Human infection with a zoonotic orthopoxvirus in the country of Georgia.

During 2013, cutaneous lesions developed in two men in the country of Georgia after they were exposed to ill cows. The men had never received vaccination against smallpox. Tests of lesion material with the use of a quantitative real-time polymerase-chain-reaction assay for non-variola virus orthopoxviruses were positive, and DNA sequence analysis implicated a novel orthopoxvirus species. During the ensuing epidemiologic investigation, no additional human cases were identified. However, serologic evidence of exposure to an orthopoxvirus was detected in cows in the patients' herd and in captured rodents and shrews. A third case of human infection that occurred in 2010 was diagnosed retrospectively during testing of archived specimens that were originally submitted for tests to detect anthrax. Orthopoxvirus infection should be considered in persons in whom cutaneous lesions develop after contact with animals.

Assessing the potency and immunogenicity of inactivated poliovirus vaccine after exposure to freezing temperatures.

According to manufacturers, inactivated poliovirus vaccines (IPVs) are freeze sensitive and require storage between 2°C and 8°C, whereas oral poliovirus vaccine requires storage at -20 °C. Introducing IPV into ongoing immunization services might result in accidental exposure to freezing temperatures and potential loss of vaccine potency. To better understand the effect of freezing IPVs, samples of single-dose vaccine vials from Statens Serum Institut (VeroPol) and multi-dose vaccine vials from Sanofi Pasteur (IPOL) were exposed to freezing temperatures mimicking what a vaccine vial might encounter in the field. D-antigen content was measured to determine the in vitro potency by ELISA. Immunogenicity testing was conducted for a subset of exposed IPVs using the rat model. Freezing VeroPol had no detectable effect on in vitro potency (D-antigen content) in all exposures tested. Freezing of the IPOL vaccine for 7 days at -20 °C showed statistically significant decreases in D-antigen content by ELISA in poliovirus type 1 (p < 0.0001) and type 3 (p = 0.048). Reduction of poliovirus type 2 potency also approached significance (p = 0.062). The observed loss in D-antigen content did not affect immunogenicity in the rat model. Further work is required to determine the significance of the loss observed and the implications for vaccine handling policies and practices.

Surveillance Systems to Track Progress Toward Polio Eradication - Worldwide, 2015-2016.

Global measures to eradicate polio began in 1988; as of 2014, four of six World Health Organization (WHO) regions have been certified polio-free. Within the two endemic regions (African and Eastern Mediterranean), Nigeria, Afghanistan, and Pakistan have never interrupted transmission of wild poliovirus (WPV) (1). The primary means of detecting poliovirus transmission is surveillance for acute flaccid paralysis (AFP) among children aged <15 years, combined with collection and testing of stool specimens from persons with AFP for detection of WPV and vaccine-derived polioviruses (VDPVs) (viruses that differ genetically from vaccine viruses and can emerge in areas with low vaccination coverage and cause paralysis) in WHO-accredited laboratories within the Global Polio Laboratory Network (2,3). AFP surveillance is supplemented by environmental surveillance for polioviruses in sewage from selected locations (4). Genomic sequencing of the VP1-coding region of isolated polioviruses enables mapping transmission by time and place, assessment of potential gaps in surveillance, and identification of the emergence of VDPVs. This report presents poliovirus surveillance data from 2015 and 2016, with particular focus on 20 countries in the African Region and six in the Eastern Mediterranean Region that reported WPV or circulating VDPVs (cVDPVs) during 2011-2016, as well as the three countries most affected by the 2014-2015 Ebola virus disease (Ebola) outbreak (Guinea, Liberia, and Sierra Leone). During 2016, 12 (60%) of the 20 African Region countries and all six of the Eastern Mediterranean Region countries met both surveillance quality indicators (nonpolio AFP rates of ≥2 per 100,000 persons aged <15 years per year and ≥80% of AFP cases with adequate stool specimens [stool adequacy]) at the national level; however, provincial-level variation was seen. To complete and certify polio eradication, surveillance gaps must be identified and surveillance activities, including supervision, monitoring, and specimen collection and handling, further strengthened.

COVID-19 pandemic and other factors associated with unfavorable tuberculosis treatment outcomes-Almaty, Kazakhstan, 2018-2021.

Introduction: The COVID-19 pandemic negatively influenced the availability of tuberculosis (TB) services, such as detection, diagnosis and treatment, around the world, including Kazakhstan. We set out to estimate the COVID-19 pandemic influence on TB treatment outcomes by comparing outcomes among people starting treatment before the pandemic (2018-2019) and during the pandemic (2020-2021) and to determine risk factors associated with unfavorable outcomes. Methods: We conducted a retrospective cohort study among all people newly diagnosed with drug-sensitive pulmonary or extrapulmonary TB at least 18 years old who initiated treatment from 2018 to 2021 in Almaty. We abstracted data from the national electronic TB register. Unfavorable treatment outcomes were ineffective treatment, death, loss to follow-up, results not evaluated, and transferred. We used multivariable Poisson regression to calculate adjusted relative risk (aRR) and 95% confidence intervals (95%CI). Results: Among 1548 people newly diagnosed with TB during the study period, average age was 43 years (range 18-93) and 52% were male. The number of people initiating treatment was higher before than the pandemic (935 vs. 613, respectively). There was significantly different proportions before compared to during the pandemic for people diagnosed through routine screening (39% vs. 31%, p < 0.001), 60 years and older (16% vs. 22%, p = 0.005), and with diabetes (5% vs. 8%, p = 0.017). There was no difference in the proportion of HIV (8% in both periods). Unfavorable outcomes increased from 11 to 20% during the pandemic (aRR = 1.83; 95% CI: 1.44-2.31). Case fatality rose from 6 to 9% (p = 0.038). Risk factors for unfavorable TB treatment outcomes among all participants were being male (aRR = 1.44, 95%CI = 1.12-1.85), having HIV (aRR = 2.72, 95%CI = 1.99-3.72), having alcohol use disorder (aRR = 2.58, 95%CI = 1.83-3.62) and experiencing homelessness (aRR = 2.94, 95%CI = 1.80-4.80). Protective factors were being 18-39 years old (aRR = 0.33, 95%CI = 0.24-0.44) and 40-59 years old (aRR = 0.56, 95%CI = 0.41-0.75) compared to 60 years old and up. Conclusion: COVID-19 pandemic was associated with unfavorable treatment outcomes for people newly diagnosed with drug-sensitive TB in Almaty, Kazakhstan. People with fewer comorbidities were at increased risk. Results point to the need to maintain continuity of care for persons on TB treatment, especially those at higher risk for poor outcomes during periods of healthcare service disruption.

Knowledge, attitudes, and practices related to anthrax and animal care: A case-control study in Georgia.

INTRODUCTION: Anthrax is endemic in Georgia and recent outbreaks prompted a livestock-handler case-control study with a component to evaluate anthrax knowledge, attitudes, and practices (KAP) among livestock handlers or owners. METHODS: Cases were handlers of livestock with confirmed animal anthrax from June 2013-May 2015. Handlers of four matched unaffected animals were selected as controls, two from the same village as the case animal ("village control") and two from 3-10 km away ("area control"). Descriptive statistics were reported and conditional logistic regression was performed to estimate the magnitude of the association of cases with specific study KAP factors. RESULTS: Cases were more likely male, had lower level college education, less animal care experience, and provided more animal care to their cattle. Cases had lower odds of burying a suddenly dead animal compared to all controls (Odds Ratio [OR]: 0.32, 95% Confidence interval [CI]:0.12, 0.88) and area controls (OR: 0.32, 95% CI: 0.11, 0.91). On an 8-point knowledge scale, cases having an animal with anthrax had a 1.31 times greater knowledge score compared to all controls (95% CI: 1.03, 1.67). Cases had higher odds of ever having human anthrax or knowing another person who had anthrax compared to all controls (OR: 4.56, 95% CI: 1.45, 14.30) and area controls (OR: 7.16, 95% CI: 1.52, 33.80). DISCUSSION: Cases were more knowledgeable of anthrax and had better anthrax prevention practices, but these are likely a result of the case investigation and ring vaccination following the death of their animal. CONCLUSIONS: The findings reveal a low level of knowledge and practices related to anthrax control and prevention, and will guide educational material development to fill these gaps.

Cost-analysis of different management policies for patients with mild hepatitis A virus infection in Kazakhstan.

OBJECTIVE: For patients with mild hepatitis A virus (HAV) infection, this study compared estimates of total costs associated with managing cases under a policy of mandatory hospitalization in the Republic of Kazakhstan and estimates of total costs associated with managing cases in outpatient settings. Costs were estimated both from the perspective of the Ministry of Health and from a broader societal perspective. METHODS: Data were collected by using a standardized structured questionnaire. For cases of mild HAV infection, medical records were obtained from 200 patients managed by hospitalization and from 251 patients managed in an outpatient setting. Personal interviews were also conducted to collect information on productivity losses and out-of-pocket expenses. RESULTS: Nationally, we estimated about 21,600 cases of mild HAV infection annually. The mean annual treatment costs in hospital for mild HAV infection was estimated at 3.39 million US dollars (2001 US dollars) (95% confidence interval [CI] = [3.26 million US dollars-3.52 million US dollars]). The total annual mild HAV infection cost to the society, including direct medical and nonmedical costs and productivity losses due to 721,440 lost work days, was estimated at 6.26 million US dollars (95% CI [6.05 million US dollars-6.47 million US dollars]). In sensitivity analyses, the total annual cost of mild HAV infection ranged from 4.37 million US dollars to 24.66 million US dollars. The survey results showed that a relatively minor change in the current policy of mandatory hospitalization could result in an estimated total annual savings of 4.62 million US dollars (2001 US dollars) in Kazakhstan. CONCLUSION: Adoption of an outpatient management policy for cases of mild HAV infection would generate substantial cost savings to the Ministry of Health and society.

Investigation of an outbreak of bloody diarrhea complicated with hemolytic uremic syndrome.

In July-August 2009, eight patients with bloody diarrhea complicated by hemolytic uremic syndrome (HUS) were admitted to hospitals in Tbilisi, Georgia. We started active surveillance in two regions for bloody diarrhea and post-diarrheal HUS. Of 25 case-patients who developed HUS, including the initial 8 cases, half were ⩾15 years old, 67% were female and seven (28%) died. No common exposures were identified. Among 20 HUS case-patients tested, Shiga toxin was detected in the stools of 2 patients (one with elevated serum IgG titers to several Escherichia coli serogroups, including O111 and O104). Among 56 persons with only bloody diarrhea, we isolated Shiga toxin-producing E. coli (STEC) O104:H4 from 2 and Shigella from 10; 2 had serologic evidence of E. coli O26 infection. These cases may indicate a previously unrecognized burden of HUS in Georgia. We recommend national reporting of HUS and improving STEC detection capacity.