A pediatric HIV outbreak in Pakistan.

Background: Following reports of an outbreak of HIV infection among children in Larkana District, Pakistan, an international team investigated the extent and cause of the outbreak between April and June 2019. Aims: To investigate the incidence of HIV among children in Larkana District, Pakistan and describe the distribution of cases by time, place and person. Methods: Self-referred persons were tested for HIV using the national testing protocol. Local epidemiology of HIV was reviewed to generate hypotheses. An infection prevention and control (IPC) team conducted site visits and reviewed IPC practices. Results: Between 25 April and 27 June 2019, a total of 30 191 persons were tested for HIV in Larkana District, and 876 of them tested positive. Of those who tested positive, 719 (82%) were children aged <15 years. Traditional skin piercing procedures and transmission from high-risk populations to children were ruled out during the investigation. Informative interviews with parents or guardians of a convenience sample of 211 children aged <15 years showed that 99% of children had an injection or infusion for medical treatment within the past 12 months. Our investigation identified lack of HIV prevalence data for the general population including tuberculosis patients and those who attended antenatal care services. Conclusions: Investigations indicate that unsafe healthcare practices in formal and informal healthcare settings as the most likely cause of the 2019 outbreak of HIV infection in Larkana, Pakistan. Measures should be taken to improve IPC practices at the facility level, especially in pediatric and antenatal care clinics.

Availability and Suitability of Digital Health Tools in Africa for Pandemic Control: Scoping Review and Cluster Analysis.

BACKGROUND: Gaining oversight into the rapidly growing number of mobile health tools for surveillance or outbreak management in Africa has become a challenge. OBJECTIVE: The aim of this study is to map the functional portfolio of mobile health tools used for surveillance or outbreak management of communicable diseases in Africa. METHODS: We conducted a scoping review by combining data from a systematic review of the literature and a telephone survey of experts. We applied the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching for articles published between January 2010 and December 2020. In addition, we used the respondent-driven sampling method and conducted a telephone survey from October 2019 to February 2020 among representatives from national public health institutes from all African countries. We combined the findings and used a hierarchical clustering method to group the tools based on their functionalities (attributes). RESULTS: We identified 30 tools from 1914 publications and 45 responses from 52% (28/54) of African countries. Approximately 13% of the tools (4/30; Surveillance Outbreak Response Management and Analysis System, Go.Data, CommCare, and District Health Information Software 2) covered 93% (14/15) of the identified attributes. Of the 30 tools, 17 (59%) tools managed health event data, 20 (67%) managed case-based data, and 28 (97%) offered a dashboard. Clustering identified 2 exceptional attributes for outbreak management, namely contact follow-up (offered by 8/30, 27%, of the tools) and transmission network visualization (offered by Surveillance Outbreak Response Management and Analysis System and Go.Data). CONCLUSIONS: There is a large range of tools in use; however, most of them do not offer a comprehensive set of attributes, resulting in the need for public health workers having to use multiple tools in parallel. Only 13% (4/30) of the tools cover most of the attributes, including those most relevant for response to the COVID-19 pandemic, such as laboratory interface, contact follow-up, and transmission network visualization.

Data collection for outbreak investigations: process for defining a minimal data set using a Delphi approach.

BACKGROUND: Timely but accurate data collection is needed during health emergencies to inform public health responses. Often, an abundance of data is collected but not used. When outbreaks and other health events occur in remote and complex settings, operatives on the ground are often required to cover multiple tasks whilst working with limited resources. Tools that facilitate the collection of essential data during the early investigations of a potential public health event can support effective public health decision-making. We proposed to define the minimum set of quantitative information to collect whilst using electronic device or not. Here we present the process used to select the minimum information required to describe an outbreak of any cause during its initial stages and occurring in remote settings. METHODS: A working group of epidemiologists took part in two rounds of a Delphi process to categorise the variables to be included in an initial outbreak investigation form. This took place between January-June 2019 using an online survey. RESULTS: At a threshold of 75 %, consensus was reached for nineteen (23.2%) variables which were all classified as 'essential'. This increased to twenty-six (31.7%) variables when the threshold was reduced to 60% with all but one variable classified as 'essential'. Twenty-five of these variables were included in the 'Time zero initial case investigation' '(T0)' form which was shared with the members of the Rapid Response Team Knowledge Network for field testing and feedback. The form has been readily available online by WHO since September 2019. CONCLUSION: This is the first known Delphi process used to determine the minimum variables needed for an outbreak investigation. The subsequent development of the T0 form should help to improve the efficiency and standardisation of data collection during emergencies and ultimately the quality of the data collected during field investigation.

Electronic data collection, management and analysis tools used for outbreak response in low- and middle-income countries: a systematic review and stakeholder survey.

BACKGROUND: Use of electronic data collection, management and analysis tools to support outbreak response is limited, especially in low income countries. This can hamper timely decision-making during outbreak response. Identifying available tools and assessing their functions in the context of outbreak response would support appropriate selection and use, and likely more timely data-driven decision-making during outbreaks. METHODS: We conducted a systematic review and a stakeholder survey of the Global Outbreak Alert and Response Network and other partners to identify and describe the use of, and technical characteristics of, electronic data tools used for outbreak response in low- and middle-income countries. Databases included were MEDLINE, EMBASE, Global Health, Web of Science and CINAHL with publications related to tools for outbreak response included from January 2010-May 2020. Software tool websites of identified tools were also reviewed. Inclusion and exclusion criteria were applied and counts, and proportions of data obtained from the review or stakeholder survey were calculated. RESULTS: We identified 75 electronic tools including for data collection (33/75), management (13/75) and analysis (49/75) based on data from the review and survey. Twenty-eight tools integrated all three functionalities upon collection of additional information from the tool developer websites. The majority were open source, capable of offline data collection and data visualisation. EpiInfo, KoBoCollect and Open Data Kit had the broadest use, including for health promotion, infection prevention and control, and surveillance data capture. Survey participants highlighted harmonisation of data tools as a key challenge in outbreaks and the need for preparedness through training front-line responders on data tools. In partnership with the Global Health Network, we created an online interactive decision-making tool using data derived from the survey and review. CONCLUSIONS: Many electronic tools are available for data -collection, -management and -analysis in outbreak response, but appropriate tool selection depends on knowledge of tools' functionalities and capabilities. The online decision-making tool created to assist selection of the most appropriate tool(s) for outbreak response helps by matching requirements with functionality. Applying the tool together with harmonisation of data formats, and training of front-line responders outside of epidemic periods can support more timely data-driven decision making in outbreaks.

Event-based surveillance at health facility and community level in low-income and middle-income countries: a systematic review.

BACKGROUND: The International Health Regulations require member states to establish "capacity to detect, assess, notify and report events". Event-based surveillance (EBS) can contribute to rapid detection of acute public health events. This is particularly relevant in low-income and middle-income countries (LMICs) which may have poor public health infrastructure. To identify best practices, we reviewed the literature on the implementation of EBS in LMICs to describe EBS structures and to evaluate EBS systems. METHODS: We conducted a systematic literature search of six databases to identify articles that evaluated EBS in LMICs and additionally searched for grey literature. We used a framework approach to facilitate qualitative data synthesis and exploration of patterns across and within articles. RESULTS: We identified 778 records, of which we included 15 studies concerning 13 different EBS systems. The 13 EBS systems were set up as community-based surveillance, health facility-based surveillance or open surveillance (ie, notification by non-defined individuals and institutions). Four systems were set up in outbreak settings and nine outside outbreaks. All EBS systems were integrated into existing routine surveillance systems and pre-existing response structures to some extent. EBS was described as useful in detecting a large scope of events, reaching remote areas and guiding outbreak response. CONCLUSION: Health facility and community-based EBS provide valuable information that can strengthen the early warning function of national surveillance systems. Integration into existing early warning and response systems was described as key to generate data for action and to facilitate rapid verification and response. Priority in its implementation should be given to settings that would particularly benefit from EBS strengths. This includes areas most prone to outbreaks and where traditional 'routine' surveillance is suboptimal.

Sensitivity and specificity of WHO's recommended four-symptom screening rule for tuberculosis in people living with HIV: a systematic review and meta-analysis.

BACKGROUND: Since 2011, WHO recommends a four-symptom screening rule to exclude active tuberculosis in people living with HIV before starting tuberculosis preventive treatment (ie, absence of current cough, weight loss, night sweats, or fever). We assessed the sensitivity and specificity of the screening rule among people living with HIV based on antiretroviral therapy (ART) status and the added contribution of chest radiography. METHODS: We did a systematic review and meta-analysis. We searched PubMed, Embase, and the Cochrane Library from Jan 1, 2011, to March 12, 2018, for studies published after the WHO issued recommendations on the use of the four-symptom screening rule. We also searched abstracts from relevant international conferences. We included studies that collected sputum or any specimens (eg, urine, blood, or fine-needle aspirates from lymph nodes) from people with HIV regardless of signs or symptoms. Case-control studies were excluded because they are prone to bias. Active tuberculosis was diagnosed with bacteriological confirmation by culture or Xpert MTB/RIF of any specimens. Two investigators extracted the data, including age, sex, and ART status. We calculated sensitivity, specificity, and 95% CI. When at least four studies were available, we estimated pooled sensitivity and specificity using random and effects bivariate models; otherwise we used univariate random-effects models. FINDINGS: Of 4615 records identified by the search, 21 were included in the review (involving 15 427 people including 1559 with active tuberculosis). 18 eligible studies were included in the final meta-analysis. Seven studies provided data on people receiving ART. The pooled sensitivity of the four-symptom screening rule was lower for 4640 people on ART (51·0%, 95% CI 28·4-73·2) than for 8664 who were ART-naive (89·4%, 83·0-93·5). Pooled specificity for those on ART was 70·7% (95% CI 47·8-86·4) and for ART-naive people was 28·1% (18·6-40·1). On the basis of data from 646 individuals in two studies, the addition of any abnormal chest radiographic findings in people on ART improved sensitivity from 52·2% (95% CI 38·0-66·0) to 84·6% (69·7-92·9) but decreased specificity from 55·5% (95% CI 51·8-59·2) to 29·8% (26·3-33·6). INTERPRETATION: Our review suggested a lower sensitivity of the WHO four-symptom screening rule among people with HIV who are on ART than in those who are ART naive. The addition of chest radiography could improve the screening rule in people living with HIV who are on ART, provided it does not pose a barrier to preventive treatment. FUNDING: None.

[Tuberculosis Guideline for Adults - Guideline for Diagnosis and Treatment of Tuberculosis including LTBI Testing and Treatment of the German Central Committee (DZK) and the German Respiratory Society (DGP)]. / S2k-Leitlinie: Tuberkulose im Erwachsenenalter.

Since 2015 a significant increase in tuberculosis cases is notified in Germany, mostly due to rising numbers of migrants connected to the recent refugee crisis. Because of the low incidence in previous years, knowledge on tuberculosis is more and more limited to specialized centers. However, lung specialist and healthcare workers of other fields have contact to an increasing number of tuberculosis patients. In this situation, guidance for the management of standard therapy and especially for uncommon situations will be essential. This new guideline on tuberculosis in adults gives recommendations on diagnosis, treatment, prevention and prophylaxis. It provides a comprehensive overview over the current knowledge, adapted to the specific situation in Germany. The German Central Committee against Tuberculosis (DZK e. V.) realized this guideline on behalf of the German Respiratory Society (DGP). A specific guideline for tuberculosis in the pediatrics field will be published separately. Compared to the former recommendations of the year 2012, microbiological diagnostics and therapeutic drug management were given own sections. Chapters about the treatment of drug-resistant tuberculosis, tuberculosis in people living with HIV and pharmacological management were extended. This revised guideline aims to be a useful tool for practitioners and other health care providers to deal with the recent challenges of tuberculosis treatment in Germany.

Molecular typing of toxic shock syndrome toxin-1- and Enterotoxin A-producing methicillin-sensitive Staphylococcus aureus isolates from an outbreak in a neonatal intensive care unit.

Outbreaks of Staphylococcus aureus are common in neonatal intensive care units (NICUs). Usually they are documented for methicillin-resistant strains, while reports involving methicillin-susceptible S. aureus (MSSA) strains are rare. In this study we report the epidemiological and molecular investigation of an MSSA outbreak in a NICU among preterm neonates. Infection control measures and interventions were commissioned by the Local Public Health Authority and supported by the Robert Koch Institute. To support epidemiological investigations molecular typing was done by spa-typing and Multilocus sequence typing; the relatedness of collected isolates was further elucidated by DNA SmaI-macrorestriction, microarray analysis and bacterial whole genome sequencing. A total of 213 neonates, 123 healthcare workers and 205 neonate parents were analyzed in the period November 2011 to November 2012. The outbreak strain was characterized as a MSSA spa-type t021, able to produce toxic shock syndrome toxin-1 and Enterotoxin A. We identified seventeen neonates (of which two died from toxic shock syndrome), four healthcare workers and three parents putatively involved in the outbreak. Whole-genome sequencing permitted to exclude unrelated cases from the outbreak and to discuss the role of healthcare workers as a reservoir of S. aureus on the NICU. Genome comparisons also indicated the presence of the respective clone on the ward months before the first colonized/infected neonates were detected.

Viral hepatitis in Germany: poor vaccination coverage and little knowledge about transmission in target groups.

BACKGROUND: In Germany, vaccination against hepatitis B is recommended for infants, children and adolescents since 1995 and for specific target groups since 1982. Little is known about knowledge about viral hepatitis and attitudes toward hepatitis B vaccination-factors likely to influence vaccine uptake. METHODS: In order to estimate vaccination coverage in adult target groups and in the overall adult population and to assess knowledge and attitudes, we conducted a nationwide cross-sectional telephone survey among 412 persons in November 2004. We defined participants as being vaccinated if they reported at least one previous vaccination against hepatitis B. RESULTS: Vaccination coverage (vc) standardised for age, sex and residence was 29.6% in the general population and 58.2% in target groups for hepatitis B vaccination. Particular gaps in vaccine coverage were detected among health care workers (vc: 69.5%) and chronically ill persons (vc: 22.0%). Knowledge on risk factors and transmission was far below expectations, whereas the acceptance of vaccination in the majority of the population (79.0%) was good. CONCLUSION: We conclude that educational measures could lead to a higher vaccination uptake in adult target groups.

Visceral leishmaniasis in southeastern Nepal: a cross-sectional survey on Leishmania donovani infection and its risk factors.

OBJECTIVE: To document the frequency of Leishmania donovani infection at community level in a highly endemic region in southeastern Nepal, and to assess socioeconomic and environmental risk factors. METHODS: A random cross-sectional population survey was held in two visceral leishmaniasis (VL) foci in Morang District in April to May 2003, enrolling individuals 2 years or older and residing in the endemic area for at least 12 months. Leishmania infection was defined as a direct agglutination test (DAT) titre equal to or higher than 1:3200. Risk factors were identified by logistic regression. RESULTS: The direct agglutination test was positive in 7.5% (95% CI: 5.1-10.8) and the leishmanin skin test (LST) in 13.2% (95% CI: 9.9-17.2) of the 373 study participants. No case of current kala-azar was found, but 5.1 % (95% CI: 3.1-7.8) reported having suffered from VL. Independent risk factors for Leishmania infection were proximity of the house to ponds [odds ratio (OR) 3.7, 95% CI: 1.6-8.5], family size (OR 4.4, 95% CI: 1.6-12.6), age > or =15 years (OR 5.5, 95% CI: 1.2-25.0) and house constructed in mud (OR 3.0, 95% CI: 1.1-7.6). Bednets, not impregnated and in poor condition, were used by 95.2% (95% CI: 92.3-97.0) of the population, but did not show any protective effect. CONCLUSION: This study shows that there is a serious problem of transmission of VL in this area of Nepal. The risk factors identified are linked with the socioeconomic level and the environment. The population would benefit from a community intervention to improve the environmental and housing conditions in the villages.

Influenza vaccination in German health care workers: effects and findings after two rounds of a nationwide awareness campaign.

In Germany, despite longstanding recommendations for influenza vaccination, uptake among health care workers (HCW) is poor. We conducted and evaluated a 2-year nationwide campaign to increase influenza vaccination rates among German HCW. The campaign was tailored to the results of a baseline survey and included the distribution of information material to all German hospitals (n approximately 2000) and engagement of stakeholders, such as professional HCW associations. Human and financial resources consisted of one full-time public health scientist (2 months) and approximately USD 45,000 to produce and distribute materials. We evaluated the intervention in a survey among a systematic sample of HCW in a sample of selected 20 hospitals. HCW were stratified by profession and asked to self-administer a questionnaire inquiring about self-perceived risk for influenza, belief of effectiveness of the vaccine, and influenza vaccination before the starting season (2003/2004) as well as the previous two seasons (2001/2002, 2002/2003). Three hundred and ninety-six of 800 (50%) HCW who were addressed in the evaluated hospitals participated in the evaluation survey. The overall influenza vaccination rate among respondents increased from 21% (2001/2002) to 26% (2003/2004), which was mostly due to a significant increase among physicians (2001/2002: 21%; 2003/2004: 31%; nurses: 20% and 22%, respectively). Significantly more physicians than nurses felt at increased risk for influenza and believed that the vaccine is very effective. Increased uptake among physicians (compared to nurses) was likely due to physicians' higher awareness of their risk and trust in the vaccine. In the future it may be necessary to address nurses differently than physicians. We conclude that a national campaign with very limited resources is feasible and capable of achieving measurable results in a short time frame.