Poisoning Associated with Consumption of a Homemade Medicinal Liquor - Chongqing, China, 2018.

On May 3, 2018, Chongqing Center for Disease Control and Prevention (CQCDC) received a report of 15 persons with numbness of the tongue or limbs and vomiting of unknown etiology; all ill persons had attended an adult birthday luncheon in Bishan District, Chongqing municipality, in southwest China. Initial reports indicated that one person had died. Within 2 hours, CQCDC and Western Chinese Field Epidemiology Training Program staff members launched an investigation that included identification of cases, laboratory testing of drinks, and patient interviews to identify the cause of what appeared to be a poisoning. Among the 15 cases, five persons died. The investigation of this apparent mass intoxication implicated a homemade alcoholic beverage produced from a highly toxic flowering plant in the genus Aconitum used in traditional Chinese medicine. Although the risk of aconite toxicity is known, approximately 5,000 cases of aconite poisoning incidents were reported in China, Germany, Japan, and other countries during 1993-2005; most cases of fatal poisoning occurred in China (1). This event highlights the importance of enforcing and complying with existing regulations regarding sale and purchase of Aconitum species (also known as wolfbane), and of dissemination of critical public health messages.

Risk factors for measles virus infection and susceptibility in persons aged 15 years and older in China: A multi-site case-control study, 2012-2013.

INTRODUCTION: Endemic measles persists in China, despite >95% reported coverage of two measles-containing vaccine doses and nationwide campaign that vaccinated >100 million children in 2010. An increasing proportion of infections now occur among adults and there is concern that persistent susceptibility in adults is an obstacle to measles elimination in China. We performed a case-control study in six Chinese provinces between January 2012 to June 2013 to identify risk factors for measles virus infection and susceptibility among adults. METHODS: Persons ≥15 years old with laboratory-confirmed measles were age and neighborhood matched with three controls. Controls had blood specimens collected to determine their measles IgG serostatus. We interviewed case-patients and controls about potential risk factors for measles virus infection and susceptibility. Unadjusted and adjusted matched odds ratios and 95% confidence intervals (CIs) were calculated via conditional logistic regression. We calculated attributable fractions for infection for risk factors that could be interpreted as causal. RESULTS: 899 cases and 2498 controls were enrolled. Among controls, 165 (6.6%) were seronegative for measles IgG indicating persistent susceptibility to infection. In multivariable analysis, hospital visit and travel outside the prefecture in the prior 1-3 weeks were significant risk factors for measles virus infection. Occupation and reluctance to accept measles vaccination were significant risk factors for measles susceptibility. The calculated attributable fraction of measles cases from hospital visitation was 28.6% (95% CI: 20.6-38.8%). CONCLUSIONS: Exposure to a healthcare facility was the largest risk factor for measles virus infection in adults in China. Improved adherence to hospital infection control practices could reduce risk of ongoing measles virus transmission and increase the likelihood of achieving and sustaining measles elimination in China. The use of control groups stratified by serological status identified distinct risk factors for measles virus infection and susceptibility among adults.

Surveillance Training for Ebola Preparedness in Côte d'Ivoire, Guinea-Bissau, Senegal, and Mali.

The 2014-2015 epidemic of Ebola virus disease in West Africa primarily affected Guinea, Liberia, and Sierra Leone. Several countries, including Mali, Nigeria, and Senegal, experienced Ebola importations. Realizing the importance of a trained field epidemiology workforce in neighboring countries to respond to Ebola importations, the Centers for Disease Control and Prevention Field Epidemiology Training Program unit implemented the Surveillance Training for Ebola Preparedness (STEP) initiative. STEP was a mentored, competency-based initiative to rapidly build up surveillance capacity along the borders of the at-risk neighboring countries Côte d'Ivoire, Mali, Senegal, and Guinea-Bissau. The target audience was district surveillance officers. STEP was delivered to 185 participants from 72 health units (districts or regions). Timeliness of reporting and the quality of surveillance analyses improved 3 months after training. STEP demonstrated that mentored, competency-based training, where learners attain competencies while delivering essential public health services, can be successfully implemented in an emergency response setting.

Lessons Learned and Legacy of the Stop Transmission of Polio Program.

In 1988, the by the World Health Assembly established the Global Polio Eradication Initiative, which consisted of a partnership among the World Health Organization (WHO), Rotary International, the Centers for Disease Control and Prevention (CDC), and the United Nations Children's Fund. By 2016, the annual incidence of polio had decreased by >99.9%, compared with 1988, and at the time of writing, only 3 countries in which wild poliovirus circulation has never been interrupted remain: Afghanistan, Nigeria, and Pakistan. A key strategy for polio eradication has been the development of a skilled and deployable workforce to implement eradication activities across the globe. In 1999, the Stop Transmission of Polio (STOP) program was developed and initiated by the CDC, in collaboration with the WHO, to train and mobilize additional human resources to provide technical assistance to polio-endemic countries. STOP has also informed the development of other public health workforce capacity to support polio eradication efforts, including national STOP programs. In addition, the program has diversified to address measles and rubella elimination, data management and quality, and strengthening routine immunization programs. This article describes the STOP program and how it has contributed to polio eradication by building global public health workforce capacity.

Risk factors for measles infection in 0-7 month old children in China after the 2010 nationwide measles campaign: A multi-site case-control study, 2012-2013.

INTRODUCTION: Endemic measles persists in China, despite >95% reported coverage of two measles-containing vaccine doses and nationwide campaign that vaccinated more than 100 million children in 2010. We performed a case-control study in six Chinese provinces during January 2012 through June 2013 to identify risk factors for measles infection among children aged 0-7 months. METHODS: Children with laboratory-confirmed measles were neighborhood matched with three controls. We interviewed parents of case and control infants on potential risk factors for measles. Adjusted matched odds ratios (mOR) and 95% confidence intervals (CIs) were calculated by multivariable conditional logistic modeling. We calculated attributable fractions for risk factors that could be interpreted as causal. RESULTS: Eight hundred thirty cases and 2303 controls were enrolled. In multivariable analysis, male sex (mOR 1.6 [1.3, 2.0]), age 5-7 months (mOR 3.9 [3.0, 5.1]), migration between counties (mOR 2.3 [1.6, 3.4]), outpatient hospital visits (mOR 9.4 [6.6, 13.3]) and inpatient hospitalization (mOR 107.1 [48.8, 235.1]) were significant risk factors. The calculated attributable fractions for hospital visits was 43.1% (95% CI: 40.1, 47.5%) adjusted for age, sex and migration. CONCLUSIONS: Hospital visitation was the largest risk factor for measles infection in infants. Improved hospital infection control practices would accelerate measles elimination in China.

Risk factors for measles in children aged 8 months-14 years in China after nationwide measles campaign: A multi-site case-control study, 2012-2013.

INTRODUCTION: Endemic measles persists in China, despite >95% reported coverage of two measles-containing vaccine doses and nationwide campaign that vaccinated more than 100 million children in 2010. In 2011, almost half of the 9943 measles cases in China occurred in children eligible for measles vaccination. We conducted a case-control study during 2012-2013 to identify risk factors for measles infection in children aged 8 months-14 years. METHODS: Children with laboratory-confirmed measles were age- and neighborhood-matched with three controls. We interviewed parents of case and control infants on potential risk factors for measles. We calculated adjusted matched odds ratios and 95% confidence intervals of risk factors. We calculated attributable fractions for risk factors that could be interpreted as causal and vaccine efficacy (VE) for the measles containing vaccine (MCV) used in the Chinese immunization program. RESULTS: In all, 969 case-patients and 2845 controls were enrolled. In multivariable analysis, lack of measles vaccination both overall (mOR 22.7 [16.6, 31.1] and when stratified by region (east region, mOR 74.2 [27.3, 202]; central/western regions mOR 17.4 [12.5, 24.3]), hospital exposure (mOR 63.0, 95% CI [32.8, 121]), and migration among counties (overall mOR 3.0 [2.3, 3.9]) were significant risk factors. The calculated VE was 91.9-96.1% for a single dose of MCV and 96.6-99.5% for 2 doses. CONCLUSIONS: Lack of vaccination was the leading risk factor for measles infection, especially in children born since the 2010 supplementary immunization activity. Reducing missed vaccination opportunities, improving immunization access for migrant children, and strengthening school/kindergarten vaccine checks are needed to strengthen the routine immunization program and maintain progress toward measles elimination in China.

Verbal Autopsy: Evaluation of Methods to Certify Causes of Death in Uganda.

To assess different methods for determining cause of death from verbal autopsy (VA) questionnaire data, the intra-rater reliability of Physician-Certified Verbal Autopsy (PCVA) and the accuracy of PCVA, expert-derived (non-hierarchical) and data-driven (hierarchal) algorithms were assessed for determining common causes of death in Ugandan children. A verbal autopsy validation study was conducted from 2008-2009 in three different sites in Uganda. The dataset included 104 neonatal deaths (0-27 days) and 615 childhood deaths (1-59 months) with the cause(s) of death classified by PCVA and physician review of hospital medical records (the 'reference standard'). Of the original 719 questionnaires, 141 (20%) were selected for a second review by the same physicians; the repeat cause(s) of death were compared to the original,and agreement assessed using the Kappa statistic.Physician reviewers' refined non-hierarchical algorithms for common causes of death from existing expert algorithms, from which, hierarchal algorithms were developed. The accuracy of PCVA, non-hierarchical, and hierarchical algorithms for determining cause(s) of death from all 719 VA questionnaires was determined using the reference standard. Overall, intra-rater repeatability was high (83% agreement, Kappa 0.79 [95% CI 0.76-0.82]). PCVA performed well, with high specificity for determining cause of neonatal (>67%), and childhood (>83%) deaths, resulting in fairly accurate cause-specific mortality fraction (CSMF) estimates. For most causes of death in children, non-hierarchical algorithms had higher sensitivity, but correspondingly lower specificity, than PCVA and hierarchical algorithms, resulting in inaccurate CSMF estimates. Hierarchical algorithms were specific for most causes of death, and CSMF estimates were comparable to the reference standard and PCVA. Inter-rater reliability of PCVA was high, and overall PCVA performed well. Hierarchical algorithms performed better than non-hierarchical algorithms due to higher specificity and more accurate CSMF estimates. Use of PCVA to determine cause of death from VA questionnaire data is reasonable while automated data-driven algorithms are improved.

Accelerating measles elimination and strengthening routine immunization services in Guizhou Province, China, 2003-2009.

BACKGROUND: To develop a successful model for accelerating measles elimination in poor areas of China, we initiated a seven-year project in Guizhou, one of the poorest provinces, with reported highest measles incidence of 360 per million population in 2002. METHODS: Project strategies consisted of strengthening routine immunization services, enforcement of school entry immunization requirements at kindergarten and school, conducting supplemental measles immunization activities (SIAs), and enhancing measles surveillance. We measured coverage of measles containing vaccines (MCV) by administrative reporting and population-based sample surveys, systematic random sampling surveys, and convenience sampling surveys for routine immunization services, school entry immunization, and SIAs respectively. We measured impact using surveillance based measles incidence. RESULTS: Routine immunization coverage of the 1st dose of MCV (MCV1) increased from 82% to 93%, while 2nd dose of MCV (MCV2) coverage increased from 78% to 91%. Enforcement of school entry immunization requirements led to an increase in MCV2 coverage from 36% on primary school entry in 2004 to 93% in 2009. Province-wide SIAs achieved coverage greater than 90%. The reported annual incidence of measles dropped from 200 to 300 per million in 2003 to 6 per million in 2009, and sustained at 0.9-2.2 per million in 2010-2013. CONCLUSIONS: This project found that a package of strategies including periodic SIAs, strengthened routine immunization, and enforcing school entry immunization requirements, was an effective approach toward achieving and sustaining measles elimination in less-developed area of China.

Validity of verbal autopsy procedures for determining malaria deaths in different epidemiological settings in Uganda.

BACKGROUND: Verbal autopsy (VA) procedures can be used to estimate cause of death in settings with inadequate vital registries. However, the sensitivity of VA for determining malaria-specific mortality may be low, and may vary with transmission intensity. We assessed the diagnostic accuracy of VA procedures as compared to hospital medical records for determining cause of death in children under five in three different malaria transmission settings in Uganda, including Tororo (high), Kampala (medium), and Kisoro (low). METHODS AND FINDINGS: Caretakers of children who died in participating hospitals were interviewed using a standardized World Health Organization questionnaire. Medical records from the child's hospitalization were also reviewed. Causes of death based on the VA questionnaires and the medical records were assigned independently by physician reviewers and then compared. A total of 719 cases were included in the final analysis, 67 in Tororo, 600 in Kampala, and 52 in Kisoro. Malaria was classified as the underlying or contributory cause of death by review of medical records in 33 deaths in Tororo, 60 in Kampala, and 0 in Kisoro. The sensitivity of VA procedures for determining malaria deaths in Tororo was 61% (95% CI 44-78%) and 50% in Kampala (95% CI 37-63%). Specificity for determining malaria deaths in Tororo and Kampala was high (>88%), but positive predictive value varied widely, from 83% in Tororo to 34% in Kampala (difference 49%, 95% CI 31-67, p<0.001). The difference between the cause-specific mortality fraction for malaria as determined by VA procedures and medical records was -11% in Tororo, +5% in Kampala, and +14% in Kisoro. CONCLUSIONS: Our results suggest that these VA methods have an acceptable level of diagnostic accuracy for determining malaria deaths at the population level in high and medium transmission areas, but not in low transmission areas.

Epidemiologic and virologic assessment of the 2009 influenza A (H1N1) pandemic on selected temperate countries in the Southern Hemisphere: Argentina, Australia, Chile, New Zealand and South Africa.

UNLABELLED: INTRODUCTION AND SETTING: Our analysis compares the most comprehensive epidemiologic and virologic surveillance data compiled to date for laboratory-confirmed H1N1pdm patients between 1 April 2009 - 31 January 2010 from five temperate countries in the Southern Hemisphere-Argentina, Australia, Chile, New Zealand, and South Africa. OBJECTIVE: We evaluate transmission dynamics, indicators of severity, and describe the co-circulation of H1N1pdm with seasonal influenza viruses. RESULTS: In the five countries, H1N1pdm became the predominant influenza strain within weeks of initial detection. South Africa was unique, first experiencing a seasonal H3N2 wave, followed by a distinct H1N1pdm wave. Compared with the 2007 and 2008 influenza seasons, the peak of influenza-like illness (ILI) activity in four of the five countries was 3-6 times higher with peak ILI consultation rates ranging from 35/1,000 consultations/week in Australia to 275/100,000 population/week in New Zealand. Transmission was similar in all countries with the reproductive rate ranging from 1.2-1.6. The median age of patients in all countries increased with increasing severity of disease, 4-14% of all hospitalized cases required critical care, and 26-68% of fatal patients were reported to have ≥1 chronic medical condition. Compared with seasonal influenza, there was a notable downward shift in age among severe cases with the highest population-based hospitalization rates among children <5 years old. National population-based mortality rates ranged from 0.8-1.5/100,000. CONCLUSIONS: The difficulty experienced in tracking the progress of the pandemic globally, estimating its severity early on, and comparing information across countries argues for improved routine surveillance and standardization of investigative approaches and data reporting methods.

Assessing the impact of indoor residual spraying on malaria morbidity using a sentinel site surveillance system in Western Uganda.

A single round of indoor residual spraying (IRS) using lambda-cyhalothrin was implemented in a district of Uganda with moderate transmission intensity in 2007. Individual patient data were collected from one health facility within the district 8 months before and 16 months after IRS. There was a consistent decrease in the proportion of patients diagnosed with clinical malaria after IRS for patients < 5 and > 5 years of age (52% versus 26%, P < 0.001 and 36% versus 23%, P < 0.001, respectively). There was a large decrease in the proportion of positive blood smears in the first 4 months after IRS for patients < 5 (47% versus 14%, P < 0.001) and > 5 (26% versus 9%, P < 0.001) years of age, but this effect waned over the subsequent 12 months. IRS was effective in reducing malaria morbidity, but this was not sustained beyond 1 year for the proportion of blood smears read as positive.

Improved malaria case management after integrated team-based training of health care workers in Uganda.

Malaria case management in Africa is characterized by presumptive treatment and substantial overtreatment. We evaluated an integrated team-based training program on malaria case management. Surveillance data 120 days before and after training were compared at eight health facilities in Uganda. After training, the proportion of patients with suspected malaria referred for blood smears increased from 38.3% to 54.6% (P=0.04) in persons<5 years of age years and from 34.1% to 53.4% (P=0.02) in those>or=5 years of age. The proportion of patients with negative blood smears prescribed antimalarial drugs decreased from 47.9% to 19.6% (P<0.001) in persons<5 years of age and from 38.8% to 15.6% (P<0.001) in those>or=5 years of age. Training did not improve the proportion of patients with positive blood smears prescribed antimalarial drugs, the proportion of patients prescribed appropriate antimalarial drugs, or the diagnostic accuracy of microscopy. Integrated team-based training may improve malaria case management and reduce the number of unnecessary antimalarial treatments.

Predictors of smallpox vaccination among healthcare workers and other first responders.

BACKGROUND: The goal of the National Smallpox Vaccination Program was to vaccinate a cadre of healthcare workers and first responders who could care for smallpox patients in the event of an attack. METHODS: Using a convenience sample of 36 health departments and 34 hospitals in California, we conducted a telephone interview between July 2003 and April 2004 of healthcare workers and first responders to determine predictors of smallpox vaccination. FINDINGS: The response rate was 54.1%. Of 477 respondents with no contraindications to vaccination, 106 were vaccinated and 371 were unvaccinated. Among the vaccinated, the leading reason for vaccination was wanting to be part of a smallpox response team (74%). Among the unvaccinated, leading reasons for not being vaccinated included thinking the risk of smallpox was not high enough (25%) and concern about side effects (19%). Factors independently associated with vaccination include previous smallpox vaccination (adjusted odds ratio [AOR]=4.1, 95% confidence interval [CI]=1.2-14.1), having little or no concern about vaccine adverse events (AOR=3.0, CI=1.3-7.0, compared with somewhat/very), reporting their employer had a policy to reimburse for travel or other out of pocket costs (AOR=2.5, CI=1.1-5.7, compared with no policy), very high to high chance of compensation if adverse events occurred (AOR=2.9, CI=1.2-6.3, compared with low chance), and answering in the negative to questions about concerns about potential costs. Blacks were less likely than whites to be vaccinated (AOR=0.04, CI=0.03-0.6). CONCLUSIONS: Clearly communicating the risks and benefits of vaccination and addressing issues of cost, convenience, and compensation may be important for any program where vaccination is provided in the national interest and when the direct benefits of vaccination are unknown.

Healthcare workers who elected not to receive smallpox vaccination.

BACKGROUND: The goal of the National Smallpox Vaccination Program was to vaccinate a cadre of healthcare workers and first responders who could care for smallpox patients in the event of an attack. METHODS: Using a convenience sample of health departments (n=49) and hospitals (n=60) in five states, we conducted a telephone interview between July 2003 and April 2004 of healthcare workers and first responders who chose not to receive smallpox vaccination. (Data were analyzed in 2004 and 2005.) RESULTS: The response rate was 63%. Of 1895 respondents, 723 (38.2%) reported having a contraindication, 280 (14.8%) reported being contraindicated because of a household member's condition, and 892 (47.0%) reported having no contraindication to smallpox vaccination. Among respondents with no contraindication, the leading reasons for nonvaccination were concerns about side effects (20.6%) and not feeling that the risk of outbreak was high enough (19.5%). More than half (54.8%) were somewhat or very concerned about having an adverse reaction to the vaccine; Hispanics, blacks, and Asians were significantly more likely than whites to be somewhat or very concerned about side effects. Less than one fifth (17.9%) reported that there was a policy to financially compensate employees who developed side effects from vaccination, and 40.7% reported that there was a policy to provide liability coverage to employees who transmitted vaccinia to a patient. CONCLUSIONS: Many people who chose not to receive smallpox vaccine perceived their personal risk-benefit balance as not favoring vaccination. The success of future smallpox vaccination efforts or vaccination against other bioterrorist health threats depends on addressing potential barriers to participation including compensation and liability issues, in addition to clearly communicating risks and benefits.

Persistence of vaccine-derived polioviruses among immunodeficient persons with vaccine-associated paralytic poliomyelitis.

To estimate long-term poliovaccine virus persistence among immunodeficient patients with vaccine-associated paralytic poliomyelitis (iVAPP), cases reported in the United States during 1975-1997 were reviewed, with subsequent follow-up and virological testing. Six (16.2%) of 37 subjects excreted poliovaccine viruses for > or =6 months. Partial genomic sequencing of their available poliovirus isolates showed considerable divergence from the prototype Sabin strain in all cases. Poliovirus persistence declined over time since the last oral poliovaccine dose: at 6 months, 19.4%; 1 year, 14.3%; 5 years, 4%; and 10 years, 0% (P<.05) of patients. Despite the high prevalence of poliovaccine virus persistence among patients with iVAPP, this group appears to be an unlikely source of poliovirus reintroduction in developed countries because of the rarity and high fatality rate of iVAPP and the possible spontaneous clearance of polioviruses. These results are important for developing "endgame" strategies for the Global Poliomyelitis Eradication Program.

The value of community participation in disease surveillance: a case study from Niger.

A team of researchers, including one behavioral scientist (S.M.N.) and three epidemiologists (L.Q., O.S. and S.N.) conducted community analyses to assess the social and cultural factors that affect the detection and reporting of disease cases in a surveillance system, using acute flaccid paralysis (AFP) surveillance in Niger as a case study. Over a 60-day period in the country, the research team reviewed written field reports and interviewed epidemiologists, nurses, community members and persons in governmental and non-governmental organizations. Overall, we found that the logistical difficulties of travel and communication, which are common in developing countries, constrain the conventional surveillance system that relies on epidemiologists visiting sites to discover and investigate cases, particularly in rural areas. Other challenges include: community members' lack of knowledge about the possible link between a case of paralysis and a dangerous, communicable disease; lack of access to health care, including the low number of clinics and health care workers; cultural beliefs that favor seeking a local healer before consulting a nurse or physician; and health workers' lack of training in AFP surveillance. The quality of surveillance in developing countries can improve if a community-based approach is adopted. Such a system has been used successfully in Niger during smallpox-eradication and guinea worm-control campaigns. In a community-based system, community members receive basic education or more extensive training to motivate and enable them to notify health care staff about possible cases of disease in a timely fashion. Local organizations, local projects and local leaders must be included to ensure the success of such a program. In Niger we found sufficient quantities of this type of social capital, along with enough local experience of past health campaigns, to suggest that a community-based approach can improve the level of comprehensiveness and sensitivity of surveillance.

Polio eradication initiative in Africa: influence on other infectious disease surveillance development.

BACKGROUND: The World Health Organization (WHO) and partners are collaborating to eradicate poliomyelitis. To monitor progress, countries perform surveillance for acute flaccid paralysis (AFP). The WHO African Regional Office (WHO-AFRO) and the U.S Centers for Disease Control and Prevention are also involved in strengthening infectious disease surveillance and response in Africa. We assessed whether polio-eradication initiative resources are used in the surveillance for and response to other infectious diseases in Africa. METHODS: During October 1999-March 2000, we developed and administered a survey questionnaire to at least one key informant from the 38 countries that regularly report on polio activities to WHO. The key informants included WHO-AFRO staff assigned to the countries and Ministry of Health personnel. RESULTS: We obtained responses from 32 (84%) of the 38 countries. Thirty-one (97%) of the 32 countries had designated surveillance officers for AFP surveillance, and 25 (78%) used the AFP resources for the surveillance and response to other infectious diseases. In 28 (87%) countries, AFP program staff combined detection for AFP and other infectious diseases. Fourteen countries (44%) had used the AFP laboratory specimen transportation system to transport specimens to confirm other infectious disease outbreaks. The majority of the countries that performed AFP surveillance adequately (i.e., non polio AFP rate = 1/100,000 children aged <15 years) in 1999 had added 1-5 diseases to their AFP surveillance program. CONCLUSIONS: Despite concerns regarding the targeted nature of AFP surveillance, it is partially integrated into existing surveillance and response systems in multiple African countries. Resources provided for polio eradication should be used to improve surveillance for and response to other priority infectious diseases in Africa.