Frontline Field Epidemiology Training Programs as a Strategy to Improve Disease Surveillance and Response.

Since 1980, Field Epidemiology Training Programs (FETPs) have trained highly qualified field epidemiologists to work for ministries of health (MOH) around the world. However, the 2013-2015 Ebola epidemic in West Africa, which primarily affected Guinea, Liberia, and Sierra Leone, demonstrated a lack of field epidemiologists at the local levels. Trained epidemiologists at these levels could have detected the Ebola outbreak earlier. In 2015, the US Centers for Disease Control and Prevention (CDC) launched FETP-Frontline, a 3-month field training program targeting local MOH staff in 24 countries to augment local public health capacity. As of December 2016, FETP-Frontline has trained 1,354 graduates in 24 countries. FETP-Frontline enhances global health security by training local public health staff to improve surveillance quality in their jurisdictions, which can be a valuable strategy to strengthen the capacity of countries to more rapidly detect, respond to, and contain public health emergencies at the source.

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

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

A network model for Ebola spreading.

The availability of accurate models for the spreading of infectious diseases has opened a new era in management and containment of epidemics. Models are extensively used to plan for and execute vaccination campaigns, to evaluate the risk of international spreadings and the feasibility of travel bans, and to inform prophylaxis campaigns. Even when no specific therapeutical protocol is available, as for the Ebola Virus Disease (EVD), models of epidemic spreading can provide useful insight to steer interventions in the field and to forecast the trend of the epidemic. Here, we propose a novel mathematical model to describe EVD spreading based on activity driven networks (ADNs). Our approach overcomes the simplifying assumption of homogeneous mixing, which is central to most of the mathematically tractable models of EVD spreading. In our ADN-based model, each individual is not bound to contact every other, and its network of contacts varies in time as a function of an activity potential. Our model contemplates the possibility of non-ideal and time-varying intervention policies, which are critical to accurately describe EVD spreading in afflicted countries. The model is calibrated from field data of the 2014 April-to-December spreading in Liberia. We use the model as a predictive tool, to emulate the dynamics of EVD in Liberia and offer a one-year projection, until December 2015. Our predictions agree with the current vision expressed by professionals in the field, who consider EVD in Liberia at its final stage. The model is also used to perform a what-if analysis to assess the efficacy of timely intervention policies. In particular, we show that an earlier application of the same intervention policy would have greatly reduced the number of EVD cases, the duration of the outbreak, and the infrastructures needed for the implementation of the intervention.

Italian family paediatricians' approach and management of celiac disease: a cross-sectional study in Puglia Region, 2012.

BACKGROUND: Celiac disease (CD) is a chronic autoimmune illness of the small intestine triggered by gluten consumption in genetically predisposed individuals. CD presentation is not limited to the gastrointestinal tract and it is still under-diagnosed. Complete resolution of clinical manifestations follows if a gluten-free diet is adopted. In western countries, CD prevalence is approximately 1%. Age of onset is often between 6 months and 7 years.We assessed the approach to diagnosis and management of celiac patients by the paediatricians in Puglia Region, Italy. METHODS: We conducted a cross-sectional survey among the 589 Apulian Family Paediatricians (FPs) during January 2011-January 2012 using a self-administered web-based standardized questionnaire including self-assessment of their knowledge, diagnostic path and type of management they would follow for CD, clinical information on their celiac patients. We assessed associations among the explored variables by defining double-entry contingency tables and calculating Odds Ratio (OR) with 95% Confidence Intervals (CIs). RESULTS: The 218 (37%) FPs participating in the study reported 1,020 CD patients (representing approximately 1% of the child population covered by the enrolled FPs). Of them, 55% were female; 45% were aged 5-10 years. Weight loss and stunting were the main reported symptoms at diagnosis (41%). The majority (98%) of FPs requested anti-transglutaminase antibody (tTG-Ab) titres for CD diagnosis. Approximately 78% of FPs recommended gluten introduction in the diet of infants at the age of 6 months; 12% and 8% recommended introduction of gluten before and after 6 months of age respectively.The degree of knowledge for either CD diagnosis making process or CD related diseases was medium/high in 97% and 82% of the participating FPs respectively. FPs (83%) who had a medium or high degree of knowledge of CD patients' diet were more likely to experience low or no difficulty in providing their patients with dietary advices (OR:5.5; 95%CI:1.7-17.5). CONCLUSIONS: Apulian FPs report a good degree of knowledge of CD, its diagnosis and its management. We will diffuse results and recommendations to all paediatricians in the Region. Actions aiming to continued education on CD in medical under and postgraduate trainings are crucial to prevent under-diagnosis.

Results from ad hoc and routinely collected data among celiac women with infertility or pregnancy related disorders: Italy, 2001-2011.

Celiac disease (CD) is a chronic autoimmune illness triggered by gluten consumption in genetically predisposed individuals. Worldwide, CD prevalence is approximately 1%. Several studies suggest a higher prevalence of undiagnosed CD in patients with infertility. We described reproductive disorders and assessed the frequency of hospital admissions for infertility among celiac women aged 15-49. We conducted two surveys enrolling a convenient sample of celiac women, residing in Apulia or in Basilicata (Italy). Moreover, we selected hospital discharge records (HDRs) of celiac women and women with an exemption for CD, and matched the lists with HDRs for reproductive disorders. In the surveys we included 91 celiac women; 61.5% of them reported menstrual cycle disorders. 47/91 reported at least one pregnancy and 70.2% of them reported problems during pregnancy. From the HDRs and the registry of exemption, we selected 4,070 women with CD; the proportion of women hospitalized for infertility was higher among celiac women than among resident women in childbearing age (1.2% versus 0.2%). Our findings highlight a higher prevalence of reproductive disorders among celiac women than in the general population suggesting that clinicians might consider testing for CD women presenting with pregnancy disorders or infertility.

Clinical and epidemiological performance of WHO Ebola case definitions: a systematic review and meta-analysis.

BACKGROUND: Ebola virus disease case definition is a crucial surveillance tool to detect suspected cases for referral and as a screening tool for clinicians to support admission and laboratory testing decisions at Ebola health facilities. We aimed to assess the performance of the WHO Ebola virus disease case definitions and other screening scores. METHODS: In this systematic review and meta-analysis, we searched PubMed, Scopus, Embase, and Web of Science for studies published in English between June 13, 1978, and Jan 14, 2020. We included studies that estimated the sensitivity and specificity of WHO Ebola virus disease case definitions, clinical and epidemiological characteristics (symptoms at admission and contact history), and predictive risk scores against the reference standard (laboratory-confirmed Ebola virus disease). Summary estimates of sensitivity and specificity were calculated using bivariate and hierarchical summary receiver operating characteristic (when four or more studies provided data) or random-effects meta-analysis (fewer than four studies provided data). FINDINGS: We identified 2493 publications, of which 14 studies from four countries (Sierra Leone, Guinea, Liberia, and Angola) were included in the analysis. 12 021 people with suspected disease were included, of whom 4874 were confirmed as positive for Ebola virus infection. Six studies explored the performance of WHO case definitions in non-paediatric populations, and in all of these studies, suspected and probable cases were combined and could not be disaggregated for analysis. The pooled sensitivity of the WHO Ebola virus disease case definitions from these studies was 81·5% (95% CI 74·1-87·2) and pooled specificity was 35·7% (28·5-43·6). History of contact or epidemiological link was a key predictor for the WHO case definitions (seven studies) and for risk scores (six studies). The most sensitive symptom was intense fatigue (79·0% [95% CI 74·4-83·0]), assessed in seven studies, and the least sensitive symptom was pain behind the eyes (1·0% [0·0-7·0]), assessed in three studies. The performance of fever as a symptom varied depending on the cutoff used to define fever. INTERPRETATION: WHO Ebola virus disease case definitions perform suboptimally to identify cases at both community level and during triage at Ebola health facilities. Inclusion of intense fatigue as a key symptom and contact history could improve the performance of case definitions, but implementation of these changes will require effective collaboration with, and trust of, affected communities. FUNDING: Médecins sans Frontières.

Prevention of herpes zoster and its painful and debilitating complications.

BACKGROUND: Reactivation of latent varicella-zoster virus in sensory neurons to cause herpes zoster (shingles) is common in adults 50 years of age and older; half of adults experience an episode by age 85 years. Herpes zoster is attributable to the progressive decline in the VZV-specific cell-mediated immunity that occurs with aging or other conditions that cause immune compromise. Herpes zoster and complications, such as postherpetic neuralgia (PHN), can have a substantial negative impact on quality of life. DISCUSSION: The incidence of herpes zoster and its associated morbidity is increasing worldwide as the population ages. Nevertheless, the severity and impact of this condition, and its painful sequelae, are often unrecognized. Many patients delay seeking medical attention, complicating both diagnosis and treatment. Prevention appears to be the best option. A new herpes zoster vaccine significantly reduced the burden of illness (61.1%), the incidence of PHN (66.5%), and the incidence of herpes zoster (51.3%) (p < 0.001). Vaccine tolerability was good, with minor local injection site reactions the most common adverse event. CONCLUSIONS: Herpes zoster and PHN represent a substantial burden in terms of suffering and associated costs. Immunization of older adults is a good option to prevent herpes zoster and PHN.

Towards the 13-valent pneumococcal conjugate universal vaccination: effectiveness in the transition era between PCV7 and PCV13 in Italy, 2010-2013.

Pneumococcal disease epidemiology has changed after introduction of pneumococcal conjugate vaccines. Seven-valent vaccine (PCV7) has been effective in reducing invasive pneumococcal disease (IPD). In Europe, PCV13 effectiveness was estimated at 78% (95% CI: -18-96%) for 2-priming doses. In Italy, PCV7 was introduced in 2006 in the childhood immunization schedule and replaced with PCV13 in 2010. In Apulia, vaccination coverage has reached 95.1% (birth-cohort 2010). We estimated PCV program effectiveness and its impact on S. pneumoniae diseases. PCV EFFECTIVENESS: We used the screening method. We calculated the Proportion of Population Vaccinated from immunization registries and detected cases through a laboratory-confirmed surveillance among hospitalized children≤60 months. A confirmed IPD case was a child with PCR positive for S. pneumoniae. Differences among children were assessed with the Chi-square or the Fisher exact test (P value<0.05). PCV IMPACT: We constructed time series using outcome-specific Poisson regression models: hospitalization rate in pre-PCV era and hospitalization risk ratios (RRs) with 95% CIs for both PCV7 and PCV7/PCV13 shifting era. We calculated hospitalization RR with 95% CIs comparing pre-PCV years with vaccination period. The PCV effectiveness was 84.3% (95% CI: 84.0-84.6%). In May 2010-January 2013, we enrolled 159 suspected IPD of whom 4 were confirmed. Two (fully vaccinated) were caused by serotype 9V, 1 (not vaccinated) by serotype 3, 1 (vaccinated with 2 PCV13 doses) by 15B/C. The most important reduction was for pneumococcal pneumonia (RR: 0.43, 95% CI: 0.21-0.90). The PCV program show promising results in terms of both PCV13 effectiveness and its impact in reducing IPD in children<5 years.

Lessons learnt from a birthday party: a Bacillus cereus outbreak, Bari, Italy, January 2012.

INTRODUCTION: Bacillus cereus, a ubiquitous bacterium, can be isolated in various starchy food items, causing both emetic and diarrhoeal disease. The real burden of B. cereus outbreaks is actually poorly known in Italy. We report a B. cereus foodborne outbreak that occurred in a pub in Bari (Italy) on January 22nd 2012 during a birthday party, promptly reported by the pub owner. MATERIALS AND METHODS: Between January 22nd and 24th 2012, we performed a retrospective cohort study among the guests of the party to identify risk factors associated with illness. Leftovers of different meals were available for microbiological analysis. Faecal specimens were collected from cases. RESULTS: A total of 12 cases among the 13 customers (attack rate: 92%) were reported. All cases had consumed basmati rice and sweet and sour vegetables (aetiological fraction: 100%). B. cereus was isolated from both basmati rice served during the party and faecal specimens. DISCUSSION: The close collaboration between the pub owner and the public health officers and the possibility to test food leftovers and stool samples contributed to prevent further cases.

Violence against civilians and access to health care in North Kivu, Democratic Republic of Congo: three cross-sectional surveys.

BACKGROUND: The province of North Kivu in the Democratic Republic of Congo has been afflicted by conflict for over a decade. After months of relative calm, offences restarted in September 2008. We did an epidemiological study to document the impact of violence on the civilian population and orient pre-existing humanitarian aid. METHODS: In May 2009, we conducted three cross-sectional surveys among 200 000 resident and displaced people in North Kivu (Kabizo, Masisi, Kitchanga). The recall period covered an eight month period from the beginning of the most recent offensives to the survey date. Heads of households provided information on displacement, death, violence, theft, and access to fields and health care. RESULTS: Crude mortality rates (per 10 000 per day) were below emergency thresholds: Kabizo 0.2 (95% CI: 0.1-0.4), Masisi 0.5 (0.4-0.6), Kitchanga 0.7 (0.6-0.9). Violence was the reported cause in 39.7% (27/68) and 35.8% (33/92) of deaths in Masisi and Kitchanga, respectively. In Masisi 99.1% (897/905) and Kitchanga 50.4% (509/1020) of households reported at least one member subjected to violence. Displacement was reported by 39.0% of households (419/1075) in Kitchanga and 99.8% (903/905) in Masisi. Theft affected 87.7% (451/514) of households in Masisi and 57.4% (585/1019) in Kitchanga. Access to health care was good: 93.5% (359/384) of the sick in Kabizo, 81.7% (515/630) in Masisi, and 89.8% (651/725) in Kitchanga received care, of whom 83.0% (298/359), 87.5% (451/515), and 88.9% (579/651), respectively, did not pay. CONCLUSIONS: Our results show the impact of the ongoing war on these civilian populations: one third of deaths were violent in two sites, individuals are frequently subjected to violence, and displacements and theft are common. While humanitarian aid may have had a positive impact on disease mortality and access to care, the population remains exposed to extremely high levels of violence.

Malnutrition and mortality patterns among internally displaced and non-displaced population living in a camp, a village or a town in Eastern Chad.

BACKGROUND: Certain population groups have been rendered vulnerable in Chad because of displacement of more than 200,000 people over the last three years as a result of mass violence against civilians in the east of the country. The objective of the study was to assess mortality and nutritional patterns among displaced and non-displaced population living in camps, villages and a town in the Ouddaï and Salamat regions of Chad. METHODOLOGY: Between May and October 2007, two stage, 30-cluster household surveys were conducted among 43,900 internally displaced persons (IDPs) living in camps in Ouaddai region (n = 898 households), among 19,400 non-displaced persons (NDPs) living in 42 villages in Ouaddai region (n = 900 households) and among 17,000 NDPs living in a small town in Salamat region (n = 901 households). Data collection included anthropometric measurements, measles vaccination rates and retrospective mortality. Crude mortality rate (CMR), mortality rate among children younger than 5 years (U5MR), causes of death and the prevalence of wasting (weight-for-height z score <-2) among children aged 6 to 59 months were the main outcome measures. CONCLUSIONS: The CMR among the 4902 IDPs in Gozbeida camps, 4477 NDPs living in a village and 4073 NDPs living in a town surveyed was 1.8 (95% CI, 1.2-2.8), 0.3 (95% CI, 0.2-0.4), 0.3 (95% CI, 0.2-0.5) per 10,000 per day, respectively. The U5MR in a camp (n = 904), a village (n = 956) and a town (n = 901) was 4.1 (95% CI, 2.1-7.7), 0.5 (95% CI, 0.3-0.9) and 0.7 (95% CI, 0.4-1.4) per 10,000 per day, respectively. Diarrhoea was reported to be the main cause of death. Acute malnutrition rates (according to the WHO definition) among 904 IDP children, 956 NDPs children living in a village, 901 NDP children living in a town aged 6 to 59 months were 20.6% (95% CI, 17.9%-23.3%), 16.4% (95% CI, 14.0%-18.8%) and 10.1% (95% CI, 8.1%-12.2%) respectively. The study found a high mortality rate among IDPs and an elevated prevalence of wasting not only in IDP camps but also in villages located in the same region. The town-dweller population remains at risk of malnutrition. Appropriate contingency plans need to be made to ensure acceptable living standards for these populations.