Risk of foot and mouth disease spread through cattle movements in Uganda.

Foot and mouth disease (FMD) is endemic in Uganda, where livestock movements through porous borders and beyond play a key role in the spread of transboundary animal diseases. Data from published and unpublished sources were used to conduct a qualitative risk assessment based on the World Organisation for Animal Health framework to assess the risk of foot and mouth disease virus spread in Uganda through pastoral and trade-related cattle movements from the country's southern border districts. A scenario tree was developed as a conceptual framework, and the risk was assessed by considering factors including the cattle population, proportion of vaccinated cattle, number of live cattle legally moved from districts along the Ugandan-Tanzanian border, the production system in the destination districts and the purpose of the movement. Factors associated with higher risk included live cattle movements for pastoral/grazing and breeding purposes, particularly those towards agro-pastoral (AP) areas, which have the potential to lead to outbreaks on several farms in the destination district and other districts countrywide. Prophylactic vaccination should therefore prioritise districts from which movements of large volumes of cattle to other areas originate and the AP destination districts. Specific awareness campaigns should be conducted in destination districts to improve preventative measures and farm biosecurity levels. This study will inform the revision of the risk-based strategic plan, aimed at reducing FMD impacts in Uganda, as the country progresses along the progressive control pathway for FMD.

La fièvre aphteuse est présente à l'état endémique en Ouganda, pays où les mouvements de bétail à travers et au-delà des frontières poreuses jouent un rôle déterminant dans la propagation des maladies animales transfrontalières. Une évaluation qualitative des risques basée sur le cadre de l'Organisation mondiale de la santé animale a été réalisée, en utilisant des données provenant aussi bien de sources publiées que non publiées, afin d'évaluer les risques de propagation du virus de la fièvre aphteuse en Ouganda par le biais des mouvements pastoraux et commerciaux de bétail en provenance des districts frontaliers du sud du pays. Un arbre de scénarios a été élaboré en tant que cadre conceptuel. Les risques ont été évalués en tenant compte de facteurs tels que les effectifs du cheptel bovin, la proportion de bovins vaccinés, le nombre de bovins vivants déplacés légalement depuis les districts situés le long de la frontière entre l'Ouganda et la Tanzanie, le système de production pratiqué dans les districts de destination et la finalité des déplacements du bétail. Les principaux facteurs associés à un risque accru étaient les mouvements de bovins vivants liés à l'élevage pastoral/ la mise en pâturage ou à des fins de reproduction, et plus particulièrement les déplacements vers les zones agro-pastorales, en raison du potentiel épidémique qu'ils peuvent avoir dans les fermes du district de destination et d'autres districts à l'échelle du pays. La vaccination prophylactique devrait donc être conduite en priorité dans les districts de provenance des bovins déplacés en grand nombre vers d'autres zones, ainsi que dans les districts de destination lorsqu'ils sont à dominante agro-pastorale. Des campagnes spécifiques d'information et de sensibilisation devraient être menées dans les districts de destination afin d'améliorer les mesures de prévention et le niveau de biosécurité des élevages. Les résultats de cette étude étayeront la mise à jour du plan stratégique fondé sur les risques, qui vise à réduire l'impact de la fièvre aphteuse en Ouganda parallèlement aux avancées du pays sur la voie de l'approche progressive de la lutte contre la fièvre aphteuse.

La fiebre aftosa es endémica en Uganda, país donde los desplazamientos de ganado a través y más allá de sus porosas fronteras son un factor decisivo en la propagación de enfermedades animales transfronterizas. Los autores exponen una evaluación cualitativa del riesgo realizada a partir de datos publicados e inéditos con empleo del marco de la Organización Mundial de Sanidad Animal. Se trataba de evaluar así el riesgo de propagación del virus de la fiebre aftosa en Uganda a resultas de los desplazamientos de ganado desde los distritos fronterizos meridionales con fines de pastoreo o de comercio. Tras elaborar como marco teórico un árbol de hipótesis, se determinó el riesgo teniendo en cuenta, como principales factores, la cabaña bovina, la proporción de ejemplares vacunados, el número de animales vivos transportados legalmente desde los distritos que bordean la frontera entre Uganda y Tanzania, el sistema productivo en los distritos de destino y la finalidad de cada desplazamiento. Entre los factores ligados a un aumento del riesgo destacaba el desplazamiento de animales vivos con fines de pastoreo y de reproducción, en particular con destino a zonas agropastorales, pues ello puede provocar brotes en múltiples explotaciones no solo del distrito de destino, sino también de otros distritos de todo el país. En las actividades de vacunación profiláctica, por lo tanto, conviene otorgar prioridad a los distritos de los que parten grandes contingentes de ganado hacia otras zonas y también a los distritos de destino agropastorales. También habría que implantar campañas específicas de sensibilización en los distritos de destino para mejorar en ellos las medidas de prevención y los niveles de seguridad biológica de las explotaciones. Este estudio servirá de base para la revisión del plan estratégico basado en los riesgos, encaminado a reducir las repercusiones de la fiebre aftosa en Uganda, a la par que el país va cubriendo etapas en la senda progresiva de control de la fiebre aftosa.

Foot-and-Mouth Disease Impact on Smallholders - What Do We Know, What Don't We Know and How Can We Find Out More?

Foot-and-mouth disease (FMD) endemic regions contain three-quarters of the world's FMD susceptible livestock and most of the world's poor livestock keepers. Yet FMD impact on smallholders in these regions is poorly understood. Diseases of low mortality can exert a large impact if incidence is high. Modelling and field studies commonly find high FMD incidence in endemic countries. Sero-surveys typically find a third of young cattle are sero-positive, however, the proportion of sero-positive animals that developed disease, and resulting impact, are unknown. The few smallholder FMD impact studies that have been performed assessed different aspects of impact, using different approaches. They find that FMD impact can be high (>10% of annual household income). However, impact is highly variable, being a function of FMD incidence and dependency on activities affected by FMD. FMD restricts investment in productive but less FMD-resilient farming methods, however, other barriers to efficient production may exist, reducing the benefits of FMD control. Applying control measures is costly and can have wide-reaching negative impacts; veterinary-cordon-fences may damage wildlife populations, and livestock movement restrictions and trade bans damage farmer profits and the wider economy. When control measures are ineffective, farmers, society and wildlife may experience the burden of control without reducing disease burden. Foot-and-mouth disease control has benefitted smallholders in South America and elsewhere. Success takes decades of regional cooperation with effective veterinary services and widespread farmer participation. However, both the likelihood of success and the full cost of control measures must be considered. Controlling FMD in smallholder systems is challenging, particularly when movement restrictions are hard to enforce. In parts of Africa this is compounded by endemically infected wildlife and limited vaccine performance. This paper reviews FMD impact on smallholders in endemic countries. Significant evidence gaps exist and guidance on the design of FMD impact studies is provided.

Environmental challenges of identifying a patient zone and the healthcare zone in a crowded Vietnamese hospital.

BACKGROUND: The application of the World Health Organization (WHO) 'My five moments for hand hygiene' was designed for a healthcare environment with levels of bed spacing and occupancy normally present in developed countries. However, overcrowded healthcare facilities in Vietnam and other challenged settings require strategies to adapt 'My five moments for hand hygiene' in order to meet their situational needs. AIM: To identify the environmental challenges to compliance with the 'My five moments' indications. METHODS: Overt observation using the WHO hand hygiene audit tool was conducted in two clinical departments at a large teaching hospital in Vietnam. Clinical practice movements and the 'My five moments' indications were detailed diagrammatically. FINDINGS: Sharing a bed is widely practised outside the intensive care unit in this country, which makes visualizing a patient zone according to the WHO instructions difficult. In addition, decreased spacing between shared beds in overcrowded conditions results in the close proximity of patients to the shared healthcare zone. These two barriers prevent attempts to apply the 'My five moments' correctly. CONCLUSION: Undertaking hand hygiene and conducting audits in accordance with the 'My five moments for hand hygiene' assumes a separation of patients and individual healthcare zones. The barriers to applying 'My five moments' include the lack of distinct zones between patients and their shared healthcare zone, and amelioration requires resources beyond current chronic resource challenges. Until environmental resources can meet the western standards required for application of the 'Five moments' principle, healthcare workers urgently need detailed clarification of modifications that would empower them to comply.

The 'My five moments for hand hygiene' concept for the overcrowded setting in resource-limited healthcare systems.

Hand hygiene is a core activity of patient safety for the prevention of healthcare-associated infections (HCAIs). To standardize hand hygiene practices globally the World Health Organization (WHO) released Guidelines on Hand Hygiene in Health Care and introduced the 'My five moments for hand hygiene' concept to define indications for hand hygiene rooted in an evidence-based model for transmission of micro-organisms by healthcare workers' (HCWs) hands. Central to the concept is the division of the healthcare environment into two geographical care zones, the patient zone and the healthcare zone, that requires the HCW to comply with specific hand hygiene moments. In resource-limited, overcrowded healthcare settings inadequate or no spatial separation between beds occurs frequently. These conditions challenge the HCW's ability to visualize and delineate patient zones. The 'My five moments for hand hygiene' concept has been adapted for these conditions with the aim of assisting hand hygiene educators, auditors, and HCWs to minimize ambiguity regarding shared patient zones and achieve the ultimate goal set by the WHO Guidelines--the reduction of infectious risks.

Risk factors for infection with Foot-and-Mouth Disease virus in a cattle population vaccinated with a non-purified vaccine in Iran.

In this study, we estimated the level of Foot-and-Mouth (FMD) virus infection in a cattle-dense north-western province of Islamic Republic of Iran and analyzed putative risk factors for FMD infection. Calves (6-24 months of age) from all 17 districts of West Azerbaijan were tested for antibodies against non-structural proteins (NSP-Ab) of FMD virus. A proportional stratification with a minimum of 30 epi-units was applied for 3 different husbandry systems: villages, dairy and mixed farms. Within an epi-unit, 30 calves were sampled. For the interpretation of ELISA test results, we used the 50% inhibition (50PI) cut-off as per producer's instructions and created one at 75% inhibition (75PI) based on the lowest point of the histogram of PI results. This approach resulted in three categories of outcomes; negative (N), low-positive (LP) and high-positive (HP). A generalized mixed-effect model for binary outcomes was used for analysing putative risk factors and was run for both cut-off values. A total of 8378 calves from 202 villages, 51 dairy farms and 28 mixed farms were eligible for analysis. The percentage of calves testing positive (LP+HP) was 53.7% (95% Confidence interval (CI): 52.6%-54.8%), with 39.6% (95% CI: 38.6-40.7%) testing HP (n=3309) while 14.1% (95% CI: 13.5-15.0%) of calves tested LP (n=1188). Of 281 epi-units sampled, all calves sampled tested negative in only 2 epi-units (0.7% (95% CI: 0.1-2.5%)) and more than 25 calves tested positive in 29 epi-units (10.3% (95% CI: 7.0-14.5%)). Outcomes of regression modelling using the 50 PI cut-off indicated that, for each month increase in age, the odds of testing positive increased 1.01 times (95% CI: 1.00-1.03). The odds of calves testing NSP-positive increased 1.46 times (95% CI: 1.22-1.77) for calves residing in epi-units that had experienced clinical FMD in the 12 months preceding this study. The odds of calves owned by livestock owners who traded livestock testing positive were 1.4-1.6 times higher than those owned by persons not engaged in trading while the odds for calves testing positive in dairy herds was 1.62 (95% CI: 1.10-2.35) times higher compared with calves in villages. The results of the model using the 75 PI cut-off value resulted in comparable estimates, with the age-effect becoming more evident. These results have confirmed widespread FMD infection and were used in developing a risk-based control strategy on FMD, in line with Stage 1 of the Progressive Control Pathway for FMD (PCP-FMD).

Antibody response and risk factors for seropositivity in backyard poultry following mass vaccination against highly pathogenic avian influenza and Newcastle disease in Indonesia.

A large-scale mass vaccination campaign was carried out in Java, Indonesia in an attempt to control outbreaks of highly pathogenic avian influenza (HPAI) in backyard flocks and commercial smallholder poultry. Sero-monitoring was conducted in mass vaccination and control areas to assess the proportion of the target population with antibodies against HPAI and Newcastle disease (ND). There were four rounds of vaccination, and samples were collected after each round resulting in a total of 27 293 samples. Sampling was performed irrespective of vaccination status. In the mass vaccination areas, 20-45% of poultry sampled had a positive titre to H5 after each round of vaccination, compared to 2-3% in the control group. In the HPAI + ND vaccination group, 12-25% of the population had positive ND titres, compared to 5-13% in the areas without ND vaccination. The level of seropositivity varied by district, age of the bird, and species (ducks vs. chickens).

The effectiveness of preventative mass vaccination regimes against the incidence of highly pathogenic avian influenza on Java Island, Indonesia.

We conducted an operational research study involving backyard and semicommercial farms on Java Island, Indonesia, between April 2008 and September 2009 to evaluate the effectiveness of two preventive mass vaccination strategies against highly pathogenic avian influenza (HPAI). One regimen used Legok 2003 H5N1 vaccine, while the other used both Legok 2003 H5N1 and HB1 Newcastle disease (ND) vaccine. A total of 16 districts were involved in the study. The sample size was estimated using a formal power calculation technique that assumed a detectable effect of treatment as a 50% reduction in the baseline number of HPAI-compatible outbreaks. Within each district, candidate treatment blocks with village poultry populations ranging from 80 000 to 120 000 were created along subdistrict boundary lines. Subsequently, four of these blocks were randomly selected and assigned one treatment from a list that comprised control, vaccination against HPAI, vaccination against HPAI + ND. Four rounds of vaccination were administered at quarterly intervals beginning in July 2008. A vaccination campaign involved vaccinating 100 000 birds in a treatment block, followed by another 100 000 vaccinations 3 weeks later as a booster dose. Data on disease incidence and vaccination coverage were also collected at quarterly intervals using participatory epidemiological techniques. Compared with the unvaccinated (control) group, the incidence of HPAI-compatible events declined by 32% (P = 0.24) in the HPAI-vaccinated group and by 73% (P = 0.00) in the HPAI- and ND-vaccinated group. The effect of treatment did not vary with time or district. Similarly, an analysis of secondary data from the participatory disease and response (PDSR) database revealed that the incidence of HPAI declined by 12% in the HPAI-vaccinated group and by 24% in the HPAI + ND-vaccinated group. The results suggest that the HPAI + ND vaccination significantly reduced the incidence of HPAI-compatible events in mixed populations of semicommercial and backyard poultry.

Facilitators for influenza vaccination uptake in nurses at the Shiraz University of Medical Sciences.

OBJECTIVE: Influenza is an important cause of morbidity and mortality. The aim of this study was to identify facilitators for vaccination in nursing staff at the Shiraz University of Medical Sciences. DESIGN: Cross-sectional study. METHOD: A self-administered questionnaire was distributed among nurses between November 2005 and February 2006. RESULTS: The response rate was 100%. Sixty-one percent (89/145) of nurses reported that they had continued working while sick with an influenza-like illness, and 21% (35/166) of nurses had been vaccinated for the current season. The most common reasons given for uptake of the current influenza vaccine were the belief that they were at risk of influenza due to the nature of their work (80%, 28/35), and concern about transmitting influenza to their patients (31%, 11/35). Vaccinated nurses were 3.4 times more likely [95% confidence interval (CI) 1.0-11.7; P = 0.05] to have the intention to be vaccinated next season than unvaccinated nurses. Respondents who intended to be vaccinated next season were 10.3 times more likely (95% CI 4.4-23.2; P = 0.000) to recommend the vaccine to their family and coworkers, and 4.6 times more likely (95% CI 1.9-11.0; P = 0.001) to recommend vaccination to their patients. CONCLUSION: Free of charge and widely available vaccination programmes, and the belief that nurses are at risk of influenza due to the nature of their work improve vaccination uptake among nurses, and thereby reduce the risk of healthcare-associated infection in susceptible patient populations.

Integration of participatory approaches into surveillance systems.

Animal health surveillance is essential for protecting public health, enhancing access to international markets for animals and their products, and improving animal health, production and welfare. It is of vital importance for protecting and improving the livelihoods of diverse groups of livestock keepers and stakeholders in livestock value chains. Surveillance systems consist of sets of complementary components which generate information to inform risk assessment, decision-making and policy formulation for both national programmes and international trade. Participatory approaches have the potential to add value to surveillance systems by enhancing their performance, especially their sensitivity and timeliness, and encouraging the inclusion of marginalised groups. This paper summarises key considerations in the assessment and design of animal health surveillance and discusses how participatory approaches can be integrated into comprehensive surveillance systems, leading to a more effective overall outcome for both domestic and international purposes.

Hand hygiene in rural Indonesian healthcare workers: barriers beyond sinks, hand rubs and in-service training.

Few attempts to increase healthcare workers' hand hygiene compliance have included an in-depth analysis of the social and behavioural context in which hand hygiene is not undertaken. We used a mixed method approach to explore hand hygiene barriers in rural Indonesian healthcare facilities to develop a resource-appropriate adoption of international guidelines. Two hospitals and eight clinics (private and public) in a rural Indonesian district were studied for three months each. Hand hygiene compliance was covertly observed for two shifts each in three adult wards at two hospitals. Qualitative data were collected from direct observation, focus group discussions and semistructured in-depth and informal interviews within healthcare facilities and the community. Major barriers to compliance included longstanding water scarcity, tolerance of dirtiness by the community and the healthcare organisational culture. Hand hygiene compliance was poor (20%; 57/281; 95% CI: 16-25%) and was more likely to be undertaken after patient contact (34% after-patient contact vs 5% before-patient contact, P<0.001) and 'inherent' opportunities associated with contacts perceived to be dirty (49% 'inherent' vs 11% 'elective' opportunities associated with clean contacts, P<0.001). Clinicians frequently touched patients without hand hygiene, and some clinicians avoided touching patients altogether. The provision of clean soap and water and in-service training will not overcome strong social and behavioural barriers unless interventions focus on long term community education and managerial commitment to the provision of supportive working conditions.

A survey of medical staff attitudes to an antibiotic approval and stewardship programme.

BACKGROUND: Antibiotic stewardship programmes (ASPs) are advocated to ensure appropriate antimicrobial use; with short-term evidence they may improve outcomes, limit adverse effects, encourage cost-effectiveness and reduce antibiotic resistance. At Concord Hospital, a 450-bed acute care hospital, we have used a telephone-based ASP for 15 years. There may be differences in attitudes to the ASP by prescribers, which may influence its long-term efficacy. METHOD: A 40-item self-administered questionnaire was sent to 190 junior and 250 specialist medical staff. We aimed to elicit medical staff attitudes to the ASP's utility, educational value, effect on patient care and ease of use. RESULTS: One hundred and sixty-four completed questionnaires were returned. Most (82%, 95% confidence interval (95%CI) 75-87%) clinicians had used the ASP, 98% of whom believed it to be a reasonable system. Most staff (85%, 95%CI 79-90%) believed that seeking approval made teams think carefully about antibiotic choice, agreed it provided helpful advice (91%, 95%CI 85-95%) and that the approval system provided useful advice and was educational (88%, 95%CI 81-92%). The ASP was felt time-consuming and detracting from clinical duties by 33% (95%CI 26-41%), while 10% (95%CI 5.8-15.7%) believed it undervalued intuition and experience. Few (19%, 95%CI 13-25%, P < 0.0001) clinicians believed it infringed their autonomy. The advice given through the ASP was believed by most (89%, 95%CI 81-92%) to improve patient outcomes. CONCLUSION: The ASP was surprisingly well supported by all levels of staff, and reinforced the benefits of maintaining an ASP policy.

Changing epidemiology of meticillin-resistant S. aureus in Queensland, Australia, 2000-2006: use of passive surveillance of susceptibility phenotypes.

The epidemiology of meticillin-resistant S. aureus (MRSA) infection has changed remarkably in recent years with the appearance of new MRSA strains causing infections in the community. These strains have now begun to cause healthcare-associated infections. The ability to track such changes is necessary to guide clinical and public health action. Here we report passive surveillance of all public laboratory susceptibility data in Queensland to track changes in MRSA phenotypes corresponding to the major epidemic strains from 2000 to 2006. The inpatient rate of MRSA isolation from pus, tissue and fluid (PTF) and blood culture (BC) specimens declined by 26% and 35%, respectively. The rate of isolation of the AUS-2/3-like phenotype (corresponding to ST239-MRSA-III) decreased from 651 to 242 isolates per million accrued patient days in inpatient PTF and BC, whereas that for non-multiresistant MRSA (nmMRSA, corresponding to community MRSA strains) increased from 71 to 315. The overall outpatient rate of MRSA isolation from PTF and BC increased by 224% and 31%, respectively. The rate of AUS-2/3-like isolates in outpatient PTF decreased from 131 to 60 per million outpatient occasions of service while the nmMRSA rate increased from 52 to 490. Surveillance of phenotypes derived from routine susceptibility data is a useful tool for tracking changes in the epidemiology of MRSA over large geographical regions.

Attitudes towards and evaluation of medical emergency teams: a survey of trainees in intensive care medicine.

A survey was conducted to explore the perception of intensive care registrars on the impact of activities outside the intensive care unit (ICU), particularly in medical emergency teams, on their training and the care of patients. An anonymous mail-out survey was sent to 356 trainees registered with the Joint Faculty of Intensive Care Medicine, half of whom were determined to be involved in ICU duties. No patients were involved and respondents participated voluntarily. The main outcome measures were barriers and predictors of satisfaction with ICU training. One-hundred-and-thirty-six (38%) trainees responded. Seventy-eight percent had participated in a medical emergency team, of whom 99% of respondents stated the medical emergency team included an ICU registrar but rarely (3%) an ICU consultant. Sixty-six percent of respondents reported that medical emergency team involvement had a positive effect on training but 77% reported little or no supervision of team duties. While trainees did not believe they spent too much time performing medical emergency team duties, the time spent on medical emergency teams at night, when ICU staffing levels are at their lowest, was the same as during the day. Serious concern was expressed about the negative impact of medical emergency team activities on their ability to care for ICU patients and the additional stress on ICU medical and nursing staff Overall, ICU trainees regarded participation in a medical emergency team as positive on training and on patient care in wards, but other results have resource implications for the provision of clinical emergency response systems, care of patients in ICUs and the training of the future intensive care workforce.

Persistence of Salmonella on egg conveyor belts is dependent on the belt type but not on the rdar morphotype.

Commercial caged layer flocks in Alberta, Canada, are commonly monitored for Salmonella enterica serovar Enteritidis (SE) and S. enterica serovar Typhimurium (ST) by environmental sampling. In one recent case, a SE strain isolated from the egg conveyor belt was a source of persistent infection for the flock. This study was undertaken to examine Salmonella colonization on egg conveyor belts and to determine whether the rdar morphotype, a conserved physiology associated with aggregation and long-term survival, contributed to persistence. Four woven belts constructed of natural or nonnatural fibers and a 1-piece belt made of vinyl were tested with rdar-positive ST and SE strains and a rdar-negative ST DeltaagfD reference strain. The type of egg belt was the most important factor influencing Salmonella colonization and persistence. The vinyl belt, with the least surface area available for colonization, had the fewest Salmonella remaining after washing and disinfection, whereas the hemp-plastic belt, with the greatest surface area, had the most Salmonella remaining. Real-time gene expression indicated that the rdar morphotype was involved in colonizing the egg belt pieces; however, it was not essential for persistence. In addition, rdar-positive and rdar-negative strains were equally similarly to disinfection on the egg belt pieces. The results indicate that Salmonella can persist on a variety of egg belts by mechanisms other than the rdar morphotype, and that using egg conveyer belts with reduced surface area for bacterial colonization can lessen contamination problems.

Post-discharge surgical site surveillance: does patient education improve reliability of diagnosis?

Post-discharge surgical infection surveillance by patients remains an integral part of many infection control programmes despite proven unreliability. We attempted to improve the validity of patient recognition of signs and symptoms of wound infection and post-discharge postal questionnaire responses through specific education prior to discharge. In total, 588 patients were studied after random assignment into two intervention groups, one of which received relevant education. Both groups were followed for four weeks post-operatively, with features of infection assessed weekly by experienced infection control nurses (ICNs) and by patient responses to routine postal questionnaires. Those patients who received education demonstrated a significantly poorer correlation with ICN diagnosis compared to the non-educated group (Kappa 0.69 and 0.81 respectively, P=0.05). Both patient groups achieved the same sensitivity for recall (83.3%), with high specificity demonstrated by both groups [educated (93.7%); non-educated (98.1%)]. The positive predictive value was 65.2% for the educated group and 83.3% for the non-educated patient group. When infected wounds identified by patients were examined for the proportion that were overdiagnosed, the excess of SSI identified by the educated patient group was 44.4% and by the non-educated group 16.7%. These results suggest that pre-discharge education causes patients to overdiagnose clinical features of wound infection and fails to improve the validity of diagnosis. This outcome further questions the value of post-discharge infection rates obtained by patient self-assessment as a measure of quality of performance.

Hindsight: a re-analysis of the severe acute respiratory syndrome outbreak in Beijing.

OBJECTIVE: To review the severe acute respiratory syndrome (SARS) epidemic in Beijing using basic epidemiological principles omitted from the original analysis. STUDY DESIGN: Analysis of Prospective surveillance data for Beijing collected during the outbreak. METHODS: Surveillance data were reclassified according to World Health Organization criteria. Cases previously excluded without date of onset of illness were included in the epidemic curve from estimates using the average time between date of onset and date of hospitalization for cases with both dates. Cases who failed to give a contact history were now included; 7% (n=5) of cases during the import phase and 61% (n=365) during the peak phase. Previously excluded cases were included for plotting on an epidemic curve, and basic spot mapping for distribution of cases was used from attack rates recalculated for age, gender, occupation, residential location, date of onset of illness and demographics. RESULTS: The spot map effectively illustrated clusters by residency, with the inner-city sustaining the highest attack rate (33.42 per 100,000), followed by an easterly distribution 5-30km away (21.62 per 10,000), and lowest in districts 60-160km away (9.21 per 100,000). The new epidemic curve shows the outbreak commencing 10 days earlier than initially reported, with a three-fold greater increase in cases during the escalation phase than previously estimated. CONCLUSION: In hindsight, the investigation of the Beijing SARS would have benefited from the use of spot maping as an essential outbreak tool for early identification of specific geographical area(s) for quarantining. If a spot map of incidence density rates was used during the early phase of the outbreak, the inner city might have been identified as a major risk factor requiring rapid quarantining. Contact history became uncommon as the outbreak progressed, suggesting that hospitals were over-burdened or pathogenesis and environment risk factors changed, strengthening the usefulness of early spot mapping and the need to modify risk factors included as contact history as the epidemic progresses.

A tsunami related tetanus epidemic in Aceh, Indonesia.

In January 2005, a tetanus epidemic was discovered amongst survivors of the Boxing Day Tsunami in Aceh, Indonesia. Our aim was to describe the extent of the tetanus outbreak in tsunami survivors admitted and describe the case outcomes from one hospital. All clinicians were instructed to report suspected cases to a centralised organisation using a standardised data collection tool. Active case finding was carried out by a trained team that visited hospital wards in Aceh. Of the 106 cases, 79% was above 25 years old (the median age was 40 years) and 62% was male. The mortality rate in Aceh was 19% and that of in follow up cases was 17%. Fifteen of the follow-up cases were admitted with severe tetanus associated with superficial wounds, three of whom had a history of immersion. Supplies to treat the tetanus cases in this epidemic were initially limited as disaster relief agencies were not prepared for the resultant tetanus epidemic. The mortality rate of 17%, was significantly less than was usual for tetanus in adults (>50%) and children (80%) in underdeveloped countries. To reduce mortality and morbidity, rapid disaster relief organisations should include supplies for vaccination and treatment of tetanus cases and consider early tracheotomy for severe cases.