Community Surveillance System Research Articles

Case Management of Imported Crimean-Congo Hemorrhagic Fever, Senegal, July 2023.

We report an imported Crimean-Congo hemorrhagic fever case in Senegal. The patient received PCR confirmation of virus infection 10 days after symptom onset. We identified 46 patient contacts in Senegal; 87.7% were healthcare professionals. Strengthening border crossing and community surveillance systems can help reduce the risks of infectious disease transmission.

Intestinal carriage and molecular characteristics of carbapenem resistant Escherichia coli and Klebsiella pneumoniae among patients in intensive care units and outpatients in a tertiary care hospital

Intestinal carriage of carbapenem-resistant and (CREK) plays an important role in the epidemiology of carbapenemase producers. Less is known about the carriage of CREK among the outpatients when compared to carriage among patients in Intensive Care Units. (ICU) Therefore the present study was performed to detect colonization of CREK among ICU patients and outpatients of our tertiary care hospital. Rectal swabs from ICU patients and stool specimens from outpatients were collected. Identification and antimicrobial susceptibility were performed using Vitek 2 compact system. Screening for CREK was done by two methods and confirmed for carbapenemase production by mCIM. Carbapenemase genes were detected by multiplex polymerase chain reaction.Overall 460 patients were analyzed for the intestinal carriage of CREK, 230 patients each from ICU and outpatients. 10.4% of outpatients and 26% of ICU patients found positive for CREK carriage. The target genes for carbapenemase production found in 78/86 CREK isolates. The majority of isolates 50/78 (64%) harbored beta-lactamase (bla) NDM gene followed by blaOXA-48 like in 18/78 (23%) isolates and 10/78(12%) isolates had both the genes.Detection of carbapenem-resistant genes in commensal flora of the gut is worrisome. Building proper awareness about the use of antimicrobials in the community and strict surveillance systems to monitor these resistant bacteria in humans, food-producing animals, and the environment could all help to reduce the colonization of CREK among healthy individuals. Implementation of strict infection control measures and prudent use of carbapenems can help to limit the spread of these superbugs in the hospital.

Test-Trace strategy for disease control and management: South Africa’s control measures to contain the spread of COVID-19

This chapter provides a critical examination of South Africa’s COVID-19 testing and contact tracing response, including emerging successes and weaknesses. Lessons emerging from South Africa’s COVID-19 testing and contact tracing strategy highlight the importance of rapid roll-out of community screening and testing across the country, robust implementation of public health measures, and leveraging existing healthcare services such as the deployment of existing Community Health Workers. The absence of a standardised national information system to support contact tracing efforts, long turnaround times and backlogs in testing, and low uptake of digital solutions such as the COVIDConnect and COVID Alert Apps, were noted as some of the challenges of the process. New considerations to take into account in planning for any future outbreaks include ways to enhance intersectoral approaches and integrate with other community surveillance systems, how to rationalise health workforce redistribution during surge periods by prioritising cases, and the use of technology solutions to manage data.

Sustained Management of COVID-19: Doing More of What Works to Control Future Surges.

Increasing COVID-19 infection rates and the prospect of a significant fall surge are concerning to state and territorial public health leaders. Health officers are charged with preparing for ongoing management of the pandemic while addressing pushback against public health mitigation efforts and public sentiment that the pandemic is “over.” While hospitalizations continue to remain manageable as of June 2022, now is the time for public health officials to prepare for responses to upcoming surges of COVID-19 in tandem with other seasonal respiratory viruses such as influenza and respiratory syncytial virus. Experts have learned a great deal about effective prevention, mitigation, and management of COVID-19 over the last 2 years to help guide future efforts. Planning for future response should draw upon evidence-based prevention efforts and what has worked in the past 2 years. A “Technical Package” of Effective Public Health Approaches to Managing COVID-19 This article summarizes approaches to preventing COVID-19 infection with an eye toward sustained management of COVID-19 in the fall of 2022 and beyond. We bundle these interventions into a “technical package,” a set of recommendations to the field to guide future public health responses to COVID-19. ASTHO technical packages are based on evidence-based interventions, promising practices, subject matter expert recommendations, and—where it exists—consensus from the field. Technical packages are not intended to be comprehensive but instead help prioritize efforts toward what works to address a particular problem, such as COVID-19, and establish a focused and proactive approach to technical assistance. The ASTHO technical package to support the sustained management of COVID-19 comprises 5 major categories, described as follows, with additional details outlined in the Table. Increase immunization rates and capacity: Vaccines, both the primary series and booster dose, are critical tools to prevent severe illness from COVID-19 infection. Engaging health care providers, who are often the trusted source of information for individuals who have questions about vaccines or who may be hesitant, is an established evidence-based practice for addressing vaccine hesitancy. Expanded availability of vaccine in health care settings will be particularly important in pediatric COVID-19 vaccination. National data already indicate a preference for pediatric COVID-19 vaccination in medical settings,1 and vaccination can serve as an important opportunity for families to reengage their children in well childcare following the pandemic shutdowns. States can identify and address financial, access, and administrative barriers to participation in the COVID-19 vaccination program. They can also work with their state Immunization Information Systems (IIS) to review immunization data use and exchange policies to identify potential barriers and leverage the IIS reminder and recall function so that medical practices can easily identify and outreach to patients who are not fully vaccinated. Identify and address COVID-19 health disparities: Population-based data are foundational to public health practice. Having the capability to identify disparities in case numbers, hospitalizations, death, vaccination status, and access to therapeutics by race, ethnicity, and urban/rural differences is essential to guide redistribution of interventions and services, target outreach, and inform public policy. Health equity cannot be realistically addressed without accurate and complete race and ethnicity data in all public health data sets. States can consider engaging health information exchanges in matching public health data sets with vital statistics and other data sources; incentivize medical providers and commercial laboratories to provide more complete race and ethnicity data; and expand the use of the social vulnerability index to identify vulnerable rural populations at a greatest risk of poor COVID-19 outcomes. Expand the capacity and scope of the public health workforce: Response to the COVID-19 pandemic should include health agency efforts to sustain their investments to support, expand, and increase the effectiveness of the public health workforce. Investment in community-based public health workers (eg, community health workers [CHWs], promotoras, peer recovery coaches) has been widely recognized as an evidence-based approach to improving individual and community health and addressing health disparities.2 Their ability to build trust and relationships in underserved communities is essential to successful public health work in the future. Community-based public health workers have a deep understanding of their communities through lived experience, which makes them uniquely qualified to address social and behavioral determinants of health. Early contact tracing needs led to widespread use of CHWs through contractual and temporary hiring. This capacity could be sustained and redirected to other aspects of public health by standardizing CHW job descriptions, salary ranges, and supervision structures in state/local human resources systems and by partnering with local and national community-based organizations. More broadly, states can conduct workforce surveys and update workforce policies, including sick leave policies. Prepare the public to make risk-based decisions: The availability of highly effective COVID-19 vaccinations has dramatically reduced the risk of severe disease and death, and effective therapeutic agents are widely available for individuals at high risk who can be quickly treated after confirmed infection. Home COVID-19 testing now provides an accessible and convenient mechanism for early diagnosis. The use of these important assets in the COVID-19 response must be communicated to the public through succinct messaging guided by audience testing. Variation in community transmission, and the risk associated with certain behaviors, should be made clear so that individuals can make their own decisions about avoiding gatherings, social distancing, or wearing masks. In addition, new social norms of staying home when sick or wearing a mask when exposed should be reinforced with expanded workforce sick leave benefits and periodic, localized use of testing, contact tracing, and mask wearing requirements during disease surges. Implement environmental interventions in schools, workplaces, and other congregate indoor settings: Infectious diseases such as COVID-19 can spread through the inhalation of airborne particles and aerosols. Environmental interventions to reduce COVID-19 spread in confined workplaces such as meat and poultry processing facilities were highly successful early in the pandemic.3 There is broad consensus that improving indoor air quality in school buildings can reduce the risk of COVID-19 spread among students and teachers.4 Many school systems are now working to upgrade their HVAC systems, and similar approaches could be considered in long-term care facilities. Wastewater surveillance is an emerging community surveillance system that could be particularly useful in self-contained water treatment system settings such as large international airports and correctional facilities. TABLE - ASTHO Technical Package on COVID-19 Sustained Management Strategies Objective Potential Indicators Mechanisms Levels of Influence Increase immunization rates and capacity Provider enrollment in COVID-19 vaccine program Practices with ability to link to IIS for vaccination status Provide enrollment incentives Remove administrative burdens to enrollment Enable IIS reminder and recall functions CDC State immunization managers State medical and primary care associations Identify and address COVID-19 health disparities State public health dashboards Completeness of data reports to CDC State and federal data quality measures and benchmarks State disease reporting laws and requirements Data set comparisons and matching Reporting incentives and penalties Provider education Race and ethnicity definitions and standards Electronic transmission capabilities State HIEs State Medicaid agency State FQHC associations State medical and primary care associations CDC, ONC, CMS, OMB, HRSA National public health associations (CSTE, APHL) Expand the capacity and scope of the public health workforce CHW job descriptions, salary ranges, supervision structures in state/local HR system State CHW registries (NACHW) State and local workforce surveys State contracts with CBOs Retention/career ladders Evidence-based practice recommendations Workforce reorganization New funding lines and resources Redirection of existing funding Attrition planning Third party reimbursement State HR systems State contract policies State employee health plans National associations (NACHW, APHA) CDC HHS Office of Minority Health Prepare the public to make risk-based decisions COVID-19 vaccination rates COVID-19 therapeutics utilization rates New state policies, including the expansion of sick leave benefits Public polling COVID-19 community indicators Tax and other incentives for employers to expand benefits Required benefits standards for employers CDC Employer groups Implement environmental interventions in schools, workplaces, and other congregate and indoor settings Infection rates in congregate settings School closures Resources for environmental enhancements Regulatory and statutory requirements Participation in EPA clean air in buildings challenge CDC NIOSH EPA ASHRAE Abbreviations: APHA, American Public Health Association; APHL, Association of Public Health Laboratories; ASHRAE, American Society of Heating, Refrigerating and Air-Conditioning Engineers; CBO, community-based organization; CDC, Centers for Disease Control and Prevention; CHW, community health worker; CMS, Centers for Medicare & Medicaid Services; CSTE, Council of State and Territorial Epidemiologists; EPA, Environmental Protection Agency; FQHC, federally qualified health center; HIE, health information exchange; HR, human resources; HRSA, Health Resources and Services Administration; IIS, Immunization Information System; NACHW, National Association of Community Health Workers; NIOSH, National Institute for Occupational Safety and Health; ONC, Office of the National Coordinator for Health Information Technology; OMB, Office of Management and Budget. Conclusion State and territorial health officials have been tasked with addressing many challenges throughout the COVID-19 response. The considerations listed earlier are not comprehensive. A wide range of other strategies and approaches, such as the use of pharmacies for adult COVID-19 vaccination, have clearly been effective but have not been formally researched or evaluated. Several public health policy interventions have had unintended consequences, and external factors such as worldwide shortages of personal protective equipment and testing materials were never anticipated. The approaches in this technical package provide tangible, evidence-based actions for states and territories to consider as they plan for sustained and improved management of COVID-19 for fall 2022 and beyond.

Contribution of Auto-Visual AFP Detection and Reporting (AVADAR) on polio surveillance in South Sudan.

Introductionthe last wild polio virus in South Sudan was documented in 2009. Nonetheless, it was one of the last four countries in the WHO African region to be accepted as a polio-free country in June 2020. In line with this, to accelerate the polio-free documentation process, the country has piloted Auto Visual AFP Detection and Reporting (AVADAR) in three counties. This study examined the contribution of the AVADAR surveillance system to the traditional Acute Flaccid Paralysis (AFP) surveillance system to document lessons learnt and best practices.Methodswe performed a retrospective descriptive quantitative study design to analyze secondary AVADAR surveillance data collected from June 2018 to December 2019 and stored at the WHO AVADAR server.Resultsthe AVADAR community surveillance system has improved the two main AFP surveillance indicators in the piloted counties and made up 86% of the total number of true AFP cases detected in these counties. The completeness and timeliness of weekly zero reporting were 97% and 94%, respectively and maintained above the standard throughout the study, while the two main surveillance indicators in the project area were improved progressively except for the Gogrial West County. In contrast, main surveillance indicators declined in some of the none-AVADAR implementing counties.Conclusionthe AVADAR surveillance system can overcome the logistical and remoteness barriers that can hinder the early detection and reporting of cases due to insecurity, topographical, and communication barrier in rural and hard-to-reach areas to accomplish and sustain the two main surveillance indicators, along with the completeness and timeliness of weekly zero reporting. We recommend extending this application-based surveillance system to other areas with limited resources and similar challenges by incorporating other diseases of public health concern.

Contextualizing mobility during the Ebola epidemic in Liberia.

Based on findings from focus groups and key informant interviews conducted at five sites in Liberia between 2018 and 2019, we explore some of the key factors that influenced people’s motivation to travel during the 2014–2016 Ebola Virus Disease (EVD). We discuss how these factors led to certain mobility patterns and the implications these had for EVD response. The reasons for individual mobility during the epidemic were multiple and diverse. Some movements were related to relocation efforts as people attempted to extricate themselves from stigmatizing situations. Others were motivated by fear, convinced that other communities would be safer, particularly if extended family members resided there. Individuals also felt compelled to travel during the epidemic to meet other needs and obligations, such as attending burial rites. Some expressed concerns about obtaining food and earning a livelihood. Notably, these latter concerns served as an impetus to travel surreptitiously to evade quarantine directives aimed specifically at restricting mobility. Improvements in future infectious disease response could be made by incorporating contextually-based mobility factors, for example: the personalization of public health messaging through the recruitment of family members and trusted local leaders, to convey information that would help allay fear and combat stigmatization; activating existing traditional community surveillance systems in which entry into the community must first be approved by the community chief; and increased involvement of local leaders and community members in the provision of food and care to those quarantined so that the need to travel for these reasons is removed.

Association of premature ventricular complexes and risk of ischemic stroke: A systematic review and meta-analysis

Abstract Funding Acknowledgements Type of funding sources: None. Background/objectives: Recent studies have suggested that patients with premature ventricular complexes (PVCs) may have a higher risk of ischemic stroke. However, the data are limited and inconclusive. We conducted a systematic review and meta-analysis to investigate the association between PVCs and the risk of ischemic stroke. Methods A comprehensive literature review was conducted by searching for published articles indexed in MEDLINE and EMBASE databases from inception through September 25, 2020, to identify studies that compared the risk of ischemic stroke between patients with PVCs and individuals without PVCs. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method of Dersimonian and Laird. Results A total of four observational studies (2 prospective and 2 retrospective cohort studies) with 42,677 participants met the eligibility criteria and were included in the meta-analysis. We found that patients with PVCs have a significantly higher risk of ischemic stroke than individuals without PVCs with the pooled RR of 1.31 (95% CI, 1.07-1.60, I2 = 43%). Conclusions: From our systematic review and meta-analysis, we found that PVCs are associated with a higher risk of ischemic stroke. Whether this association is causal and how it should be addressed in clinical practice require further investigations. Table 1Ofoma et al.Agarwal et al.Lin et al.Im et al.Year of publication2012201520152018Country of originUnited StatesUnited StatesTaiwanKoreaStudy designProspective cohort studyProspective cohort studyRetrospective cohort studyRetrospective cohort studyStudy subjectsCases: Cases were patients with PVCs who were diagnosed based on 2-minute ECG. Cases were identified from the 1987 to 1989 ARIC study. Comparators: Comparators were the rest of the patients in the study who did not carry a diagnosis of PVCs. The average follow-up time was 13 years. Patients with a history of stroke, CAD, SAH, and ICH were excluded from the analysis.Cases: Cases were patients with PVCs who were diagnosed based on routine ECG. Cases were identified from the 2003 to 2007 REGARDS study. Comparators: Comparators were the rest of the patients in the study who did not carry a diagnosis of PVCs. An average (SD) follow-up time was 6 (2) years. Patients with a history of stroke or TIA and hemorrhagic stroke were excluded from the analysis.Cases: Cases were patients with PVCs (<720 beats/day) who were diagnosed based on 24-hour ECG monitoring. Cases were identified from the 2002 to 2004 Taipei Veterans General Hospital database. Comparators: Comparators were the rest of the patients in the database who did not carry a diagnosis of PVCs. The average follow-up time was 10 ± 1 years. Patients with a history of sustained or non-sustained VT, PPM, HF, MI, ablation, VHD, and PVCs > 720 beats/day were excluded from the analysis.Cases: Cases were patients with PVCs (>10%) who were diagnosed based on standard ECG or 24-hour ECG monitoring. Cases were identified from the 2013 to 2015 Kosin University database. Comparators: Comparators were the rest of the patients in the database who did not carry a diagnosis of PVCs. The average follow-up time was 4 years. Patients with a history of cardiomyopathy, VHD, CHD, hepatic or renal disease, and acute cardiovascular or cerebrovascular event within 3 months, any trauma or surgery within 3 months, hyperthyroidism, uncontrolled HT, malignancy, CTD, IHD, and any acute or chronic inflammatory disease were excluded from the analysis.Number of subjectsCases: 793Comparators: 13,700Cases: 1,415Comparators: 23,045Cases: 1,074 (Uniform PVCs), 1,166 (Multiform PVCs)Comparators: 1,111Cases: 203Comparators: 170Baseline characteristics of subjectsMean age, year: Cases: 55.97Comparators: 53.85 Mean BMI, kg/m2:Cases: 28.47Comparators: 27.61 Mean TC, mg/dL: Cases: 211.85Comparators: 214.69 Female: Case: 50.82%Comparators: 57.06% White: Case: 68.1%Comparators: 73.38% HT:Cases: 44.54 %Comparators: 32.80 % Diabetes:Cases: 13.98%Comparators: 10.76% Smoking:Cases: 25.73%Comparators: 25.83% Mean age, year: Cases: 68.3 ± 9.2 Comparators: 64.3 ± 9.3 Mean BMI, kg/m2:Cases: 29.2 ± 6.1Comparators: 29.3 ± 6.2 Mean SBP, mmHg:Cases: 130.1 ± 16.9 Comparators: 126.9 ± 16.4 Female:Cases: 45.4%Comparators: 59% Black: Cases: 41.9%Comparators: 39.9% EducationNo high school:Cases: 15.5%Comparators: 11.1% High school/no college:Cases: 26.3%Comparators: 25.6% College or professional: Cases: 58.2%Comparators: 63.3% Geographic regionNon-Belt:Cases: 47.2%Comparators: 43.9% Belt:Cases: 33.9%Comparators: 34.8% Buckle:Cases: 19.0%Comparators: 21.3% Previous heart disease: Cases: 25.4%Comparators: 12.2% HT:Cases: 64.7%Comparators: 56.2% DM: Cases: 21.8%Comparators: 19.1% AF: Cases: 9.7%Comparators: 7.8% LVH: Cases: 11.2%Comparators: 9.4% Current smoking:Cases: 13.0%Comparators: 14.0% Use of warfarin: Case: 3.5%Comparators: 2.7% Use of aspirin: Case: 48.1%Comparators: 40.9%Mean age, year: Cases: 58.7 ± 19.3 (Uniform PVCs), 65.7 ± 16.9 (Multiform PVCs)Comparators: 50.7 ± 20.1 Female:Cases: 44.9% (Uniform PVCs), 31.4% (Multiform PVCs)Comparators: 53.4% DM: Cases: 7.4% (Uniform PVCs), 9.4% (Multiform PVCs)Comparators: 5.6% HT: Cases: 31.2% (Uniform PVCs), 38.0% (Multiform PVCs)Comparators: 21.6% Hyperlipidemia: Cases: 7.4% (Uniform PVCs), 5.8% (Multiform PVCs)Comparators: 5.5% CKD: Cases: 1.4% (Uniform PVCs), 1.4% (Multiform PVCs)Comparators: 0.3% Cirrhosis: Cases: 0.8% (Uniform PVCs),0.8% (Multiform PVCs)Comparators: 0.5% AF: Cases: 6.7 % (Uniform PVCs), 6.8 % (Multiform PVCs)Comparators: 6.7% CLD: Cases: 2.6% (Uniform PVCs), 2.8% (Multiform PVCs)Comparators: 2.0% Use of AAD: Cases: 0.2% (Uniform PVCs), 0.5% (Multiform PVCs)Comparators: 0.5% Use of anti-HT: Cases: 16.4% (Uniform PVCs), 20.8 % (Multiform PVCs)Comparators: 12.2% Use of statin: Cases: 7.2 % (Uniform PVCs), 5.7% (Multiform PVCs)Comparators: 5.1% Mean age, year:Cases: 61.0 ± 15.2Comparators: 57.6 ± 16.4 Female: Cases: 56.7 %Comparators: 52.7% DM:Cases: 17.5 %Comparators: 20.0% HT:Cases: 28.4%Comparators: 30.6% CAD: Cases: 11.3%Comparators: 12.4% MedicationAmiodarone: Cases: 7.7%Comparators: 0% Propafenone: Cases: 1.0%Comparators: 0% Digoxin: Cases: 5.2%Comparators: 4.8% Beta-blocker:Cases: 53.6%Comparators: 8.2% CCB: Cases: 21.6%Comparators: 20% ARB & ACEI: Cases: 17.0%Comparators: 16.4% Statin: Cases: 39.4%Comparators: 37.6% Aspirin: Cases: 24.6%Comparators: 25.3% Clopidogrel: Cases: 13.4%Comparators: 12.0% VKA: Cases: 9.8%Comparators: 11.2%Diagnosis of PVCsPVCs were detected by 2-minute ECG.PVCs were detected by routine ECG. PVCs were detected by 24-hour Holter monitoring.PVCs were detected by standard ECG or 24-hour Holter monitoring.Diagnosis of strokeThe diagnosis of ischemic stroke was supported by annual telephone follow-up and a community surveillance system. Stroke was diagnosed by agreement of computer and reviewer classification. Disagreements were adjudicated by a second physician-reviewer.The diagnosis of ischemic stroke was supported by telephone follow-up every 6 months. Stroke events were defined following the WHO definition. The stroke was diagnosed and confirmed by an adjudication committee.Ischemic stroke was diagnosed by physicians and also confirmed by brain imaging.Ischemic stroke was determined by a neurologist if the patient felt painless, weakness, sudden numbness or dead feeling on one side of the body, sudden painless loss of vision, and sudden loss of ability to understand what people were saying and also confirmed by brain MRI in all patients.Confounder adjusted in the multivariate analysisAge, race, gender, BMI, HT, diabetes, smoking, TC levelsAge, sex, race, geographic region, education level, previous heart disease, SBP, use of antihypertensive medication, LVH, AF, DM, current smoking, use of warfarin and aspirinAge, sex, HT, DM, CKD, use of hypertensive medicationAge, AF, HT, LVH, E/E’, MR grade, NT-proBNPNewcastle-Ottawa scoreSelection: 4 stars Comparability: 2 stars Outcome: 3 starsSelection: 4 stars Comparability: 2 stars Outcome: 3 starsSelection: 3 stars Comparability: 1 star Outcome: 3 starsSelection: 4 stars Comparability: 2 stars Outcome: 3 starsBaseline characteristics of studies included in the meta-analysisAbstract Figure. Forest plot of the meta-analysis

Implementation of a comprehensive surveillance system for recording suicides and attempted suicides in rural India

IntroductionWHO reports that 78 of the 140 low-income and middle-income countries (LMICs) do not have a registration system for suicides and attempted suicides. Absence of data on suicide and attempted...

A Study of Community Surveillance System Improvement based on ResNet Person Re-identification

Most existing community surveillance systems rely on face recognition to identify pedestrian. The face image captured by community surveillance camera are not always clear enough. Thus, Person re-identification (ReID) imply critical applications in surveillance as it has more image information of pedestrian. In this paper, we refine a ResNet50 based reID model which only adds a Linear layer, a Batch Norm layer and a reLU layer in front of the classifier. The refined model is simple to build on the surveillance system, and we have tested in our demo surveillance system and Market1501 data-set. The experiment result shows it can work well on real-time. On Market1501, our results are competitive that rank-1=0.875000, rank-5=0.944477, and mAP=0.706647 since its low complexity. Our demo community surveillance system shows the refined ReID model is competent and practical for identification tasks.

Analysis of counts for cluster randomized trials: Negative controls and test-negative designs.

In cluster randomized trials (CRTs), the outcome of interest is often a count at the cluster level. This occurs, for example, in evaluating an intervention with the outcome being the number of infections of a disease such as HIV or dengue or the number of hospitalizations in the cluster. Standard practice analyzes these counts through cluster outcome rates using an appropriate denominator (eg, population size). However, such denominators are sometimes unknown, particularly when the counts depend on a passive community surveillance system. We consider direct comparison of the counts without knowledge of denominators, relying on randomization to balance denominators. We also focus on permutation tests to allow for small numbers of randomized clusters. However, such approaches are subject to bias when there is differential ascertainment of counts across arms, a situation that may occur in CRTs that cannot implement blinded interventions. We suggest the use of negative control counts as a method to remove, or reduce, this bias, discussing the key properties necessary for an effective negative control. A current example of such a design is the recent extension of test-negative designs to CRTs testing community-level interventions. Via simulation, we compare the performance of new and standard estimators based on CRTs with negative controls to approaches that only use the original counts. When there is no differential ascertainment by intervention arm, the count-only approaches perform comparably to those using debiasing negative controls. However, under even modest differential ascertainment, the count-only estimators are no longer reliable.

Village health team functionality and adherence to reporting requirements for community-based surveillance in Kasese, Uganda, 2016

Introduction: Uganda and particularly Kasese District has a high number and frequency of disease outbreaks whose detection and reporting at community level is usually absent or delayed. Most outbreaks in Kasese are detected at health facility level although the earliest point of detection should be at community level, an indicator of a poorly functioning community surveillance system. According to the Community Based Disease/Event Surveillance system in Uganda, Community Health Workers (CHWs) commonly referred to as Village Health Team members (VHTs) are expected to play a key role in Community Based Surveillance so as to enable early detection and response to priority diseases/events at community level to the nearest health facility. This study aimed to assess CHW functionality and adherence to Community Based Disease/Event Surveillance (CBS) guidelines as well as factors associated with it in Kasese so as to identify ways of enabling CHWs to improve CBS.

Community-based surveillance of norovirus disease: a systematic review

BackgroundNorovirus is a common cause of infectious gastrointestinal disease. Despite the increased ability to detect norovirus in affected people, the number of reported cases and outbreaks in the community is still substantially underestimated. We undertook a systematic review to determine the nature, scope and scale of community-based surveillance systems which capture information on norovirus disease.MethodsWe searched MEDLINE, EMBASE and Scopus for studies published between 01 January 1995 and 31 December 2015, using terms relating to norovirus and surveillance. Publications were screened independently by two reviewers using exclusion criteria. Data extraction from included papers was performed using a standardized data extraction form. Outcomes were descriptions of the methods reported in included papers, and any estimates of incidence rate of norovirus disease in each community, stratified by age.ResultsAfter exclusions, we reviewed 45 papers of which 23 described surveillance studies and 19 included estimates of incidence. The estimates of incidence varied by outcome measure, type of laboratory test and study population. There were two estimates of norovirus hospitalisation; 0.72 and 1.04 per 1000 person-years. Estimates of norovirus disease ranged between 0.024 cases per 1000 person-years and 60 cases per 1000 person-years and estimates of all gastroenteritis varied between 49 and 1100 cases per 1000 person-years.ConclusionsOur systematic review found few papers describing community-based surveillance for norovirus disease. Standardised age-specific estimates of norovirus incidence would be valuable for calculating the true global burden of norovirus disease; robust community surveillance systems would be able to produce this information.Trial RegistrationPROSPERO 2016:CRD42016048659.

The REFANI-S study protocol: a non-randomised cluster controlled trial to assess the role of an unconditional cash transfer, a non-food item kit, and free piped water in reducing the risk of acute malnutrition among children aged 6\u201359\xa0months living in camps for internally displaced persons in the Afgooye corridor, Somalia

BackgroundThe prevalence of acute malnutrition is often high in emergency-affected populations and is associated with elevated mortality risk and long-term health consequences. Increasingly, cash transfer programmes (CTP) are used instead of direct food aid as a nutritional intervention, but there is sparse evidence on their nutritional impact. We aim to understand whether CTP reduces acute malnutrition and its known risk factors.Methods/designA non-randomised, cluster-controlled trial will assess the impact of an unconditional cash transfer of US$84 per month for 5 months, a single non-food items kit, and free piped water on the risk of acute malnutrition in children, aged 6–59 months. The study will take place in camps for internally displaced persons (IDP) in peri-urban Mogadishu, Somalia.A cluster will consist of one IDP camp and 10 camps will be allocated to receive the intervention based on vulnerability targeting criteria. The control camps will then be selected from the same geographical area. Needs assessment data indicates small differences in vulnerability between camps.In each trial arm, 120 households will be randomly sampled and two detailed household surveys will be implemented at baseline and 3 months after the initiation of the cash transfer. The survey questionnaire will cover risk factors for malnutrition including household expenditure, assets, food security, diet diversity, coping strategies, morbidity, WASH, and access to health care. A community surveillance system will collect monthly mid-upper arm circumference measurements from all children aged 6–59 months in the study clusters to assess the incidence of acute malnutrition over the duration of the intervention. Process evaluation data will be compiled from routine quantitative programme data and primary qualitative data collected using key informant interviews and focus group discussions.The UK Department for International Development will provide funding for this study. The European Civil Protection and Humanitarian Aid Operations will fund the intervention. Concern Worldwide will implement the intervention as part of their humanitarian programming.DiscussionThis non-randomised cluster controlled trial will provide needed evidence on the role of unconditional CTP in reducing the risk of acute malnutrition among IDP in this context.Trial registrationISRCTN29521514. Registered 19 January 2016.

An exploration of facilitators and challenges in the scale-up of a national, public sector community health worker cadre in Zambia: a qualitative study

BackgroundIn 2010 a public sector cadre of community health workers called Community Health Assistants (CHAs) was created in Zambia through the National Community Health Worker Strategy to expand access to health services. This cadre continues to be scaled up to meet the growing demands of Zambia’s rural population. We summarize factors that have facilitated the scale-up of the CHA program into a nationwide CHW cadre and the challenges of introducing and institutionalizing the cadre within the Zambian health system.MethodsSemi-structured, individual interviews were held across 5 districts with 16 CHAs and 6 CHA supervisors, and 10 focus group discussions were held with 93 community members. Audio recordings of interviews and focus group discussions were transcribed and thematically coded using Dedoose web-based software.ResultsThe study showed that the CHAs play a critical role in providing a wide range of services at the community level, as described by supervisors and community members. Some challenges still remain, that may inhibit the CHAs ability to provide health services effectively. In particular, the respondents highlighted infrequent supervision, lack of medical and non-medical supplies for outreach services, and challenges with the mobile data reporting system.ConclusionsThe study shows that in order to optimize the impact of CHAs or other community health workers, key health-system support structures need to be functioning effectively, such as supervision, community surveillance systems, supplies, and reporting. The Ministry of Health with support from partners are currently addressing these challenges through nationwide supervisor and community data trainings, as well as advocating for adding primary health care as a specific focus area in the new National Health Strategy Plan 2017–2021. This study contributes to the evidence base on the introduction of formalized community health worker cadres in developing countries.

Decreases in Suicide Deaths and Attempts Linked to the White Mountain Apache Suicide Surveillance and Prevention System, 2001-2012.

We evaluated the impact of a comprehensive, multitiered youth suicide prevention program among the White Mountain Apache of Arizona since its implementation in 2006. Using data from the tribally mandated Celebrating Life surveillance system, we compared the rates, numbers, and characteristics of suicide deaths and attempts from 2007 to 2012 with those from 2001 to 2006. The overall Apache suicide death rates dropped from 40.0 to 24.7 per 100 000 (38.3% decrease), and the rate among those aged 15 to 24 years dropped from 128.5 to 99.0 per 100 000 (23.0% decrease). The annual number of attempts also dropped from 75 (in 2007) to 35 individuals (in 2012). National rates remained relatively stable during this time, at 10 to 13 per 100 000. Although national rates remained stable or increased slightly, the overall Apache suicide death rates dropped following the suicide prevention program. The community surveillance system served a critical role in providing a foundation for prevention programming and evaluation.

Strengthening community emergency preparedness and resilience in emerging natural and man-made threats and epidemics in Saudi Arabia and EMRO countries

Background: Globalization, increasing intense urbanization and climate changes has been linked to natural and man-made evolution and curiosity resulting in multiple threats and vulnerability. The degree, nature and extent community and household preparedness and resiliency programs and activities defined the robustness and effectiveness of local, national to regional EMRO timely response policy decision maker by policy makers, health planners and implementers. Methods: This paper analyses existing community emergency preparedness and resilience implementation and translation challenges and bottlenecks against emerging natural and man-made threats and epidemics disaster in Saudi Arabia and other EMRO countries. Results: Our results showed inefficiencies to identify, understanding and mapping of potential risks/threats and weak community early alarm and surveillance systems in threats or disaster occurrence. Also, showed that real time community-based programs are poorly interrelated and nurtured in most EMRO countries, and require fostering community guidelines and prevention and control activities. Such include social mobilization, health education in increasing alertness, awareness and community mass literacy outreach. Critically, adequate community knowledge and attitudes on preparedness and resilience on mass pilgrims influx during Hajj and Ramadan seasons, potential vulnerability to epidemics and floods indicates that policy planners and implementers could capitalize on these strengths and address the weaknesses in scaling up practical community and household emergency preparedness and management approach on and across borders populations for common beneficial expectations in upholding safety and security, healthy lives and well-being. In conclusion, we advocate that establishment of a comprehensive evidence-based local, national and regional laboratory and digital surveillance systems, community-based partnerships, investment projects and related preventive resilient measures are vital in revamping the evolving and future threats and disaster situations in Saudi Arabia and other EMRO countries in line with One Health Surveillance systems.

A qualitative review of implementer perceptions of the national community-level malaria surveillance system in Southern Province, Zambia.

BackgroundParts of Zambia with very low malaria parasite prevalence and high coverage of vector control interventions are targeted for malaria elimination through a series of interventions including reactive case detection (RCD) at community level. When a symptomatic individual presenting to a community health worker (CHW) or government clinic is diagnostically confirmed as an incident malaria case an RCD response is initiated. This consists of a CHW screening the community around the incident case with rapid diagnostic tests (RDT) and treating positive cases with artemether-lumefantrine (AL, Coartem™) in accordance with national policy. Since its inception in 2011, Zambia’s RCD programme has relied on anecdotal feedback from staff to identify issues and possible solutions. In 2014, a systematic qualitative programme review was conducted to determine perceptions around malaria rates, incentives, operational challenges and solutions according to CHWs, their supervisors and district-level managers.MethodsA criterion-based sampling framework based on training regime and performance level was used to select nine rural health posts in four districts of Southern Province. Twenty-two staff interviews were completed to produce English or bilingual (CiTonga or Silozi + English) verbatim transcripts, which were then analysed using thematic framework analysis.ResultsCHWs, their supervisors and district-level managers strongly credited the system with improving access to malaria services and significantly reducing the number of cases in their area. The main implementation barriers included access (e.g., lack of rain gear, broken bicycles), insufficient number of CHWs for programme coverage, communication (e.g. difficulties maintaining cell phones and “talk time” to transmit data by phone), and inconsistent supply chain (e.g., inadequate numbers of RDT kits and anti-malarial drugs to test and treat uncomplicated cases).ConclusionsThis review highlights the importance of a community surveillance system like RCD in shaping Zambia’s malaria elimination campaign by identifying community-based infections that might otherwise remain undetected. At this stage the system must ensure it can meet growing public demand by providing CHWs the tools and materials they need to consistently carry out their work and expand programme reach to more isolated communities. Results from this review will be used to plan programme scale-up into other parts of Zambia.

Community-based surveillance to monitor trends in unaccompanied and separated children in eastern DRC

Children who are separated from their families and usual caregivers in emergencies face a multitude of risks. The humanitarian community lacks methods to systematically capture changes in the frequency and nature of such separations over time. A mobile phone-based community surveillance system was piloted in the Democratic Republic of the Congo. The goal was to identify new cases of unaccompanied and separated children on a weekly basis. Over an 11-week period, community focal points reported 62 cases of separation across 10 communities. The majority of children had been under the care of their parents prior to separation. More than half of the children were unaccompanied, meaning that they were living without an adult relative or customary caregiver. The pilot results suggest that implementing a mobile phone-based surveillance system in a humanitarian setting may be feasible and cost-effective and fills a critical gap in the measurement of separated and unaccompanied children in emergencies. A longer pilot to better understand how the system performs over time is recommended.

Cause of Death in Women of Reproductive Age in Rural Nepal Obtained Through Community-Based Surveillance: Is Reducing Maternal Mortality the Right Priority for Women's Health Programs?

We used a community surveillance system to gather information regarding pregnancy outcomes and the cause of death for women of reproductive age (WRA) in Kanchanpur, Nepal. A total of 784 mother groups participated in the collection of pregnancy outcomes and mortality data. Of the 273 deaths among WRA, the leading causes of death reported were chronic diseases (94, 34.4%) poisoning, snake bites, and suicide (grouped together; 55, 20.1%), and accidents (29, 10.6%), while maternal mortality accounted for 7%. Nevertheless, the calculated maternal mortality ratio was quite high (259.3 per 100,000 live births).

Estimation of the quality of life effect of seasonal influenza infection in the UK with the internet-based Flusurvey cohort: an observational cohort study

BackgroundDespite the public health effect of seasonal influenza in the UK, population-wide estimates of the quality-adjusted life-year (QALY) loss associated with influenza do not exist. Such estimates are needed to quantify the overall disease burden, compare it with other diseases, and assess the cost-effectiveness of control measures. Since 2009, the Flusurvey—an internet-based community surveillance system for influenza-like illness—has been operating in the UK. UK residents are recruited through print and broadcast media, social media, and word of mouth. There were about 6000 registered participants during the 2012–13 season, during which we used the Flusurvey cohort to measure QALY loss associated with illness. MethodsEach week, participants were asked to report any symptoms and their health status. Participants were asked to score their health status on a scale of 0–100 (0 representing the worst health imaginable and 100 the best); this method has provided estimates of QALY loss that are consistent with those obtained with the more traditional EQ-5D during the 2009 influenza pandemic. The analysis presented is based on participants who completed the health score at least once when symptomatic and at least once when free of symptoms, allowing the effect of illness on quality of life to be measured in individuals. Results were stratified by age group (0–17, 18–44, 45–64, and ≥65 years) and by severity of symptoms (acute respiratory infection [ARI] and influenza-like illness [ILI]; appendix). FindingsIllness lasted longer for cases of ILI (median 9 days, IQR 6–15) than for ARI (6 days, 4–10) and increased somewhat with age (appendix). The median baseline health score, reported when individuals were free from symptoms, was 90 (IQR 83–95). Individuals with ILI reported low health scores (median 60, IQR 43–75; 1837 episodes); a small reduction was reported by those with ARI (80, 70–85; 1297 episodes). The scores were similar in different age groups. The mean loss of quality-adjusted life was about 2·0 days (SD 2·5) for ILI cases (median 1·1 days, IQR 0·5–2·6) and 0·6 days (SD 0·9) for ARI cases (median 0·3 days, IQR 0·1–0·7). The quality-adjusted life-day (QALD) loss was thus over three times higher for ILI than for ARI. The mean estimated ILI QALD loss was close to that estimated for influenza during the 2009 influenza pandemic (2·0 vs 2·7 days). QALD loss increased with age for both ARI and ILI (appendix) and was significantly higher in individuals experiencing fever (p<0·0001). There was weak evidence for an increase of QALD loss in smokers (p=0·07) but no association with being in a risk group (p=0·15) or being vaccinated (p=0·73). InterpretationThis internet-based approach opens the way for standardised and refined measure of the public health effect of seasonal influenza and other respiratory infections in the UK and elsewhere. However, the study has limitations: it was a non-random, self-selecting sample, in which children were under-represented, and the self-reported symptoms were not validated by a medical practitioner. FundingThe Flusurvey is funded by Epiwork as part of the EU Seventh Framework Programme. AC and SF are both funded by a Medical Research Council Career Development Award in Biostatistics. KE is funded by a Career Development Fellowship supported by the National Institute for Health Research. The views expressed in this publication are those of the authors and not necessarily those of the funders.