Management Of Disease Outbreaks Research Articles

History of ZIKV Infections in India and Management of Disease Outbreaks.

Zika virus (ZIKV) is an emerging arbovirus infection endemic in multiple countries spread from Asia, Africa to the Americas and Europe. Previously known to cause rare and fairly benign human infections, ZIKV has become a major international public health emergency after being linked to unexpected neurological complications, that includes fetal brain damage/death and microcephaly in babies born to infected mothers and Guillain-Barre syndrome (GBS) in adults. It appears that a single genetic mutation in the ZIKV genome, likely acquired during explosive ZIKV outbreak in French Polynesia (2013), made virus causing mild disease to target fetus brain. The Aedes mosquitoes are found to be the main carrier of ZIKV, passing the virus to humans. Originally isolated from patients in Africa in 1954 (African lineage), virus disseminated to Southeast Asia (Asian lineage), establishing new endemic foci, including one in India. Numerous cases of ZIKV infection have been reported in several locations in India and neighboring countries like Pakistan and Bangladesh since mid of the last century, suggesting that the virus reached this part of Asia soon after it was first discovered in Uganda in 1947. Although, the exact means by which ZIKV was introduced to India remains unknown, it appears that the ZIKV strain circulating in India possibly belongs to the “Asian lineage,” which has not yet been associated with microcephaly and other neurological disorders. However, there still exists a threat that the contemporary ZIKV virulent strain from South America, carrying a mutation can return to Asia, posing a potential crisis to newborns and adult patients. Currently there is no specific vaccine or antiviral medication to combat ZIKV infection, thus, vector control and continuous monitoring of potential ZIKV exposure is essential to prevent the devastating consequences similar to the ones experienced in Brazil. However, the major obstacle faced by Indian healthcare agencies is that most cases of ZIKV infection have been reported in rural areas that lack access to rapid diagnosis of infection. In this review, we attempt to present a comprehensive analysis of what is currently known about the ZIKV infection in India and the neighboring countries.

Evolutions in global epidemic and pandemic preparedness

The 21st century poses complex challenges for public health. Our planet is experiencing unprecedented levels of globalization, urbanization and mobility of its 7 billion inhabitants, many of whom live in poverty, conflict or are at risk of natural disasters and suffering from the effects of climate change. Infectious hazards, new and old, threaten the lives and well-being of billions of people across the globe. As the UN's specialized agency for health, WHO investigates around 300 disease outbreaks every year. But detecting and managing epidemic and pandemic-prone diseases is harder than ever. During the last two decades, several high profile disease outbreaks have had a profound effect on public health's response to epidemics and pandemics. Today, in sharp contrast to the last century, there is an expectation that we detect outbreaks faster and manage them better. The response to health emergencies today is vastly different from previous eras where containment was a pre-dominant strategy. Today, for any outbreak, we need to systematically use the combination of modern epidemiology utilizing the power of technology; new and easy-to -use field-based rapid diagnostic tools; clinical care even in the harshest of conditions, vaccines and other medical counter-measures, rapidly developing them if they don’t already exist; real-time training of front-line responders; and effective risk communication and community engagement. This new recognition that we need to marry the social aspects of epidemic and pandemic response with an ever stronger bio-medical response is changing the way disease outbreaks are being managed. Just in the last decade, lessons learnt from MERsCoV in Saudi Arabia and South Korea; Ebola in West Africa; Zika in South America; Yellow Fever in Angola and the Democratic republic of Congo, several ongoing outbreaks of Cholera and Diphtheria in Bangladesh have created the momentum to re-think disease outbreak management to prevent epidemics or pandemics. As the science of epidemic and pandemic diseases marches forward, and social science makes its presence increasingly felt, there is an effort to make the response operations more effective, particularly for large-scale epidemics. The introduction of Emergency Operations Centers (EOCs) in countries, and WHO's own reform establishing the use of an incident management system (IMS) have had an impact on how disease outbreaks are viewed and managed. As the current generation of public health experts and personnel, we will undoubtedly write the next chapter in how the epidemics and pandemics of the rest of the 21st century will be managed.

Development of a multiplex real-time PCR method for early diagnosis of three bacterial diseases in fish: A real-case study in trout aquaculture

Lactococcus garvieae, Yersinia ruckeri and Flavobacterium psychrophilum are three of the most important pathogens in worldwide rainbow trout aquaculture (Oncorrhynchus mykiss Walbaum). In this work, a multiplex quantitative PCR (qPCR) method for the simultaneous detection of the three pathogens was developed and tested in a commercial trout farm. Fifty-four spleen and brain samples from a trout farm were analyzed using both multiplex qPCR and classic microbiological methods. When comparing qPCR results and classic plate diagnostic techniques no negative deviations were observed, which resulted in a 100% relative sensitivity of the multiplex qPCR method developed. In addition, efficiency of the qPCR method ranged between 97.5% and 108.8%. The specificity of the combination of primers and probes was successfully tested in 57 target and non-target bacterial strains Hence, the multiplex qPCR method developed in the present study could be used as a reliable diagnostic tool for the detection of L. garvieae, Y. ruckeri and F. psychrophilum in rainbow trout farms, enabling faster diagnostics (only a few hours) and contributing to a quick response and management of bacterial disease outbreaks.

The use of tabletop exercises in nuclear security education

PurposeThe purpose of this paper is to explore the role of tabletop exercises (TTXs) in graduate nuclear security education, their effectiveness and their relationship to traditional forms of classroom instruction. The paper highlights both the benefits and challenges of TTX implementation—the former including higher student motivation and material retention, and the latter including motivational shifts toward “winning” and possible student exclusionary behavior.Design/methodology/approachSurvey results from 49 former students in a US university were collected electronically and combined with anecdotal evidence from student, facilitator and teaching assistant interviews following five iterations of a specifically designed, semester-long, TTX case study. The case study focused on securing a fictional nuclear facility.FindingsStudents found the TTX more memorable and retained more course material when asked to compare the TTX’s effectiveness to long-term course projects in other courses. Their in-class motivations tended to shift from traditional classroom motivations toward “winning,” and “not letting down their classmates.” In some iterations, students also observed classmates becoming more tempted to cheat or otherwise violate academic ethics. Mitigation strategies to prevent such temptations (e.g. removing direct student vs student TTX structures) were found to be effective.Originality/valueThis is the first report on the effective use of a semester-long TTX in a graduate nuclear security classroom. The flexibility of this instructional tool demonstrates its applicability to other classroom subjects including homeland security, emergency management, disease outbreak management and public policy among others.

Leptospirosis Outbreak After the 2014 Major Flooding Event in Kelantan, Malaysia: A Spatial-Temporal Analysis.

Severe floods increase the risk of leptospirosis outbreaks in endemic areas. This study determines the spatial-temporal distribution of leptospirosis in relation to environmental factors after a major flooding event in Kelantan, Malaysia. We conducted an observational ecological study involving incident leptospirosis cases, from the 3 months before, during, and three months after flood, in reference to the severe 2014 Kelantan flooding event. Geographical information system was used to determine the spatial distribution while climatic factors that influenced the cases were also analyzed. A total of 1,229 leptospirosis cases were notified within the three study periods where incidence doubled in the postflood period. Twelve of 66 subdistricts recorded incidence rates of over 100 per 100,000 population in the postflood period, in comparison with only four subdistricts in the preflooding period. Average nearest neighborhood analysis indicated that the cases were more clustered in the postflood period as compared with the preflood period, with observed mean distance of 1,139 meters and 1,666 meters, respectively (both at P < 0.01). Global Moran's I was higher in the postflood period (0.19; P < 0.01) as compared with the preflood period (0.06; P < 0.01). Geographic weighted regression showed that living close to water bodies increased the risk of contracting the disease. Postflooding hotspots were concentrated in areas where garbage cleanup occurred and the incidence was significantly associated with temperature, humidity, rainfall, and river levels. Postflooding leptospirosis outbreak was associated with several factors. Understanding the spatial distribution and associated factors of leptospirosis can help improve future disease outbreak management after the floods.

Meningitis Vaccination, Knowledge, and Awareness Among YMSM in Chicago.

Serogroup C invasive meningococcal disease (IMD) outbreaks in men who have sex with men (MSM) have been occurring with greater frequency in urban areas across the United States. An effective vaccine for IMD is available and is recommended for MSM in outbreak settings. Particular subgroups of MSM have been disproportionately represented in outbreaks, specifically young, Black, and HIV-positive MSM. As little is known about the knowledge, awareness, and vaccination status of young MSM, we sought to describe this and explore racial/ethnic differences. Data were collected from an established cohort study-RADAR-of 16- to 29-year-old MSM recruited through previous cohort studies and/or by being a partner or peer of a current study member. A total of 486 young MSM (YMSM) responded to 13 IMD-related questions. Approximately half of the sample correctly identified how IMD is spread and 58.6% accurately responded that vaccination was the best prevention method; however, more than 60% of participants felt they were at no risk of getting meningitis and only 49% self-reported vaccination. Additionally, White YMSM were significantly more likely to be vaccinated and to have accurate knowledge and risk perception of IMD compared with Black YMSM. Findings have important implications for disease control, outbreak management, and intervention development.

Host size and proximity to diseased neighbours drive the spread of a coral disease outbreak in Hawai'i.

Understanding how disease risk varies over time and across heterogeneous populations is critical for managing disease outbreaks, but this information is rarely known for wildlife diseases. Here, we demonstrate that variation in host and pathogen factors drive the direction, duration and intensity of a coral disease outbreak. We collected longitudinal health data for 200 coral colonies, and found that disease risk increased with host size and severity of diseased neighbours, and disease spread was highest among individuals between 5 and 20 m apart. Disease risk increased by 2% with every 10 cm increase in host size. Healthy colonies with severely diseased neighbours (greater than 75% affected tissue) were 1.6 times more likely to develop disease signs compared with colonies with moderately diseased neighbours (25-75% affected tissue). Force of infection ranged from 7 to 20 disease cases per 1000 colonies (mean = 15 cases per 1000 colonies). The effective reproductive ratio, or average number of secondary infections per infectious individual, ranged from 0.16 to 1.22. Probability of transmission depended strongly on proximity to diseased neighbours, which demonstrates that marine disease spread can be highly constrained within patch reefs.

Towards Multiplex Molecular Diagnosis-A Review of Microfluidic Genomics Technologies.

Highly sensitive and specific pathogen diagnosis is essential for correct and timely treatment of infectious diseases, especially virulent strains, in people. Point-of-care pathogen diagnosis can be a tremendous help in managing disease outbreaks as well as in routine healthcare settings. Infectious pathogens can be identified with high specificity using molecular methods. A plethora of microfluidic innovations in recent years have now made it increasingly feasible to develop portable, robust, accurate, and sensitive genomic diagnostic devices for deployment at the point of care. However, improving processing time, multiplexed detection, sensitivity and limit of detection, specificity, and ease of deployment in resource-limited settings are ongoing challenges. This review outlines recent techniques in microfluidic genomic diagnosis and devices with a focus on integrating them into a lab on a chip that will lead towards the development of multiplexed point-of-care devices of high sensitivity and specificity.

Pediatric Resident Education and Preparedness Regarding Vaccine-Preventable Diseases.

This study assessed pediatric residents' reported knowledge of and self-confidence in identifying/treating 8 vaccine-preventable diseases. Pediatric residents nationwide (n = 385) reported (1) if they had previously diagnosed measles, mumps, rubella, diphtheria, tetanus, pertussis, varicella, and/or polio; (2) their comfort level in treating these diseases; (3) the likelihood of identifying symptoms; and (4) 16 disease-related statements as true/false. More than 25% of residents were not comfortable treating 5 of the 8 diseases. More than 25% reported themselves as unlikely/extremely unlikely to identify symptoms of 3 of these diseases. Third- or fourth-year residents did not feel more confident in identifying disease symptoms than first-year residents, except for pertussis ( P ≤ .01). True/false statement accuracy ranged from 56.8% correct (polio) to 94.6% correct (pertussis). Most residents (73.3%) were "extremely concerned" regarding parental vaccine refusal, and 96.0% felt that they would benefit from receiving more information. Increased emphasis on this subject in residency education is essential for the management of potential disease outbreaks.

Effective surveillance and predictive mapping of mosquito-borne diseases using social media

Healthcare Emergency Management involves preventing, handling, organizing and controlling of specific events and in response to emergency situations. A social media based mosquito-borne disease surveillance and outbreak management using spatial and temporal information which help in identification, characterization, and modeling of user behavioral patterns on the web have been presented through this paper. The proposed predictive mapping based on geo-tagging data has a significant impact on preventing and tracking mosquito-borne disease in the specific area with limited resources. The tracking of real-time public sentiments provides an early discovery or alarming related to outbreak. Latent Dirichlet allocation (LDA) based topic modeling techniques have been applied to filter out relevant topics related to symptoms, prevention and fear. The two steps fine-grained classifications of data have been performed using Naive Bayes and Support Vector machine. The proposed framework focused on alternative methods of analysis and visualization of user's opinions that do not depend upon the assumption of normality. A novel intelligent surveillance process model has been presented which help government agencies for proper management of time and resources. The utilization of standard kernel density estimate (KDE) with important factors derived from Twitter and RSS feeds have been presented for predictive mapping. The model uses latent Dirichlet allocation for identification of coherent topics from collected data set at a particular interval. This model has been applied to predict the occurrence of mosquito-borne disease in India.

Exploring the Diversity of Field Strains of Brucella abortus Biovar 3 Isolated in West Africa.

Brucellosis is one of the most widespread bacterial zoonotic diseases in the world, affecting both humans and domestic and wild animals. Identification and biotyping of field strains of Brucella are of key importance for a better knowledge of the epidemiology of brucellosis, for identifying appropriate antigens, for managing disease outbreaks and for setting up efficient preventive and control programmes. Such data are required both at national and regional level to assess potential threats for public health. Highly discriminative genotyping methods such as the multiple locus variable number of tandem repeats analysis (MLVA) allow the comparison and assessment of genetic relatedness between field strains of Brucella within the same geographical area. In this study, MLVA biotyping data retrieved from the literature using a systematic review were compared using a clustering analysis and the Hunter-Gaston diversity index (HGDI). Thus, the analysis of the 42 MLVA genotyping results found in the literature on West Africa [i.e., from Ivory Coast (1), Niger (1), Nigeria (34), The Gambia (3), and Togo (3)] did not allow a complete assessment of the actual diversity among field strains of Brucella. However, it provided some preliminary indications on the co-existence of 25 distinct genotypes of Brucella abortus biovar 3 in this region with 19 genotypes from Nigeria, three from Togo and one from Ivory Coast, The Gambia, and Niger. The strong and urgent need for more sustainable molecular data on prevailing strains of Brucella in this sub-region of Africa and also on all susceptible species including humans is therefore highlighted. This remains a necessary stage to allow a comprehensive understanding of the relatedness between field strains of Brucella and the epidemiology of brucellosis within West Africa countries.

Allelic Variation in Outer Membrane Protein A and Its Influence on Attachment of Escherichia coli to Corn Stover.

Understanding the genetic factors that govern microbe-sediment interactions in aquatic environments is important for water quality management and reduction of waterborne disease outbreaks. Although chemical properties of bacteria have been identified that contribute to initiation of attachment, the outer membrane proteins that contribute to these chemical properties still remain unclear. In this study we explored the attachment of 78 Escherichia coli environmental isolates to corn stover, a representative agricultural residue. Outer membrane proteome analysis led to the observation of amino acid variations, some of which had not been previously described, in outer membrane protein A (OmpA) at 10 distinct locations, including each of the four extracellular loops, three of the eight transmembrane segments, the proline-rich linker and the dimerization domain. Some of the polymorphisms within loops 1, 2, and 3 were found to significantly co-occur. Grouping of sequences according to the outer loop polymorphisms revealed five distinct patterns that each occur in at least 5% of our isolates. The two most common patterns, I and II, are encoded by 33.3 and 20.5% of these isolates and differ at each of the four loops. Statistically significant differences in attachment to corn stover were observed among isolates expressing different versions of OmpA and when different versions of OmpA were expressed in the same genetic background. Most notable was the increased corn stover attachment associated with a loop 3 sequence of SNFDGKN relative to the standard SNVYGKN sequence. These results provide further insight into the allelic variation of OmpA and implicate OmpA in contributing to attachment to corn stover.

Infectious Disease Reporting and Outbreak Management Improvement Project

ObjectiveImprove disease reporting and outbreak mangement.IntroductionSpecific communicable diseases have to be reported by law withina specific time period. In Ohio, prior to 2001, most of these diseasereports were on paper reports that were reported from providers tolocal health departments. In turn the Communicable Disease Nursemailed the hardcopies to the Ohio Department of Health (ODH).In 2001 the Ohio Disease Reporting System (ODRS) was rolled out toall local public health agencies in Ohio.1ODRS is Ohio’s portion ofthe National Electronic Disease Surveillance System. ODRS shouldnot be confused with syndromic surveillance systems that are fordetecting a disease outbreak before the disease itself is detected.2Chronic disease surveillance system data has been evaluated forlong term trends and potential enhancements.3However, the use ofcommunicable disease reports vary greatly.4 However, the exportdata has not routinely been used for quality improvement purposesof the disease reporting process itself. In December 2014, GreeneCounty Public Health (GCPH) begain a project to improve reportingof communicable diseases and the response to disease outbreaks.MethodsInitial efforts were to understand the current disease reportingprocess: Quantitative management techniques including creating alogic model and process map of the existing process, brainstormingand ranking of issues. The diseases selected to study included:Campylobacteriosis, Cryptosporidiosis, E. coli O157:H7 &amp;shiga toxin-producing E. coli, Giardiasis, Influenza-associatedhospitalization, Legionnaires’ disease, Pertussis, Salmonellosis,and Shigellosis. The next steps included creating a data collectionand analysis plan. An updated process map was created and thepre- and post-process maps were compared to identify areas toimprove. The median number of days were compared before andafter improvements were implemented. Modeling of the impact ofthe process improvements on the median number of days reportedwas conducted. Estimation of the impact in healthy number of daysderived from the reduction in days to report (if any) were calculated.ResultsProcess improvements identified: Ensure all disease reportersuse digital reporting methods preferably starting with electroniclaboratory reporting directly to the online disease reporting system,with other methods such as direct web data entry into system, faxinglab reports, orsecure emailing reports, with no or little hard copy mailing;Centralize incoming email and fax reports (eliminating process steps);Standardize backup staffing procedures for disease reporting staff;Formalize incident command procedures under the authorized personin charge for every incident rather than distribute command betweenenvironmental and clinical services; and place communicable diseasereporting under that single authority rather than clinical services. Thedays to report diseases were reduced from a median of 2 to .5 days(p&lt;.001). All the diseases were improved except for crytosporodiumdue to an outlier report two months late. The estimated societalhealthy days saved were valued at $52,779 in the first eight monthsafter implementation of the improvements.ConclusionsImprovements in disease reporting decreased the reporting timefrom over 2 days to less than 1 day on average. Estimated societalhealthy days saved by this project during the first 9 months was$52,779. Management of early command and control for outbreakresponse was improved.

Orchestrating BigData Analysis Workflows

Data analytics has become not only an essential part of day-to-day decision making, but also reinforces long-term strategic decisions. Whether it is real-time fraud detection, resource management, tracking and prevention of disease outbreak, natural disaster management or intelligent traffic management, the extraction and exploitation of insightful information from unparalleled quantities of data (BigData) is now a fundamental part of all decision making processes. Success in making smart decisions by analyzing BigData is possible due to the availability of improved analytical capabilities, increased access to different data sources, and cheaper and improved computing power in the form of cloud computing. However, BigData analysis is far more complicated than the perception created by the recent publicity. For example, one of the myths is that BigData analysis is driven purely by the innovation of new data mining and machine learning algorithms. While innovation of new data mining and machine learning algorithms is critical, this is only one aspect of producing BigData analysis solutions. Just like many other software solutions, BigData analysis solutions are not monolithic pieces of software that are developed specifically for every application. Instead, they often combine and reuse existing trusted software components that perform necessary data analysis steps. Furthermore, in order to deal with the large variety, volume and velocity of BigData, they need to take advantage of the elasticity of cloud and edge datacenter computation and storage resources as needed to meet the requirements of their owners.

Plant Pathology and Information Technology: Opportunity for Management of Disease Outbreak and Applications in Regulation Frameworks

In many European rural areas, agriculture is not only an economic activity, but it is strictly linked to environmental and social characteristics of the area. Thus, sometimes, a pathogen can become a social threat, as in the case of Xylella fastidiosa and olive trees (Olea europaea L.) in Salento. Fast and systemic response to threats represents the key to success in stopping pest invasions, and proves a great help in managing lots of data in a short time or coordinating large-scale monitoring coming from applying Information Technology tools. Regarding the field of applications, the advantages provided by new technologies are countless. However, is it the same in agriculture? Electronic identification tools can be applied for plant health management and certification. Treatments, agrochemical management or impact assessment may also be supported by dematerialization of data. Information Technology solution for urban forestry management or traceability of commodities belonging to “Food from Somewhere” regimes were analyzed and compared to protection from pests of a unique tree heritage such as olive trees in Salento.

Effect of water temperature on mortality of Pacific oysters Crassostrea gigas associated with microvariant ostreid herpesvirus 1 (OsHV-1 µVar)

The ostreid herpesvirus 1 microvariant (OsHV-1 µVar) causes mass mortality of Pacific oysters Crassostrea gigas. Water temperature can directly influence the incidence of disease or correlate with seasonal changes in the environment and oyster physiology that modify the susceptibility of the oysters to disease. The effect of water temperature was evaluated in con- trolled laboratory conditions by intramuscular injection of OsHV-1 µVar after acclimation of 8 mo old spat and 17 mo old adult oysters at 4 different temperatures (14, 18, 22 and 26°C). Mortality was 84 and 77% at 26 and 22°C, respectively, compared to 23% at 18°C and nil at 14°C. There was a statistically significant interaction between the dose of OsHV-1 µVar and water temperature. At 18°C, mortality occurred exclusively at a dose of 10 6 OsHV-1 µVar genome copies per oyster whereas at the higher temperatures, oysters challenged with 10 3 copies per oyster also died. Mor- tality did not occur at 14°C and OsHV-1 µVar was detected in tissues of only 1% of the oysters after 14 d. When accounting for temperature and dose, spat (8 mo) were 2.7 times more likely to die than adults (17 mo). Our study confirms a direct effect of water temperature on infection and dis- ease caused by OsHV-1 µVar. We identified a threshold water temperature of between 14 and 18°C below which productive infection does not occur and the requirement for a higher dose of OsHV-1 µVar to initiate infection at 18°C than at 22°C. These results have implications for predict- ing and managing disease outbreaks caused by OsHV-1 µVar.

PREVALENCE OF FOOT AND MOUTH DISEASE AT CHUADANGA SADAR UPAZILLA IN BANGLADESH

A study on clinical observation, management and complication of foot and mouth disease (FMD) outbreak in cattle was carried out in Chuadanga sadar upazilla during 24 weeks period from July 2012 to January 2013. Clinical data were collected from 108 cattle of both sexes. The effect of season, breed, age, sex and purpose of keeping cattle on the incidence of the disease was analyzed. Seasonal variation of the disease was significant. Crossbred was found to be more susceptible than local breed. The prevalence of the disease was found significantly higher in male than female. The clinical prevalence of FMD increased in the month of November (31.48%). The prevalence of FMD in other months varies from 5-21%. Clinical observation of FMD affected cattle showed fever, anorexia, salivation and erosive lesion on oral mucosa and inter digital region of foot. Antibacterial drug could be recommended for clinical practice to control secondary bacterial infection in complicated FMD cases.

Field Evaluation of a Competitive Lateral-Flow Assay for Detection of Alternaria brassicae in Vegetable Brassica Crops.

On-site detection of inoculum of polycyclic plant pathogens could potentially contribute to management of disease outbreaks. A 6-min, in-field competitive immunochromatographic lateral flow device (CLFD) assay was developed for detection of Alternaria brassicae (the cause of dark leaf spot in brassica crops) in air sampled above the crop canopy. Visual recording of the test result by eye provides a detection threshold of approximately 50 dark leaf spot conidia. Assessment using a portable reader improved test sensitivity. In combination with a weather-driven infection model, CLFD assays were evaluated as part of an in-field risk assessment to identify periods when brassica crops were at risk from A. brassicae infection. The weather-driven model overpredicted A. brassicae infection. An automated 7-day multivial cyclone air sampler combined with a daily in-field CLFD assay detected A. brassicae conidia air samples from above the crops. Integration of information from an in-field detection system (CLFD) with weather-driven mathematical models predicting pathogen infection have the potential for use within disease management systems.

Digital Participatory Surveillance and the Zika Crisis: Opportunities and Caveats

Managing the global threat of Zika requires innovative solutions. This article examines the potential of Digital Participatory Surveillance to support the management of global disease outbreaks by enabling citizens to report signs of infection. We discuss the status of the current evidence-base, contextual factors influencing user engagement and data quality, challenges for evaluation, and unique aspects of Zika with implications for design. We also suggest priorities for research, development and practice, to help translate the theoretical benefits of these methods into meaningful improvements in outbreak monitoring and public health.

Intraosseous vascular access in disasters and mass casualty events: A review of the literature.

The intraosseous (IO) route of vascular access has been increasingly used to administer resuscitative fluids and drugs to patients in whom reliable intravenous (IV) access could not be rapidly or easily obtained. It is unknown that to what extent the IO route has been used to gain vascular access during disasters and mass casualty events. The purpose of this review was to examine the existing literature to answer the research question, "What is the utility of the IO route compared to other routes for establishing vascular access in patients resulting from disasters and mass casualty events?" Keyword-based online database search of PubMed, CINAHL, and the Cochrane Database of Systematic Reviews. University-based academic research cell. Included evidence were randomized and nonrandomized trials, systematic reviews with and without meta-analysis, case series, and case reports. Excluded evidence included narrative reviews and expert opinion. Not applicable. Of 297 evidence sources located, 22 met inclusion criteria. Located evidence was organized into four categories including chemical agent poisoning, IO placement, while wearing chemical protective clothing (PPE), military trauma, and infectious disease outbreak. Evidence indicates that the IO route of infusion is pharmacokinetically equal to the IV route and superior to the intramuscular (IM) and endotracheal routes for the administration of antidotal drugs in animal models of chemical agent poisoning while wearing full chemical PPE. The IO route is superior to the IM route for antidote administration during hypovolemic shock. Civilian casualties of explosive attacks and mass shootings would likely benefit from expanded use of the IO route and military resuscitation strategies. The IO route is useful for fluid resuscitation in the management of diarrheal and hemorrhagic infectious disease outbreaks.