries may provide a cost-effective and relatively unbiased method to estimate the flow of infected individuals between countries. The approach is also readily applicable for the surveillance of other disease-causing agents.

Unlocking Public Health Data: Navigating New Legal Guardrails and Emerging AI Challenges.

Here, we analyze the public health implications of recent legal developments - including privacy legislation, intergovernmental data exchange, and artificial intelligence governance - with a view toward the future of public health informatics and the potential of diverse data to inform public health actions and drive population health outcomes.

Opportunities to strengthen respiratory virus surveillance systems in Australia: lessons learned from the COVID-19 response.

Abstract: Disease surveillance data was critical in supporting public health decisions throughout the coronavirus disease 2019 (COVID-19) pandemic. At the same time, the unprecedented circumstances of the pandemic revealed many shortcomings of surveillance systems for viral respiratory pathogens. Strengthening of surveillance systems was identified as a priority for the recently established Australian Centre for Disease Control, which represents a critical opportunity to review pre-pandemic and pandemic surveillance practices, and to decide on future priorities, during both pandemic and inter-pandemic periods. On 20 October 2022, we ran a workshop with experts from the academic and government sectors who had contributed to the COVID-19 response in Australia on 'The role of surveillance in epidemic response', at the University of New South Wales, Sydney, Australia. Following the workshop, we developed five recommendations to strengthen respiratory virus surveillance systems in Australia, which we present here. Our recommendations are not intended to be exhaustive. We instead chose to focus on data types that are highly valuable yet typically overlooked by surveillance planners. Three of the recommendations focus on data collection activities that support the monitoring and prediction of disease impact and the effectiveness of interventions (what to measure) and two focus on surveillance methods and capabilities (how to measure). Implementation of our recommendations would enable more robust, timely, and impactful epidemic analysis.

Trends in Complementary Feeding Indicators in Children Aged 6-23 Months According to Participation in a Conditional Cash Transfer Program: Data from the Brazilian Food and Nutrition Surveillance System, 2015-2019.

Inadequate practices during complementary feeding are associated with malnutrition, especially in children experiencing vulnerable conditions and social inequality. The aim of this study was to evaluate the trends in complementary feeding indicators (CFIs) according to participation in a Brazilian cash transferu program-the Bolsa Família Program (BFP). This was a time-series study with secondary data from 600,138 children assisted from 2015 to 2019 and registered within the Brazilian Food and Nutrition Surveillance System. The CFIs assessed were food introduction, minimum meal frequency and appropriate consistency, minimum dietary diversity, iron-rich food, vitamin A-rich food, ultra-processed food consumption, and zero vegetable or fruit consumption. Prevalence and 95% confidence intervals were calculated for the CFIs according to BFP, the region of residence, and the child's age. The Prais-Winsten regression method was used to analyze the temporal trend. There was a steady trend for all CFIs of a healthy diet. A decrease in ultra-processed food consumption for both BFP (-10.02%) and non-BFP children (-9.34%) was observed over the years. Children residing in the North and Northeast regions and those enrolled in the BFP were more distant from the recommended feeding practices when compared to the other regions and non-BFP children. The results highlight the relevance of nutritional surveillance and the need to improve food and nutrition public policies for children aged 6-23 months, particularly for those experiencing greater social vulnerability.

Spatial and Temporal Dynamics of Chikungunya Incidence in Brazil and the Impact of Social Vulnerability: A Population-Based and Ecological Study.

To assess the temporal and spatial dynamics of chikungunya incidence and its association with social vulnerability indicators in Brazil, an ecological and population-based study was conducted herein, with confirmed cases of chikungunya and based on clinical and clinical-epidemiological criteria from 2017 to 2023. Data were obtained from the Notifiable Diseases Information System and social vulnerability indicators were extracted from the official platform of the United Nations Development Program and the Social Vulnerability Atlas. Temporal, spatial, and global spatial regression models were employed. The temporal trend showed that in 2017, the incidence increased by 1.9%, and this trend decreased from 2020 to 2021 (-0.93%). The spatial distribution showed heterogeneity and positive spatial autocorrelation (I: 0.71; p < 0.001) in chikungunya cases in Brazil. Also, the high-risk areas for the disease were concentrated in the northeast and north regions. The social vulnerability indicators associated with the outcome were those related to income, education, and housing conditions. Our analyses demonstrate that chikungunya continues to be a serious health concern in Brazil, but specially in the northeast and north regions. Lastly, mapping risk areas can provide evidence for the development of public health strategies and disease control in endemic regions.

Participatory Disease Surveillance for the Early Detection of Cholera-Like Diarrheal Disease Outbreaks in Rural Villages in Malawi: Prospective Cohort Study.

BACKGROUND: Cholera-like diarrheal disease (CLDD) outbreaks are complex and influenced by environmental factors, socioeconomic conditions, and population dynamics, leading to limitations in traditional surveillance methods. In Malawi, cholera is considered an endemic disease. Its epidemiological profile is characterized by seasonal patterns, often coinciding with the rainy season when contamination of water sources is more likely. However, the outbreak that began in March 2022 has extended to the dry season, with deaths reported in all 29 districts. It is considered the worst outbreak in the past 10 years. OBJECTIVE: This study aims to evaluate the feasibility and outcomes of participatory surveillance (PS) using interactive voice response (IVR) technology for the early detection of CLDD outbreaks in Malawi. METHODS: This longitudinal cohort study followed 740 households in rural settings in Malawi for 24 weeks. The survey tool was designed to have 10 symptom questions collected every week. The proxies' rationale was related to exanthematic, ictero-hemorragica for endemic diseases or events, diarrhea and respiratory/targeting acute diseases or events, and diarrhea and respiratory/targeting seasonal diseases or events. This work will focus only on the CLDD as a proxy for gastroenteritis and cholera. In this study, CLDD was defined as cases where reports indicated diarrhea combined with either fever or vomiting/nausea. RESULTS: During the study period, our data comprised 16,280 observations, with an average weekly participation rate of 35%. Maganga TA had the highest average of completed calls, at 144.83 (SD 10.587), while Ndindi TA had an average of 123.66 (SD 13.176) completed calls. Our findings demonstrate that this method might be effective in identifying CLDD with a notable and consistent signal captured over time (R2=0.681404). Participation rates were slightly higher at the beginning of the study and decreased over time, thanks to the sensitization activities rolled out at the CBCCs level. In terms of the attack rates for CLDD, we observed similar rates between Maganga TA and Ndindi TA, at 16% and 15%, respectively. CONCLUSIONS: PS has proven to be valuable for the early detection of epidemics. IVR technology is a promising approach for disease surveillance in rural villages in Africa, where access to health care and traditional disease surveillance methods may be limited. This study highlights the feasibility and potential of IVR technology for the timely and comprehensive reporting of disease incidence, symptoms, and behaviors in resource-limited settings.