Implementation of the 7-1-7 target for detection, notification, and response to public health threats in five countries: a retrospective, observational study.

BACKGROUND: Suboptimal detection and response to recent outbreaks, including COVID-19 and mpox (formerly known as monkeypox), have shown that the world is insufficiently prepared for public health threats. Routine monitoring of detection and response performance of health emergency systems through timeliness metrics has been proposed to evaluate and improve outbreak preparedness and contain health threats early. We implemented 7-1-7 to measure the timeliness of detection (target of ≤7 days from emergence), notification (target of ≤1 day from detection), and completion of seven early response actions (target of ≤7 days from notification), and we identified bottlenecks to and enablers of system performance. METHODS: In this retrospective, observational study, we conducted reviews of public health events in Brazil, Ethiopia, Liberia, Nigeria, and Uganda with staff from ministries of health and national public health institutes. For selected public health events occurring from Jan 1, 2018, to Dec 31, 2022, we calculated timeliness intervals for detection, notification, and early response actions, and synthesised identified bottlenecks and enablers. We mapped bottlenecks and enablers to Joint External Evaluation (second edition) indicators. FINDINGS: Of 41 public health events assessed, 22 (54%) met a target of 7 days to detect (median 6 days [range 0-157]), 29 (71%) met a target of 1 day to notify (0 days [0-24]), and 20 (49%) met a target of 7 days to complete all early response actions (8 days [0-72]). 11 (27%) events met the complete 7-1-7 target, with variation among event types. 25 (61%) of 41 bottlenecks to and 27 (51%) of 53 enablers of detection were at the health facility level, with delays to notification (14 [44%] of 32 bottlenecks) and response (22 [39%] of 56 bottlenecks) most often at an intermediate public health (ie, municipal, district, county, state, or province) level. Rapid resource mobilisation for responses (six [9%] of 65 enablers) from the national level enabled faster responses. INTERPRETATION: The 7-1-7 target is feasible to measure and to achieve, and assessment with this framework can identify areas for performance improvement and help prioritise national planning. Increased investments must be made at the health facility and intermediate public health levels for improved systems to detect, notify, and rapidly respond to emerging public health threats. FUNDING: Bill & Melinda Gates Foundation.

Symptom-based case definitions for COVID-19: Time and geographical variations for detection at hospital admission among 260,000 patients.

Introduction: Case definitions are used to guide clinical practice, surveillance and research protocols. However, how they identify COVID-19-hospitalised patients is not fully understood. We analysed the proportion of hospitalised patients with laboratory-confirmed COVID-19, in the ISARIC prospective cohort study database, meeting widely used case definitions. Methods: Patients were assessed using the Centers for Disease Control (CDC), European Centre for Disease Prevention and Control (ECDC), World Health Organization (WHO) and UK Health Security Agency (UKHSA) case definitions by age, region and time. Case fatality ratios (CFRs) and symptoms of those who did and who did not meet the case definitions were evaluated. Patients with incomplete data and non-laboratory-confirmed test result were excluded. Results: A total of 263,218 of the patients (42%) in the ISARIC database were included. Most patients (90.4%) were from Europe and Central Asia. The proportions of patients meeting the case definitions were 56.8% (WHO), 74.4% (UKHSA), 81.6% (ECDC) and 82.3% (CDC). For each case definition, patients at the extremes of age distribution met the criteria less frequently than those aged 30 to 70 years; geographical and time variations were also observed. Estimated CFRs were similar for the patients who met the case definitions. However, when more patients did not meet the case definition, the CFR increased. Conclusions: The performance of case definitions might be different in different regions and may change over time. Similarly concerning is the fact that older patients often did not meet case definitions, risking delayed medical care. While epidemiologists must balance their analytics with field applicability, ongoing revision of case definitions is necessary to improve patient care through early diagnosis and limit potential nosocomial spread.

Epidemiological characteristics of Lassa fever cases in Liberia: a retrospective analysis of surveillance data, 2019-2020.

OBJECTIVES: Liberia is endemic to Lassa fever (LF) and has the largest reported per capita incidence of LF patients in the West African region. Cases of the disease increased unprecedentedly in 2019 and 2020, characterized by a geographical drift in epidemiology and seasonal variation of occurrence. This study aims to describe the epidemiological and clinical characteristics of LF in Liberia from 2019 to 2020. METHODS: A retrospective study was conducted on cases of LF confirmed at the National Public Health Reference Laboratory from January 2019 to December 2020. Medical records were reviewed, and epidemiological and clinical data were collected in an organized manner. Descriptive and inferential statistics were carried out using Epi Info (version 7.2.5.0). RESULTS: A total of 382 suspected LF cases were reported, of which 103 were laboratory-confirmed, yielding a case positivity rate of 27% (103/382). The median age of the LF cases was 20 (IQR: 9-30). Children younger than 18 years accounted for 40.8% (42/103) of the cases and healthcare workers' cases constituted 7.7% of the cases. Bong, Nimba, and Grand Bass accounted for 87.4% of the cases with cases in new counties like Lofa, Margibi, and Grand Kru. Hemorrhage (aOR:10.2; 95% CI: 3.11-33.81), patients who did not receive ribavirin (aOR: 4.4; 95% CI: 1.12-17.57, P = 0.034), and patients aged 40 years or older (aOR: 6.2; 95% CI: 1.19-32.53, P = 0.049) were associated with LF mortality. CONCLUSION: The LF cases in 2019 and 2020 had a high case fatality rate and spread to new counties that had not previously reported LF. The disease occurred during most of the rainy season instead of the usual dry season. There is an urgent need to lower morbidity and mortality, improve early presentation to the hospital, and early initiation of appropriate medical care.

COVID-19 reinfection in Liberia: Implication for improving disease surveillance.

COVID-19 remains a serious disruption to human health, social, and economic existence. Reinfection with the virus intensifies fears and raises more questions among countries, with few documented reports. This study investigated cases of COVID-19 reinfection using patients' laboratory test results between March 2020 and July 2021 in Liberia. Data obtained from Liberia's Ministry of Health COVID-19 surveillance was analyzed in Excel 365 and ArcGIS Pro 2.8.2. Results showed that with a median interval of 200 days (Range: 99-415), 13 out of 5,459 cases were identified and characterized as reinfection in three counties during the country's third wave of the outbreak. Eighty-six percent of the COVID-19 reinfection cases occurred in Montserrado County within high clusters, which accounted for over 80% of the randomly distributed cases in Liberia. More cases of reinfection occurred among international travelers within populations with high community transmissions. This study suggests the need for continued public education and surveillance to encourage longer-term COVID-19 preventive practices even after recovery.

Lessons learned from detecting and responding to recurrent measles outbreak in Liberia post Ebola-Epidemic 2016-2017.

INTRODUCTION: Measles is an acute viral disease that remains endemic in much of sub-Sahara Africa, including Liberia. The 2014 Ebola epidemic disrupted an already fragile health system contributing to low uptake of immunization services, population immunity remained low thus facilitating recurrent outbreaks of measles in Liberia. We describe lessons learnt from detecting and responding to recurrent outbreaks of measles two years post the 2014 Ebola epidemic in Liberia. METHODS: We conducted a descriptive study using the findings from Integrated Diseases Surveillance and Response (IDSR) 15 counties, National Public Health Institute of Liberia (NPHIL), National Public Health Reference Laboratory (NPHRL) and District Health Information Software (DIHS2) data conducted from October to December, 2017. We perused the outbreaks line lists and other key documents submitted by the counties to the national level from January 2016 to December 2017. RESULTS: From January 2016 to December 2017, 2,954 suspected cases of measles were reported through IDSR. Four hundred sixty-seven (467) were laboratory confirmed (IgM-positive), 776 epidemiologically linked, 574 clinically confirmed, and 1,137 discarded (IgM-negative). Nine deaths out of 1817 cases were reported, a case fatality rate of 0.5%; 49% were children below the age of 5 years. Twenty-two percent (405/1817) of the confirmed cases were vaccinated while the vaccination status of 55% (994/1817) was unknown. CONCLUSION: Revitalization of IDSR contributed to increased detection and reporting of suspected cases of measles thus facilitating early identification and response to outbreaks. Priority needs to be given to increasing the uptake of routine immunization services, introducing a second dose of measles vaccine in the routine immunization program and conducting a high-quality supplementary measles immunization campaign for age group 1 to 10 years to provide protection for a huge cohort of susceptible.

Integrated disease surveillance and response implementation in Liberia, findings from a data quality audit, 2017.

INTRODUCTION: in spite of the efforts and resources committed by the division of infectious disease and epidemiology (DIDE) of the national public health institute of Liberia (NPHIL)/Ministry of health to strengthening integrated disease surveillance and response (IDSR) across the country, quality data management system remains a challenge to the Liberia NPHIL/MoH (Ministry of health), with incomplete and inconsistent data constantly being reported at different levels of the surveillance system. As part of the monitoring and evaluation strategy for IDSR continuous improvement, data quality assessment (DQA) of the IDSR system to identify successes and gaps in the disease surveillance information system (DSIS) with the aim of ensuring data accuracy, reliability and credibility of generated data at all levels of the health system; and to inform an operational plan to address data quality needs for IDSR activities is required. METHODS: multi-stage cluster sampling that included stage 1: simple random sample (SRS) of five counties, stage 2: simple random sample of two districts and stage 3: simple random sample of three health facilities was employed during the study pilot assessment done in Montserrado County with Liberia institute of bio medical research (LIBR) inclusive. A total of thirty (30) facilities was targeted, twenty nine (29) of the facilities were successfully audited: one hospital, two health centers, twenty clinics and respondents included: health facility surveillance focal persons (HFSFP), zonal surveillance officers (ZSOs), district surveillance officers (DSOs) and County surveillance officers (CSOs). RESULTS: the assessment revealed that data use is limited to risk communication and sensitization, no examples of use of data for prioritization or decision making at the subnational level. The findings indicated the following: 23% (7/29) of health facilities having dedicated phone for reporting, 20% (6/29) reported no cell phone network, 17% (5/29) reported daily access to internet, 56.6% (17/29) reported a consistent supply of electricity, and no facility reported access to functional laptop. It was also established that 40% of health facilities have experienced a stock out of laboratory specimens packaging supplies in the past year. About half of the surveyed health facilities delivered specimens through riders and were assisted by the DSOs. There was a large variety in the reported packaging process, with many staff unable to give clear processes. The findings during the exercise also indicated that 91% of health facility staff were mentored on data quality check and data management including the importance of the timeliness and completeness of reporting through supportive supervision and mentorship; 65% of the health facility assessed received supervision on IDSR core performance indicator; and 58% of the health facility officer in charge gave feedback to the community level. CONCLUSION: public health is a data-intensive field which needs high-quality data and authoritative information to support public health assessment, decision-making and to assure the health of communities. Data quality assessment is important for public health. In this review completeness, accuracy, and timeliness were the three most-assessed attributes. Quantitative data quality assessment primarily used descriptive surveys and data audits, while qualitative data quality assessment methods include primarily interviews, questionnaires administration, documentation reviews and field observations. We found that data-use and data-process have not been given adequate attention, although they were equally important factors which determine the quality of data. Other limitations of the previous studies were inconsistency in the definition of the attributes of data quality, failure to address data users' concerns and a lack of triangulation of mixed methods for data quality assessment. The reliability and validity of the data quality assessment were rarely reported. These gaps suggest that in the future, data quality assessment for public health needs to consider equally the three dimensions of data quality, data use and data process. Measuring the perceptions of end users or consumers towards data quality will enrich our understanding of data quality issues. Data use is limited to risk communication and sensitization, no examples of use of data for prioritization or decision making at the sub national level.

A study on influential factors of high-phosphorus wastewater treated by electrocoagulation-ultrasound.

A combined treatment of electrocoagulation and ultrasound was proposed to solve some problems which exist in the phosphorus removal processes in fine chemical industry. The intermittently discharged wastewater has the features of high initial phosphorus concentration and wide initial pH variation. The electrocoagulation-ultrasound effective performance for the removal of phosphorus was investigated. The results obtained from synthetic wastewater showed that the total phosphorus (TP) decreased from 86 to about 0.4 mg/L, and the removal efficiency reached about 99.6 %, when ultrasound was applied to the electrocoagulation cell under the optimum working conditions in 10 min. Comparatively, the TP removal efficiency of electrocoagulation group was 81.3 % and the ultrasound group has almost no change. Therefore, we can conclude that the electrocoagulation and ultrasound synergistic effect can effectively degrade high-phosphorus wastewater. We have discussed the impact of various parameters on the electrocoagulation-ultrasound based on the phosphorus removal efficiency. The results obtained from synthetic wastewater showed that the optimum working pH was found to be 6, allowing the effluent to be met the emission standards without pH adjustment. An increased current enhanced the speed of treatment significance, but higher current (>40 mA/cm(2)) enhanced ultrasonic cavitation effect causing flocculation ineffective. In addition, it was found that the optimum ultrasonic power was 4 W/cm(2) and the frequency was 20 kHz. The best ultrasound intervention and ultrasonic irradiation time were processed with electrocoagulation simultaneously. The results indicated that the electrocoagulation-ultrasound could be utilized as an attractive technique for removal of phosphate in the real wastewater.