Measles - United States, January 1, 2020-March 28, 2024.

Measles is a highly infectious febrile rash illness and was declared eliminated in the United States in 2000. However, measles importations continue to occur, and U.S. measles elimination status was threatened in 2019 as the result of two prolonged outbreaks among undervaccinated communities in New York and New York City. To assess U.S. measles elimination status after the 2019 outbreaks and to provide context to understand more recent increases in measles cases, CDC analyzed epidemiologic and laboratory surveillance data and the performance of the U.S. measles surveillance system after these outbreaks. During January 1, 2020-March 28, 2024, CDC was notified of 338 confirmed measles cases; 97 (29%) of these cases occurred during the first quarter of 2024, representing a more than seventeenfold increase over the mean number of cases reported during the first quarter of 2020-2023. Among the 338 reported cases, the median patient age was 3 years (range = 0-64 years); 309 (91%) patients were unvaccinated or had unknown vaccination status, and 336 case investigations included information on ≥80% of critical surveillance indicators. During 2020-2023, the longest transmission chain lasted 63 days. As of the end of 2023, because of the absence of sustained measles virus transmission for 12 consecutive months in the presence of a well-performing surveillance system, U.S. measles elimination status was maintained. Risk for widespread U.S. measles transmission remains low because of high population immunity. However, because of the increase in cases during the first quarter of 2024, additional activities are needed to increase U.S. routine measles, mumps, and rubella vaccination coverage, especially among close-knit and undervaccinated communities. These activities include encouraging vaccination before international travel and rapidly investigating suspected measles cases.

Deaths Associated with Pediatric Hepatitis of Unknown Etiology, United States, October 2021-June 2023.

During October 2021-June 2023, a total of 392 cases of acute hepatitis of unknown etiology in children in the United States were reported to Centers for Disease Control and Prevention as part of national surveillance. We describe demographic and clinical characteristics, including potential involvement of adenovirus in development of acute hepatitis, of 8 fatally ill children who met reporting criteria. The children had diverse courses of illness. Two children were immunocompromised when initially brought for care. Four children tested positive for adenovirus in multiple specimen types, including 2 for whom typing was completed. One adenovirus-positive child had no known underlying conditions, supporting a potential relationship between adenovirus and acute hepatitis in previously healthy children. Our findings emphasize the importance of continued investigation to determine the mechanism of liver injury and appropriate treatment. Testing for adenovirus in similar cases could elucidate the role of the virus.

Long-term Neutralizing Antibody Levels Against Measles and Rubella Viruses Among Adults With 3 Doses of Measles-Mumps-Rubella Vaccine.

Background: A third dose of measles-mumps-rubella vaccine (MMR) may be administered for various reasons, but data on long-term immunity are limited. We assessed neutralizing antibody levels against measles and rubella among adults up to 11 years after receipt of a third MMR dose. Methods: In this longitudinal study, healthy adults who received a third MMR dose as young adults (ages 18-28 years) were recalled around 5 years and 9-11 years after the third dose. Measles and rubella antibody levels were assessed by plaque-reduction and immunocolorimetric neutralization assays, respectively. Antibody concentrations <120 mIU/mL and <10 U/mL were considered potentially susceptible to measles and rubella, respectively. Geometric mean concentrations (GMCs) and 95% confidence intervals (CIs) over time were estimated from generalized estimating equation models. Results: Approximately 5 and 9-11 years after receipt of the third dose, 405 and 304 adults were assessed, respectively. Measles GMC was 428 mIU/mL (95% CI, 392-468 mIU/mL) 5 years postvaccination, declining to 381 mIU/mL (95% CI, 339-428 mIU/mL) 11 years postvaccination. At the last follow-up visit (9-11 years postvaccination), 10% of participants were potentially susceptible to measles infection. Rubella GMCs were stable throughout the follow-up period (63 U/mL to 65 U/mL); none of the participants was susceptible to rubella at the last follow-up visit. Conclusions: Eleven years after receiving a third MMR dose, measles and rubella neutralizing antibody levels remained high in adults. However, on the basis of waning antibody levels, some adults may become susceptible to measles infection over time despite receipt of 3 vaccine doses.

Paediatric acute hepatitis of unknown aetiology: a national surveillance investigation in the USA during 2021 and 2022.

BACKGROUND: Adenovirus is a known cause of hepatitis in immunocompromised children, but not in immunocompetent children. In April, 2022, following multiple reports of hepatitis of unknown aetiology and adenovirus viraemia in immunocompetent children in the USA and UK, the US Centers for Disease Control and Prevention (CDC) and jurisdictional health departments initiated national surveillance of paediatric acute hepatitis of unknown aetiology. We aimed to describe the clinical and epidemiological characteristics of children identified with hepatitis of unknown aetiology between Oct 1, 2021, and Sept 30, 2022, in the USA and to compare characteristics of those who tested positive for adenovirus with those who tested negative. METHODS: In this national surveillance investigation in the USA, children were identified for investigation if they were younger than 10 years with elevated liver transaminases (>500 U/L) who had an unknown cause for their hepatitis and onset on or after Oct 1, 2021. We reviewed medical chart abstractions, which included data on demographics, underlying health conditions, signs and symptoms of illness, laboratory results, vaccination history, radiological and liver pathology findings, diagnoses and treatment received, and outcomes. Caregiver interviews were done to obtain information on symptoms and health-care utilisation for the hepatitis illness, medical history, illness in close contacts or at school or daycare, diet, travel, and other potential exposures. Blood, stool, respiratory, and tissue specimens were evaluated according to clinician discretion and available specimens were submitted to CDC for additional laboratory testing or pathology evaluation. FINDINGS: Surveillance identified 377 patients from 45 US jurisdictions with hepatitis of unknown aetiology with onset from Oct 1, 2021, to Sept 30, 2022. The median age of patients was 2·8 years (IQR 1·2-5·0) and 192 (51%) were male, 184 (49%) were female, and one patient had sex unknown. Only 22 (6%) patients had a notable predisposing underlying condition. 347 patients (92%) were admitted to hospital, 21 (6%) subsequently received a liver transplant, and nine (2%) died. Among the 318 patients without notable underlying conditions, 275 were tested for adenovirus. Of these 116 (42%) had at least one positive specimen, and species F type 41 was the most frequent type identified (19 [73%] of 26 typed specimens were HAdV-41). Proportions of patients who had acute liver failure, received a liver transplant, and died were similar between those who tested positive for adenovirus compared with those who tested negative. Adenovirus species F was detected by polymerase chain reaction in nine pathology liver evaluations, but not by immunohistochemistry in seven of the nine with adequate liver tissue available. Interviews with caregivers yielded no common exposures. INTERPRETATION: Adenovirus, alone or in combination with other factors, might play a potential role in acute hepatitis among immunocompetent children identified in this investigation, but the pathophysiologic mechanism of liver injury is unclear. To inform both prevention and intervention measures, more research is warranted to determine if and how adenovirus might contribute to hepatitis risk and the potential roles of other pathogens and host factors. FUNDING: None.

Modeling poliovirus transmission and responses in New York State.

BACKGROUND: In July 2022, New York State (NYS) reported a case of paralytic polio in an unvaccinated young adult, and subsequent wastewater surveillance confirmed sustained local transmission of type 2 vaccine-derived poliovirus (VDPV2) in NYS with genetic linkage to the paralyzed patient. METHODS: We adapted an established poliovirus transmission and oral poliovirus vaccine (OPV) evolution model to characterize dynamics of poliovirus transmission in NYS, including consideration of the immunization activities performed as part of the declared state of emergency. RESULTS: Despite sustained transmission of imported VDPV2 in NYS involving potentially thousands of individuals (depending on seasonality, population structure and mixing assumptions) in 2022, the expected number of additional paralytic cases in years 2023 and beyond is small (less than 0.5). However, continued transmission and/or reintroduction of poliovirus into NYS and other populations remains a possible risk in communities that do not achieve and maintain high immunization coverage. CONCLUSION: In countries such as the US that use only inactivated poliovirus vaccine, even with high average immunization coverage, imported polioviruses may circulate and pose a small but non-zero risk of causing paralysis in non-immune individuals.

Measles virus transmission patterns and public health responses during Operation Allies Welcome: a descriptive epidemiological study.

BACKGROUND: On Aug 29, 2021, Operation Allies Welcome (OAW) was established to support the resettlement of more than 80 000 Afghan evacuees in the USA. After identification of measles among evacuees, incoming evacuee flights were temporarily paused, and mass measles vaccination of evacuees aged 6 months or older was introduced domestically and overseas, with a 21-day quarantine period after vaccination. We aimed to evaluate patterns of measles virus transmission during this outbreak and the impact of control measures. METHODS: We conducted a measles outbreak investigation among Afghan evacuees who were resettled in the USA as part of OAW. Patients with measles were defined as individuals with an acute febrile rash illness between Aug 29, 2021, and Nov 26, 2021, and either laboratory confirmation of infection or epidemiological link to a patient with measles with laboratory confirmation. We analysed the demographics and clinical characteristics of patients with measles and used epidemiological information and whole-genome sequencing to track transmission pathways. A transmission model was used to evaluate the effects of vaccination and other interventions. FINDINGS: 47 people with measles (attack rate: 0·65 per 1000 evacuees) were reported in six US locations housing evacuees in four states. The median age of patients was 1 year (range 0-26); 33 (70%) were younger than 5 years. The age distribution shifted during the outbreak towards infants younger than 12 months. 20 (43%) patients with wild-type measles virus had rash onset after vaccination. No fatalities or community spread were identified, nor further importations after flight resumption. In a non-intervention scenario, transmission models estimated that a median of 5506 cases (IQR 10-5626) could have occurred. Infection clusters based on epidemiological criteria could be delineated into smaller clusters using phylogenetic analyses; however, sequences with few substitution count differences did not always indicate single lines of transmission. INTERPRETATION: Implementation of control measures limited measles transmission during OAW. Our findings highlight the importance of integration between epidemiological and genetic information in discerning between individual lines of transmission in an elimination setting. FUNDING: US Centers for Disease Control and Prevention.

Early childhood outcomes of NICU graduates with cytomegalovirus infection in California.

BACKGROUND: To assess demographics and outcomes up to 3 years of age among children with cytomegalovirus (CMV) infection in California neonatal intensive care units (NICUs) during 2010-2021. METHODS: The California Perinatal Quality Care Collaborative (CPQCC) collects data on all very low birth weight (VLBW, birth weight ≤ 1500 g) and acutely ill infants with birth weight > 1500 g across 92% of NICUs in California. VLBW infants and those with neurological conditions are referred to a statewide high-risk infant follow-up (HRIF) program. CMV infection was defined as a positive culture or PCR identified during the NICU hospitalization. RESULTS: During 2010-2021, CMV reporting rates averaged 3.5/1000 VLBW infants (n = 205) and 1.1/1000 infants >1500 g (n = 128). Among all 333 infants with CMV, 314 (94%) were discharged home alive, 271 (86%) were referred for HRIF and 205 (65%) had ≥1 visit. Whereas infants born to mothers <20 years of age had highest CMV reporting rates and those born to Hispanic mothers comprised 49% of all infected infants, they had the highest loss of follow-up. At the 12-month visit (n = 152), 19 (13%) infants with CMV had bilateral blindness and 18 (12%) had hearing loss. At the 24-month visit, 5 (5%) of 103 had severe cerebral palsy. CONCLUSIONS: Among infants admitted to the NICU, those with CMV diagnoses may over represent infants with more severe CMV disease and outcomes. The CPQCC and HRIF program findings may help inform implementation of surveillance for congenital CMV infection in other U.S. states and guide strategies to reduce disparities in access to services.

Evaluation of Ethiopia's field epidemiology training program - frontline: perspectives of implementing partners.

BACKGROUND: Field Epidemiology Training Program (FETP) has been adopted as an epidemiology and response capacity building strategy worldwide. FETP-Frontline was introduced in Ethiopia in 2017 as a three-month in-service training. In this study, we evaluated implementing partners' perspectives with the aim of understanding program effectiveness and identifying challenges and recommendations for improvement. METHODS: A qualitative cross-sectional design was utilized to evaluate Ethiopia's FETP-Frontline. Using a descriptive phenomenological approach, qualitative data were collected from FETP-Frontline implementing partners, including regional, zonal, and district health offices across Ethiopia. We collected data through in-person key informant interviews, using semi-structured questionnaires. Thematic analysis was conducted, assisted with MAXQDA, while ensuring interrater reliability by using the consistent application of theme categorization. The major themes that emerged were program effectiveness, knowledge and skills differences between trained and untrained officers, program challenges, and recommended actions for improvement. Ethical approval was obtained from the Ethiopian Public Health Institute. Informed written consent was obtained from all participants, and confidentiality of the data was maintained throughout. RESULTS: A total of 41 interviews were conducted with key informants from FETP-Frontline implementing partners. The regional and zonal level experts and mentors had a Master of Public Health (MPH), whereas district health managers were Bachelor of Science (BSc) holders. Majority of the respondents reflected a positive perception towards FETP-Frontline. Regional and zonal officers as well as mentors mentioned that there were observable performance differences between trained and untrained district surveillance officers. They also identified various challenges including lack of resources for transportation, budget constraints for field projects, inadequate mentorship, high staff turnover, limited number of staff at the district level, lack of continued support from stakeholders, and the need for refresher training for FETP-Frontline graduates. CONCLUSIONS: Implementing partners reflected a positive perception towards FETP-Frontline in Ethiopia. In addition to scaling-up the program to reach all districts to achieve the International Health Regulation 2005 goals, the program also needs to consider addressing immediate challenges, primarily lack of resources and poor mentorship. Continued monitoring of the program, refresher training, and career path development could improve retention of the trained workforce.

Adeno-associated virus type 2 in US children with acute severe hepatitis.

As of August 2022, clusters of acute severe hepatitis of unknown aetiology in children have been reported from 35 countries, including the USA1,2. Previous studies have found human adenoviruses (HAdVs) in the blood from patients in Europe and the USA3-7, although it is unclear whether this virus is causative. Here we used PCR testing, viral enrichment-based sequencing and agnostic metagenomic sequencing to analyse samples from 16 HAdV-positive cases from 1 October 2021 to 22 May 2022, in parallel with 113 controls. In blood from 14 cases, adeno-associated virus type 2 (AAV2) sequences were detected in 93% (13 of 14), compared to 4 (3.5%) of 113 controls (P < 0.001) and to 0 of 30 patients with hepatitis of defined aetiology (P < 0.001). In controls, HAdV type 41 was detected in blood from 9 (39.1%) of the 23 patients with acute gastroenteritis (without hepatitis), including 8 of 9 patients with positive stool HAdV testing, but co-infection with AAV2 was observed in only 3 (13.0%) of these 23 patients versus 93% of cases (P < 0.001). Co-infections by Epstein-Barr virus, human herpesvirus 6 and/or enterovirus A71 were also detected in 12 (85.7%) of 14 cases, with higher herpesvirus detection in cases versus controls (P < 0.001). Our findings suggest that the severity of the disease is related to co-infections involving AAV2 and one or more helper viruses.

Congenital cytomegalovirus surveillance in the United States.

BACKGROUND: Congenital cytomegalovirus (cCMV) is not a nationally notifiable condition, and little is known about how U.S. health departments (HDs) currently conduct cCMV surveillance. METHODS: We surveyed U.S. HDs that conduct cCMV surveillance or screening activities identified through a web-based assessment. Meetings were held with each HD to enhance our understanding of survey responses. RESULTS: Ten states are systematically collecting cCMV case data to track cCMV cases during early infancy and to provide resources and services to families. Cases are ascertained using cCMV diagnostic codes, reported diagnosis, or laboratory results. Data elements collected for each case include demographics (all 10 states), clinical signs (8 states), laboratory data (4 states), treatment (4 states), and long-term outcomes (1 state). Annual number of cases reported by HDs ranged from 3 to 47 cases/year in seven states, which was much lower than the expected number of cCMV cases. All 10 HDs have the ability to analyze data collected and four disseminate findings. Major challenges of surveillance reported by HDs were lack of standardized case definitions, personnel constraints, and limited funding. CONCLUSIONS: A comprehensive account of cCMV disease burden is severely limited by low case ascertainment and paucity of data on long-term outcomes. A standardized public health case definition for cCMV would improve consistency in measuring disease prevalence across jurisdictions and over time. Surveillance for cCMV has the potential to increase disease awareness and inform strategies to prevent cCMV-associated disabilities.

Rapid virtual training and field deployment for COVID-19 surveillance officers: experiences from Ethiopia.

Rapid scale-up of surveillance activities is the key to successful coronavirus disease 2019 (COVID-19) pandemic prevention and mitigation. Ethiopia did not have a sufficient number of active surveillance officers for the public health COVID-19 response. Training of surveillance officers was needed urgently to fill the gap in the workforce needed. Subject-matter experts from the United States and Ethiopia developed applicable training modules including background on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), contact investigation, and communications. The training modules were delivered live in real-time via web-based virtual presentation. Seventy-seven health surveillance officers were hired, trained, and deployed in two weeks to assist with surveillance activities in Ethiopia. Electronic capacity building is needed in order to improve Web-based training in resource-limited settings where internet access is limited or unreliable. Web-based synchronously delivered course was an effective platform for COVID-19 surveillance training. However, strengthening public and private information technology capacity, literacy, and internet availability will improve Web-based education platforms in resource-limited countries.

Incorporating COVID-19 into Acute Febrile Illness Surveillance Systems, Belize, Kenya, Ethiopia, Peru, and Liberia, 2020-2021.

Existing acute febrile illness (AFI) surveillance systems can be leveraged to identify and characterize emerging pathogens, such as SARS-CoV-2, which causes COVID-19. The US Centers for Disease Control and Prevention collaborated with ministries of health and implementing partners in Belize, Ethiopia, Kenya, Liberia, and Peru to adapt AFI surveillance systems to generate COVID-19 response information. Staff at sentinel sites collected epidemiologic data from persons meeting AFI criteria and specimens for SARS-CoV-2 testing. A total of 5,501 patients with AFI were enrolled during March 2020-October 2021; >69% underwent SARS-CoV-2 testing. Percentage positivity for SARS-CoV-2 ranged from 4% (87/2,151, Kenya) to 19% (22/115, Ethiopia). We show SARS-CoV-2 testing was successfully integrated into AFI surveillance in 5 low- to middle-income countries to detect COVID-19 within AFI care-seeking populations. AFI surveillance systems can be used to build capacity to detect and respond to both emerging and endemic infectious disease threats.

Wastewater Testing and Detection of Poliovirus Type 2 Genetically Linked to Virus Isolated from a Paralytic Polio Case - New York, March 9-October 11, 2022.

In July 2022, a case of paralytic poliomyelitis resulting from infection with vaccine-derived poliovirus (VDPV) type 2 (VDPV2)§ was confirmed in an unvaccinated adult resident of Rockland County, New York (1). As of August 10, 2022, poliovirus type 2 (PV2)¶ genetically linked to this VDPV2 had been detected in wastewater** in Rockland County and neighboring Orange County (1). This report describes the results of additional poliovirus testing of wastewater samples collected during March 9-October 11, 2022, and tested as of October 20, 2022, from 48 sewersheds (the community area served by a wastewater collection system) serving parts of Rockland County and 12 surrounding counties. Among 1,076 wastewater samples collected, 89 (8.3%) from 10 sewersheds tested positive for PV2. As part of a broad epidemiologic investigation, wastewater testing can provide information about where poliovirus might be circulating in a community in which a paralytic case has been identified; however, the most important public health actions for preventing paralytic poliomyelitis in the United States remain ongoing case detection through national acute flaccid myelitis (AFM) surveillance†† and improving vaccination coverage in undervaccinated communities. Although most persons in the United States are sufficiently immunized, unvaccinated or undervaccinated persons living or working in Kings, Orange, Queens, Rockland, or Sullivan counties, New York should complete the polio vaccination series as soon as possible.

Adherence to national malaria clinical management and testing guidelines in selected private clinics of Gambela Town, Gambela Region, Ethiopia: a mixed method study.

BACKGROUND: The World Health Organization World Malaria Report of 2019 indicated an estimated 228 million cases of malaria occurred worldwide in 2018. More than 75% of the total area of Ethiopia is malarious, making malaria a leading public health problem in Ethiopia. Adherence to clinical guidelines improves the quality of care received by patients, thus improving patient outcomes. This study investigates healthcare workers' adherence to malaria testing and treatment guidelines in selected private clinics of Gambela Town, Ethiopia. METHODS: A mixed study design involving a retrospective review of 425 patient files and 20 healthcare worker interviews in private clinics was implemented. Data were collected using pre-tested data collection forms. The collected data were then cleaned and entered into statistical software for analysis, with a level of significance set at < 0.05. A qualitative analysis was also conducted using healthcare worker interviews to identify the existing barriers to guideline adherence. RESULTS: Among the 430 cases of suspected malaria, only 65% were tested for malaria. Of those tested, 75% tested positive and 25% tested negative. The most common co-morbidity in patients treated for malaria was anaemia (30%), followed by gastroenteritis (10%). Patients with co-morbidities were more likely to receive appropriate treatment (p = 0.03) compared to those without co-morbidities. All healthcare workers interviewed were aware of the existence of the malaria treatment guidelines. However, many were not aware of the contents of the guidelines and only 40% had been trained to understand the guidelines. Overall, 85% of the workers claimed to adhere to guidelines, with 15% claiming non-adherence. CONCLUSION: The gap between knowledge of the malaria treatment guidelines and their application by healthcare workers remains wide. The level of knowledge of these guidelines was also low. Continuous training, follow-up, supportive supervision, and improved adherence to the malaria guidelines are therefore recommended.

Interim Analysis of Acute Hepatitis of Unknown Etiology in Children Aged <10 Years - United States, October 2021-June 2022.

On April 21, 2022, CDC issued a health advisory† encouraging U.S. clinicians to report all patients aged <10 years with hepatitis of unknown etiology to public health authorities, after identification of similar cases in both the United States (1) and Europe.§ A high proportion of initially reported patients had adenovirus detected in whole blood specimens, thus the health advisory encouraged clinicians to consider requesting adenovirus testing, preferentially on whole blood specimens. For patients meeting the criteria in the health advisory (patients under investigation [PUIs]), jurisdictional public health authorities abstracted medical charts and interviewed patient caregivers. As of June 15, 2022, a total of 296 PUIs with hepatitis onset on or after October 1, 2021, were reported from 42 U.S. jurisdictions. The median age of PUIs was 2 years, 2 months. Most PUIs were hospitalized (89.9%); 18 (6.1%) required a liver transplant, and 11 (3.7%) died. Adenovirus was detected in a respiratory, blood, or stool specimen of 100 (44.6%) of 224 patients.¶ Current or past infection with SARS-CoV-2 (the virus that causes COVID-19) was reported in 10 of 98 (10.2%) and 32 of 123 (26.0%) patients, respectively. No common exposures (e.g., travel, food, or toxicants) were identified. This nationwide investigation is ongoing. Further clinical data are needed to understand the cause of hepatitis in these patients and to assess the potential association with adenovirus.

Trends in Acute Hepatitis of Unspecified Etiology and Adenovirus Stool Testing Results in Children - United States, 2017-2022.

In November 2021, CDC was notified of a cluster of previously healthy children with hepatitis of unknown etiology evaluated at a single U.S. hospital (1). On April 21, 2022, following an investigation of this cluster and reports of similar cases in Europe (2,3), a health advisory* was issued requesting U.S. providers to report pediatric cases† of hepatitis of unknown etiology to public health authorities. In the United States and Europe, many of these patients have also received positive adenovirus test results (1,3). Typed specimens have indicated adenovirus type 41, which typically causes gastroenteritis (1,3). Although adenovirus hepatitis has been reported in immunocompromised persons, adenovirus is not a recognized cause of hepatitis in healthy children (4). Because neither acute hepatitis of unknown etiology nor adenovirus type 41 is reportable in the United States, it is unclear whether either has recently increased above historical levels. Data from four sources were analyzed to assess trends in hepatitis-associated emergency department (ED) visits and hospitalizations, liver transplants, and adenovirus stool testing results among children in the United States. Because of potential changes in health care-seeking behavior during 2020-2021, data from October 2021-March 2022 were compared with a pre-COVID-19 pandemic baseline. These data do not suggest an increase in pediatric hepatitis or adenovirus types 40/41 above baseline levels. Pediatric hepatitis is rare, and the relatively low weekly and monthly counts of associated outcomes limit the ability to interpret small changes in incidence. Ongoing assessment of trends, in addition to enhanced epidemiologic investigations, will help contextualize reported cases of acute hepatitis of unknown etiology in U.S. children.

A comparative cross-sectional evaluation of the Field Epidemiology Training Program-Frontline in Ethiopia.

BACKGROUND: The Field Epidemiology Training Program (FETP)-Frontline is a three-month in-service training aimed at improving surveillance officers' capacity to collect, analyze, and interpret surveillance data, and respond to health emergencies. We evaluated the effectiveness of the FETP-Frontline which was introduced in Ethiopia in 2016. METHODS: We conducted a comparative, randomized cross-sectional study to assess surveillance-related knowledge, skills, and performance among trained and untrained officers using a structured questionnaire and observation checklist. We compared the knowledge, skills, and performance scores of trained and untrained officers using the Fisher's Exact test, chi-square test, and t-test at p-value < 0.05 for statistical significance. RESULTS: We conducted the study among 74 trained and 76 untrained surveillance officers. About three-quarters of all participants were male, and the average age was 34 (± 8.6) years. Completeness and timeliness of surveillance reports were significantly higher among trained than untrained surveillance officers. The trained officers were more likely to have produced epidemiologic bulletins (55% vs 33%), conducted active surveillance six months before the survey (88% vs 72%), provided surveillance training (88% vs 65%), conducted strengths, weakness, opportunities, and threats (SWOT) analysis (55% vs 17%), and utilized Microsoft Excel to manage surveillance data (87% vs 47%). We also observed improved surveillance officers' perceived skills and knowledge, and the availability and quality of surveillance formats and reports among the trained group. CONCLUSIONS: FETP-Frontline trained surveillance officers demonstrated better knowledge, skills, and performance in most surveillance activities compared to the untrained officers. FETP-Frontline can address competency gaps among district surveillance officers in Ethiopia and other countries. Scaling up the program to cover unreached districts can enable achieving the human resource development core capacity requirement of the International Health Regulations 2005.

Seroprevalence and risk factors for SARS-CoV-2 Infection in selected urban areas in Ethiopia: a cross-sectional evaluation during July 2020.

BACKGROUND: Ethiopia reported the first case of COVID-19 on 13th March, 2020 with community transmission ensuing by mid-May. A national, population-based serosurvey against anti-SARS-CoV-2 IgG was conducted to measure the prevalence of prior COVID-19 infections and better approximate the burden across major towns in Ethiopia. METHODS: We conducted a cross-sectional, population-based serosurvey from June 24 to July 8, 2020 in 14 major urban areas. Two-stage cluster sampling was used to randomly select enumeration areas and households. All persons aged ≥15 years were enrolled. Serum samples were tested by Abbott™ ARCHITECT™ assay for SARS-CoV-2 IgG antibodies. National COVID-19 surveillance data on the median date of the serosurvey is analyzed for comparison. FINDINGS: Adjusted seroprevalence was 3.5% (95% CI: 3.2%-3.8%) after controlling for age, sex and test kit performance. Males (3.7%) and females (3.3%) were nearly equally infected, while middle-aged adults '40-65 years' had the highest (4.0%) prevalence. Gambella (7.5%), Dire Dawa (6.2%) and Jigjiga (6.1%) were the most affected towns. About 6.7% and 8.0% of seropositives had symptoms and chronic underlying illness, respectively. A surveillance system had identified 4,416 RT-PCR confirmed cases in Addis Ababa. INTERPRETATION: This serosurvey shows that a majority of urban Ethiopians remain uninfected with SARS-CoV-2. Most anti-SARS-CoV-2 IgG positive cases were asymptomatic with no underlying illness, keeping case detection to a minimum.

Another dengue fever outbreak in Eastern Ethiopia-An emerging public health threat.

BACKGROUND: Dengue Fever (DF) is a viral disease primarily transmitted by Aedes (Ae.) aegypti mosquitoes. Outbreaks in Eastern Ethiopia were reported during 2014-2016. In May 2017, we investigated the first suspected DF outbreak from Kabridahar Town, Somali region (Eastern Ethiopia) to describe its magnitude, assess risk factors, and implement control measures. METHODS: Suspected DF cases were defined as acute febrile illness plus ≥2 symptoms (headache, fever, retro-orbital pain, myalgia, arthralgia, rash, or hemorrhage) in Kabridahar District residents. All reported cases were identified through medical record review and active searches. Severe dengue was defined as DF with severe organ impairment, severe hemorrhage, or severe plasma leakage. We conducted a neighborhood-matched case-control study using a subset of suspected cases and conveniently-selected asymptomatic community controls and interviewed participants to collect demographic and risk factor data. We tested sera by RT-PCR to detect dengue virus (DENV) and identify serotypes. Entomologists conducted mosquito surveys at community households to identify species and estimate larval density using the house index (HI), container index (CI) and Breteau index (BI), with BI≥20 indicating high density. RESULTS: We identified 101 total cases from May 12-31, 2017, including five with severe dengue (one death). The attack rate (AR) was 17/10,000. Of 21 tested samples, 15 (72%) were DENV serotype 2 (DENV 2). In the case-control study with 50 cases and 100 controls, a lack of formal education (AOR [Adjusted Odds Ratio] = 4.2, 95% CI [Confidence Interval] 1.6-11.2) and open water containers near the home (AOR = 3.0, 95% CI 1.2-7.5) were risk factors, while long-lasting insecticide treated-net (LLITN) usage (AOR = 0.21, 95% CI 0.05-0.79) was protective. HI and BI were 66/136 (49%) and 147 per 100 homes (147%) respectively, with 151/167 (90%) adult mosquitoes identified as Ae. aegypti. CONCLUSION: The epidemiologic, entomologic, and laboratory investigation confirmed a DF outbreak. Mosquito indices were far above safe thresholds, indicating inadequate vector control. We recommended improved vector surveillance and control programs, including best practices in preserving water and disposal of open containers to reduce Aedes mosquito density.