Endemic Disease Research Articles

Why some countries but not others? Urbanisation, GDP and endemic disease predict global SARS-CoV-2 excess mortality patterns

ContextThe global impact of the SARS-CoV-2 pandemic has been uneven, with some regions experiencing significant excess mortality while others have been relatively unaffected. Yet factors which predict this variation remain enigmatic, particularly at large spatial scales.ObjectivesWe aimed to uncover the key drivers of excess mortality across countries and regions to help understand the factors contributing to the varied impacts of the pandemic worldwide.MethodsWe used spatially explicit Bayesian models that integrate environmental, socio-demographic and endemic disease data at the country level to provide robust global estimates of excess SARS-CoV-2 mortality (P-scores) for the years 2020 and 2021.ResultsWe find that urbanization, gross domestic product (GDP) and spatial patterns are strong predictors of excess mortality, with countries characterized by low GDP but high urbanization experiencing the highest levels of excess mortality. Intriguingly, we also observed that the prevalence of malaria and human immunodeficiency virus (HIV) are associated with country-level SARS-CoV-2 excess mortality in Africa and the Western Pacific, whereby countries with low HIV prevalence but high malaria prevalence tend to have lower levels of excess mortality. While these associations are correlative in nature at the macro-scale, they emphasize that patterns of endemic disease and socio-demographic factors are needed to understand the global dynamics of SARS-CoV-2.ConclusionsOur study identifies factors associated with variation in excess mortality across countries, providing insights into why some were more impacted by the pandemic than others. By understanding these predictors, we can better inform global outbreak management strategies, such as targeting medical resources to highly urban countries with low GDP and high HIV prevalence to reduce mortality during future outbreaks.

Iodine deficiency as an environmental risk factor for thyroid gland diseases in animals

Among non-infectious diseases in humans and animals, iodine deficiency pathology is a significant problem worldwide due to its high prevalence and broad spectrum of clinical signs and consequences. Increasing anthropogenic pressure on the natural environment has led to an ecological crisis. The situation is complicated in the biogeochemical zones of Ukraine, where insufficient or excessive content of mobile forms of microelements in soils and water sources determines the biological reaction of local flora and fauna. In animals, this is manifested by endemic diseases, including hypothyroidism. Mineral elements, including iodine, are a structural material in the body of animals; they participate in the processes of digestion and absorption in the digestive tract, synthesis, splitting, and excretion of metabolic products, creating the necessary conditions for the normal functioning of enzymes, hormones, vitamins, stabilize acidic-alkaline balance and osmotic pressure. Of all the organs of the endocrine system, the thyroid gland is the most closely related to the environment since its structure and function largely depend on the supply of iodine from the outside. The authors describe in detail the role of synergists of iodine (selenium, iron, copper, zinc, cobalt) and antagonists, the imbalance of trace elements, the influence of ionizing radiation, and the nature of feeding. It is substantiated that the action of environmental elements and anthropogenic factors determines the appearance and risk of developing thyroid pathology in cows. The article presents materials from a complex study of the clinical course of iodine deficiency, as well as morphological and biochemical parameters of the blood of cows. The object of research is clinically healthy and sick animals – cattle. Diagnosis of thyroid pathology was carried out with the help of clinical and laboratory tests. The clinical examination of cows was carried out according to the generally accepted scheme, taking into account the results of the general condition and studies of individual organs and systems. The research was conducted in three districts of the Zhytomyr region (Korostenskyi, Narodytskyi, and Popilnianskyi). During the external examination of the animals, swelling in the intermaxillary space (Myxedema) was observed, which was found only in 5 out of 90 dairy cows (5.6 %), mainly from Narodytsky district (8.9 %), compared to 2.2 % in Korosten district. It was observed that goiter was established in only three cows out of 90 (3.35%); all were in Narodytsky district (6.7 %). Enophthalmos was detected in 24 out of 90 dairy cows (26.7 %), including 16 out of 45 cows (35.4 %) in the Narodytsky District, while this symptom was not detected in the Popilnya District dairy cows. It was established that the content of thyroxine in dairy cows of Narodytskyi and Korostensky districts ranged from 2.2 to 4.25 μg/100 ml (28.3–54.7 nmol/l), respectively, and was on average 3.4 ± 0.21 μg/100 ml (43.8 ± 2.70 nmol/l, in cows from the conditionally clean territory (Popelnyan district) – 5.3 ± 0.65 nmol/l.

Lively commodities and endemic diseases: Shifting commodity situations and nonhuman disability in cattle and sheep on UK farms

The concept of ‘lively commodities’ captures how aspects of the life of certain entities affect their commodification and exchange within capitalist economic systems. Their status as being, or comprised of, living things matters to their commodification in different ways in particular places and spaces and at particular times. This paper uses the empirical example of diseased farmed animals in the north of England to examine the effects of susceptibility to disease on the process of lively commodification, drawing on conceptualisations of nonhuman disability and relations of care alongside literature on lively commodities, and exploring cases of multi-lifeform co-production of disease. It thus focuses on moments where the liveliness of animals means that commodification ‘goes wrong’, because liveliness means susceptibility to injury and disease, alongside its potential for economic production. The paper focuses on two important endemic conditions affecting UK farming: lameness in cattle and sheep, and bovine viral diarrhoea (BVD) in cattle. These conditions significantly affect animals' welfare and impact on farm productivity. Drawing on qualitative analysis of transcripts from in-depth interviews with 29 farmers and 21 farm advisers (e.g. vets), the paper examines three empirical themes where farming practices are strongly affected by the lively nature of the commodities being produced: first, the anticipatory practice of breeding animals resistant or vulnerable to disease; second, lameness and nonhuman disability; and third, BVD and threats to agricultural biosecurity. The paper concludes by revisiting the concept of lively commodities in situations where farmed animals are diseased, and reflects on the implications of this for their shifting commodity status in particular times and places.

The voyage of the London whaler Lusitania, 1826–1829

The British whaling ship Lusitania left London in 1826 on a three-year voyage to the South Seas. During the course of its long voyage, the vessel spent much of its time in the waters off the Indonesian archipelago and among the islands of western Melanesia. British whalers had been driven to this challenging region because sperm whales had been severely depleted in other less difficult whaling grounds. In those tropical waters, the hot climate, endemic diseases and high death rate among the crew, as well as the routine dangers of the trade, were to try the Lusitania and her crew to the utmost. One of them kept a journal during the voyage. It chronicles the many challenges faced by this and other vessels working this whaling ground, which until recent times has been poorly documented.

An assessment of latrine front-end characteristics and associated surface E. coli indicated faecal contamination in rural Fiji

In Fiji, 90% of the population has access to basic sanitation; however, there are still persistent health risks from endemic faecal-oral diseases such as typhoid fever. There is a need to assess the contribution of existing sanitation facilities in the faecal pathogen transmission pathway. This study was conducted as part of a larger planetary health study across 29 rural communities within five river catchments. This specific research aimed to characterise latrine front-ends, both infrastructure and usage behaviour, and to assess the faecal contamination levels on various frequently contacted latrine surfaces in rural Fiji. A sanitation survey, along with observation and latrine swab sampling, was conducted in households over three phases: baseline (n = 311) (Aug–Dec 2019), endline (n = 262) (Jun–Sep 2022) and an in-depth front-end study (n = 12) (Oct–Nov 2022). Of 311 households, almost all had pedestal-type latrines, predominately cistern-flush (83%), followed by pour-flush (13%), and then hole-type (pit) latrines (4%). Washable latrine floors had significantly higher E. coli densities (6.7 × 102 CFU/25 cm2) compared to non-washable floors (1.3 × 102 CFU/25 cm2) (p = 0.05), despite washable floors indicating improved latrines. The in-depth front-end analysis found that moist latrine surfaces had significantly elevated E. coli densities (1.2 × 103 CFU/25 cm2) compared to the dry ones (14.3 CFU/25 cm2) (p < 0.001), highlighting the importance of maintaining dry latrine surfaces. Latrine floors and mid-walls were the most frequently contaminated surfaces, emphasising the need to clean and disinfect these surfaces. Only 46% of the households reported always using soap for handwashing after defecation, exacerbating the risk of transmitting faecal pathogens. This study highlights that latrine cleanliness and hygiene are as crucial as latrine infrastructures for the effective disruption of faecal pathogens transmission during latrine use.

Molecular detection of emerging porcine circovirus in Taiwan

Porcine Circovirus type (PCV) 2 is an important pathogen that has been circulating worldwide and has cuased serious economic loss in pig industry. However, both PCV3 and PCV4 are newly emerging viruses. In Taiwan, PCV2 has been one of the critical pathogens in pig frams and PCV3 has been detected since 2016; however, the epidemiolog of PCV3 in Taiwan remains unclear and PCV4 has yet to be identified. Therefore, in order to detect the positive rate of PCV2, to investigate the epidemiolog of PCV3 in the pig farms, and to examine whether pigs were infected with PCV4 in Taiwan, a total of 128 samples from 46 clinical cases of pigs were collected from September 2020 to December 2021. The case detection rates were 54.3 % for PCV2, 43.5 % for PCV3, and 2.2 % for PCV4. The results suggested that the positivity rates for both PCV2 and PCV3 were still high in Taiwan. In addition, PCV3 was detected among cases from all 7 sampled counties and in 11 of the 16 sampling months, suggesting that PCV3 may lead to endemic pig disease in Taiwan. Surprisingly, the PCV4 was also detected, suggesting the first PCV4 case in Taiwan. The complete genomes derived from the identified PCV3 and PCV4 strains were subsequently sequenced followed by phylogenetic analysis. The results suggested that the 17 identified PCV3 strains could be divided into Taiwanese-like and Japanese-like strains. In addition, the amino acid residues at positions 27, 80, and 212 in the identified PCV4 cap protein were asparagine, isoleucine, and methionine, respectively, and thus the identified PCV4 was catalorized into clade PCV4b. Consequently, it is concluded that (i) the prevalence of PCV2 and PCV3 is still high in Taiwanese pigs, (ii) PCV3 has may be an endemic infection in Taiwan and can be classified into Japanese-like and Taiwanese-like strains, (iii) PCV4 was detected for the first time in Taiwanese pigs and can be classified into PCV4b. It remains unclear how PCV2, PCV3, and PCV4 were introduced to Taiwan, and thus continuous investigation of emerging pathogens in pigs is needed.

Histoplasma capsulatum urinary antigen detection in a kidney transplant recipient with acute paracoccidioidomycosis: Case study and literature review.

Paracoccidioidomycosis (PCM) and histoplasmosis are endemic fungal diseases in South America. Both can lead to lung involvement with fungal dissemination progressing to systemic and severe clinical manifestations, especially in immunosuppressed hosts. As the population of immunosuppressed individuals has been rising, a higher occurrence of fungal infections is predicted in this setting. This poses challenges regarding the differential diagnosis due to overlapping clinical and laboratorial findings, hampering the management of cases. In this study, the authors discuss the occurrence of a false-positive Histoplasma urinary antigen detection in a kidney transplant recipient with acute PCM. Given the scarce information about this subject, a review on literature data is provided. A comprehensive literature search was conducted to investigate previous studies that found cross-reactivity between Histoplasma urinary antigen assays in human patients with confirmed diagnosis of PCM. Additionally, an update of PCM in transplant recipients is provided. The included studies reported 120 samples from patients with PCM tested for Histoplasma antigen, presenting an overall cross-reactivity of 51.67% and 17 cases of PCM in transplant recipients. CONCLUSIONS: The galactomannan urinary antigen developed to diagnose histoplasmosis can cross react with PCM, which may represent a concern in countries where both mycoses overlap.

Ocular paracoccidioidomycosis in the Western Amazon: a case report

Paracoccidioidomycosis (PCM), a systemic mycosis related to agricultural activities, is prevalent in Brazil. Its insidious evolution can have serious consequences when not diagnosed and treated early. This endemic disease affects several organs, but ocular lesions are uncommon. A bibliographic search on Scielo and Medline found very few confirmed cases. This report relates the case of a 58-year-old male patient with an ulcerated and secreting lesion on the eyelid and blurred vision. He is a resident of a rural area in the municipality of Bujari, Acre, in the Brazilian Amazon.

Fecal microbiota transplantation alleviates mild-moderate COVID-19 associated diarrhoea and depression symptoms: A prospective study of a randomized, double-blind clinical trial.

Currently, the emergence of the endemic Coronavirus disease (COVID-19) situation still poses a serious threat to public health. However, it remains elusive about the role of fecal microbiota transplantation in treating COVID-19. We performed a randomized, double-blind, placebo-controlled clinical trial enrolling a cohort of 40 COVID-19 patients with mild-moderate symptoms. Our results showed that fecal microbiota transplantation provided an amelioration in diarrhoea (p = 0.026) of digestive system and depression (p = 0.006) of neuropsychiatric-related symptom in COVID-19 patients, respectively. Meanwhile, we found that the number of patients with diarrhoea decreased from 19 to 0 on day 7 after fecal microbiota transplantation treatment, and it was statistically changed compared to the placebo group (p = 0.047). Of note, the serum concentration of aspartate aminotransferase-to-alanine aminotransferase ratio (AST/ALT, fecal microbiota transplantation, pre vs. post: 0.966 vs. 0.817), a biomarker for predicting long COVID-19, was significantly reduced by fecal microbiota transplantation. In all, our study supports that fecal microbiota transplantation could be a novel therapeutic strategy for COVID-19 patients with diarrhoea and depressive symptoms, which is potentially valuable in ameliorating long COVID-19 symptoms.

Retrospective study on the dengue fever outbreak in Puntland State, Somalia

BackgroundDengue infection is a mosquito-borne, endemic viral disease, particularly in developing countries. Here, we report the results of the clinicodemographic, serologic profile and the monthly occurrence of a recent dengue fever outbreak in Puntland State (Somalia).MethodologyWe analyzed the data of 956 dengue-suspected patients who were investigated using the rapid diagnostic testing (RDT) method for detecting NS1 (dengue virus non-structural protein) and IgM antibodies employing the SD Biosensor Dengue Dou NS Ag and IgM test kit (Germany) at the Puntland Public Health Referral Laboratory from November 21, 2022, to May 27, 2023.ResultsWe found that 118 cases were positive for dengue among the suspected patients enrolled in the present study. Of these cases, 76.2% were dengue NSI positive, 13.6% were dengue IgM positive, and 10.2% were both NSI and IgM positive. The number of females and males in the confirmed cases was equal, and most (48.3%) were aged 20 years or less. 43.1% of them lived in the Nugal region, particularly in Garowe. Clinically, fever was the most frequent symptom (88.9%). The cases peaked in December 2022 but dropped from January to March, with a slight rise in February, and then increased in April and May 2023.ConclusionThis study highlights the clinicodemographic characteristics, seroprevalence, and monthly occurrence of dengue in Puntland. We recommend improving vector control measures, enhancing case management, strengthening dengue surveillance, developing an early warning system, and conducting future studies to characterize the circulating strains.

Numerical Performance of the Fractional Direct Spreading Cholera Disease Model: An Artificial Neural Network Approach

The current investigation examines the numerical performance of the fractional-order endemic disease model based on the direct spreading of cholera by applying the neuro-computing Bayesian regularization (BR) neural network process. The purpose is to present the numerical solutions of the fractional-order model, which provides more precise solutions as compared to the integer-order one. Real values based on the parameters can be obtained and one can achieve better results by utilizing these values. The mathematical form of the fractional direct spreading cholera disease is categorized as susceptible, infected, treatment, and recovered, which represents a nonlinear model. The construction of the dataset is performed through the implicit Runge–Kutta method, which is used to lessen the mean square error by taking 74% of the data for training, while 8% is used for both validation and testing. Twenty-two neurons and the log-sigmoid fitness function in the hidden layer are used in the stochastic neural network process. The optimization of BR is performed in order to solve the direct spreading cholera disease problem. The accuracy of the stochastic process is authenticated through the valuation of the outputs, whereas the negligible calculated absolute error values demonstrate the approach’s correctness. Furthermore, the statistical operator performance establishes the reliability of the proposed scheme.

Whole-genome sequencing of multidrug-resistant Escherichia coli causing urinary tract infection in an immunocompromised patient: a case report

BackgroundEscherichia coli is a major human pathogen responsible for a broad range of clinical illnesses. It has been linked to endemic and epidemic nosocomial diseases caused by multidrug-resistant pathogens in Sudan as well as throughout the globe.Case presentationA 76-year-old African woman arrived at Saad Rashwan Medical Centre complaining of backaches and discomfort during urination. Throughout the preceding 5 years, the patient had recurrent urinary tract infections. Following overnight incubation at 37 °C, Escherichia coli was found in her midstream urine specimen on cysteine lactose electrolyte deficient agar media. Minimum inhibitory concentration (colorimetric/turbidimetric method) was employed to test a wide range of antimicrobial drugs against this bacterial strain, and the results revealed significant multidrug resistance. QIAamp® DNA Mini Kit was used to obtain DNA Template from the purified Escherichia coli (Qiagen, Hilden, Germany). The bacterial whole-genome sequence was done by Novogene company (Hong Kong) using Illumina HiSeq 2500 (Illumina, San Diego, CA, USA), followed by whole genome reconstructions, and identification of antibiotic-resistant genes. Phylogenetic analysis revealed that our strain was related to the Escherichia coli DSM30083 ( genome sequence ID: CP033092.2) from the USA. Our strain possessed the following antimicrobial-resistant genes: aminoglycoside (kdpE, baeR, cpxA, aadA5), nitroimidazole (msbA), phosphonic acid (mdtG), tetracycline (emrY), macrolide, penam, tetracycline, (evgA, TolC, H-NS), fluoroquinolone, cephalosporin, glycylcycline, penam, tetracycline, rifamycin, phenicol antibiotic, disinfecting agents and antiseptics (acrB; marA), sulfonamide (sul1), macrolide (Mrx), cephalosporin, penam (CTX-M-15), carbapenem, cephalosporin, and penam (OXA-1).ConclusionThis study found that the isolated Escherichia coli strain had varied antimicrobial resistance genes on the basis of whole-genome sequencing and phenotypic resistance analyses. Whole-genome sequencing is critical for control and preventative methods to battle the growing threat of antimicrobial resistance. A larger investigation is recommended for improved generalization of results.

Participatory Disease Surveillance for the Early Detection of Cholera-Like Diarrheal Disease Outbreaks in Rural Villages in Malawi: Prospective Cohort Study.

Cholera-like diarrheal disease (CLDD) outbreaks are complex and influenced by environmental factors, socioeconomic conditions, and population dynamics, leading to limitations in traditional surveillance methods. In Malawi, cholera is considered an endemic disease. Its epidemiological profile is characterized by seasonal patterns, often coinciding with the rainy season when contamination of water sources is more likely. However, the outbreak that began in March 2022 has extended to the dry season, with deaths reported in all 29 districts. It is considered the worst outbreak in the past 10 years. This study aims to evaluate the feasibility and outcomes of participatory surveillance (PS) using interactive voice response (IVR) technology for the early detection of CLDD outbreaks in Malawi. This longitudinal cohort study followed 740 households in rural settings in Malawi for 24 weeks. The survey tool was designed to have 10 symptom questions collected every week. The proxies' rationale was related to exanthematic, ictero-hemorragica for endemic diseases or events, diarrhea and respiratory/targeting acute diseases or events, and diarrhea and respiratory/targeting seasonal diseases or events. This work will focus only on the CLDD as a proxy for gastroenteritis and cholera. In this study, CLDD was defined as cases where reports indicated diarrhea combined with either fever or vomiting/nausea. During the study period, our data comprised 16,280 observations, with an average weekly participation rate of 35%. Maganga TA had the highest average of completed calls, at 144.83 (SD 10.587), while Ndindi TA had an average of 123.66 (SD 13.176) completed calls. Our findings demonstrate that this method might be effective in identifying CLDD with a notable and consistent signal captured over time (R2=0.681404). Participation rates were slightly higher at the beginning of the study and decreased over time, thanks to the sensitization activities rolled out at the CBCCs level. In terms of the attack rates for CLDD, we observed similar rates between Maganga TA and Ndindi TA, at 16% and 15%, respectively. PS has proven to be valuable for the early detection of epidemics. IVR technology is a promising approach for disease surveillance in rural villages in Africa, where access to health care and traditional disease surveillance methods may be limited. This study highlights the feasibility and potential of IVR technology for the timely and comprehensive reporting of disease incidence, symptoms, and behaviors in resource-limited settings.

An Evaluation of the Lineage of Brucella Isolates in Turkey by a Whole-Genome Single-Nucleotide Polymorphism Analysis.

Brucellosis is a disease caused by the Brucella (B.) species. It is a zoonotic disease that affects farm animals and causes economic losses in many countries worldwide. Brucella has the ability to persist in the environment and infect the host at low doses. Thus, it is more important to trace brucellosis outbreaks, identify their sources of infection, and interrupt their transmission. Some countries already have initial data, but most of these data are based on a Multiple-Locus Variable-Number Tandem-Repeat Analysis (MLVA), which is completely unsuitable for studying the Brucella genome. Since brucellosis is an endemic disease in Turkey, this study aimed to examine the genome of Turkish Brucella isolates collected between 2018 and 2020, except for one isolate, which was from 2012. A total of 28 strains of B. melitensis (n = 15) and B. abortus (n = 13) were analyzed using a core-genome single-nucleotide polymorphism (cgSNP) analysis. A potential connection between the Turkish isolates and entries from Sweden, Israel, Syria, Austria, and India for B. melitensis was detected. For B. abortus, there may be potential associations with entries from China. This explains the tight ties found between Brucella strains from neighboring countries and isolates from Turkey. Therefore, it is recommended that strict measures be taken and the possible effects of uncontrolled animal introduction are emphasized.

A stochastic modeling study of quarantine strategies against foot-and-mouth disease risks through cattle trades across the Thailand-Myanmar border

Foot-and-mouth disease (FMD) is an important endemic disease in livestock in Southeast Asia. Transboundary movement of animals may result in the transnational disease spread. A major cattle market is located at the Thailand-Myanmar border, where most cattle imported from Myanmar are traded. In this study, we built a stochastic susceptible-exposed-infectious-recovered (SEIR) model to investigate the effectiveness of a private animal quarantine service center in preventing FMDV from entering the major cattle market. We computed with different parameters and found that, with 50 % vaccine effectiveness, the risk of releasing infected cattle to the market per batch was generally low during the quarantine period of 21 and 28 days, with the risk ranging from 0.071 to 0.078 and 0.032 to 0.036, respectively. Despite the best scenario, the zero-risk state is difficult to attain. The sensitivity analysis highlights that the percentage of immune animals before entering the quarantine centers and the vaccine effectiveness are important factors. In conclusion, the 21-day quarantine period mitigates the risk of FMDV introduction into the cattle market. This control measure should be rigorously maintained to sustainably prevent FMDV outbreaks through transboundary animal movements, especially among countries in FMD-endemic regions.

A narrative review on trypanosomiasis and its effect on food production

Trypanosomiasis is an endemic parasitic disease affecting both humans and animal with a severe negative impact on food production in almost all parts of the world. This review seeks to summarize the history of trypanosomiasis and examine the prevalence of trypanosome infection in animals and its effects on food production. A narrative review was conducted on the history of trypanosomiasis. The literature search was conducted on different databases, and selected articles were screened, data extracted, and analyzed. It is believed that trypanosomiasis has been in existence for several decades dating as far as about 2500 BC during the era of the Egyptian kingdom. Africa was found to have the most common cases of animal trypanosomiasis, with 36 out of 40 articles reporting cases. Cattle among other mammals are the most studied animals and they are the most affected. Hence, milk and meat production are greatly affected by trypanosomiasis. The age of animals and the feed provided to animals also played a role in the prevalence and distribution of the pathogen. This review reveals a wide geographical distribution and diverse host range of trypanosome species. The study also highlights the severity of trypanosomiasis and its impact on food production.

Establishing an early warning event management system at Africa CDC.

Africa is home to hotspots of disease emergence and re-emergence. To adequately detect and respond to these health threats, early warning systems inclusive of event-based surveillance (EBS) are needed. However, data systems to manage these events are not readily available. In 2020, Africa Centres for Disease Control and Prevention developed an event management system (EMS) to meet this need. The district health information software (DHIS2), which is free and open-source software was identified as the platform for the EMS because it can support data capture and analysis and monitor and report events. The EMS was created through a collaborative and iterative prototyping process that included modifying key DHIS2 applications like Tracker Capture. Africa CDC started piloting the EMS with both signal and event data entry in June 2020. By December 2022, 416 events were captured and over 140 weekly reports, including 19 COVID-19 specific reports, were generated and distributed to inform continental awareness and response efforts. Most events detected directly impacted humans (69%), were considered moderate (50%) to high (29%) risk level and reflected both emerging and endemic infectious disease outbreaks. Highly pathogenic avian influenza, specifically H5N1, was the most frequently detected animal event and storms and flooding were most frequently detected environmental events. Both data completeness and timeliness improved over time. Country-level interest and utility resulted in four African countries adapting the EMS in 2022 and two more in 2023. This system demonstrates how integrating digital technology into health systems and utilising existing digital platforms like DHIS2 can improve early warning at the continental and country level by improving EBS workflow.

Improved water supply infrastructure to reduce acute diarrhoeal diseases and cholera in Uvira, Democratic Republic of the Congo: Results and lessons learned from a pragmatic trial.

Safely managed drinking water is critical to prevent diarrhoeal diseases, including cholera, but evidence on the effectiveness of piped water supply in reducing these diseases in low-income and complex emergency settings remains scarce. We conducted a trial of water supply infrastructure improvements in Uvira (DRC). Our primary objective was to estimate the relationship between a composite index of water service quality and the monthly number of suspected cholera cases admitted to treatment facilities and, as a secondary analysis, the number of cases confirmed by rapid diagnostic tests. Other exposures included the quantity of supplied water and service continuity. We used Poisson generalised linear models with generalised estimating equations to estimate incidence rate ratios. Associations between suspected cholera incidence and water service quality (RR 0·86, 95% CI 0·73-1·01), quantity (RR 0·80, 95% CI 0·62-1·02) and continuity (RR 0·81, 95% CI 0·77-0·86) were estimated. The magnitudes of the associations were similar between confirmed cholera incidence and water service quality (RR 0·84, 95% CI 0·73-0·97), quantity (RR 0·76, 95% CI 0·61-0·94) and continuity (RR 0·75, 95% CI 0·69-0·81). These results suggest that an additional 5 L/user/day or 1.2 hour per day of water production could reduce confirmed cholera by 24% (95% CI 6-39%) and 25% (95% CI 19-31%), respectively. Ensuring a sufficient and continuous piped water supply may substantially reduce the burden of endemic cholera and diarrhoeal diseases but evaluating this rigorously is challenging. Pragmatic strategies are needed for public health research on complex interventions in protracted emergency settings. The trial is registered in ClinicalTrials.gov ID NCT02928341. https://classic.clinicaltrials.gov/ct2/show/NCT02928341.

Cost-effectiveness of sentinel screening of endemic diseases alongside malaria diagnosis: A case study in schistosomiasis.

In countries where malaria is endemic, the use of rapid diagnostic tests(RDTs) has become routine, especially in rural settings. Such regions are characterised by often having other co-endemic infectious diseases, at high levels of prevalence. To illustrate the potential added-value of "sentinel" screening for patients presenting for a routine diagnostic test for malaria, at healthcare facilities in Uganda. We developed an economic model by combining two decision trees, one for malaria and a second for the co-endemic disease schistosomiasis. The integrated model was designed to inform policy strategies for the co-endemic disease in addition to malaria (i.e., whether to test opportunistically for schistosomiasis or use mass drug administration(MDA) as per usual practice).We performed the analysis on three comparators varying testing accuracy and costs. Sentinel screening can provide added value to the testing of patients compared with the status quo: when schistosomiasis prevalence is high then MDA is preferential; if low prevalence, treating no one is preferred. If the disease has average levels of prevalence, then a strategy involving testing is preferred. Prevalence thresholds driving the dominant strategy are dependent upon the model parameters, which are highly context specific. At average levels of prevalence for schistosomiasis and malaria for Uganda, adding a sentinel screening was cost-effective when the accuracy of test was higher than current diagnostics and when economies of scope were generated(Expected value clinical Information = 0.65$ per DALY averted, 137.91$ per correct diagnoses).Protocols using diagnostics with current accuracy levels were preferred only for levels of MDA coverage below 75%. The importance of the epidemiological setting is crucial in determining the best cost-effective strategy for detecting endemic disease. Economies of scope can make sentinel screenings cost-effective strategies in specific contexts. Blanket thresholds recommended for MDA may not always be the preferred option for endemic diseases.

Tick-Borne Relapsing Fever Infection from a Bunker, a Case Report on a "One Health" Approach.

Background: Tick-borne relapsing fever (TBRF) caused by Borrelia persica is an endemic disease in Israel and highly prevalent in military personnel. Prevention among the Israel Defense Force soldiers is based on increased awareness mainly in hyperendemic areas and selective postexposure prophylaxis with doxycycline. In this study, we report the presence of a suspected outbreak of TBRF in four soldiers who spent 30 h inside a deserted bunker. Materials and Methods: Clinical data on TBRF suspected cases were retrieved from clinical records, soft ticks were collected using carbon dioxide (CO2) traps and their DNA was extracted and analysed by PCR and nucleotide sequencing. Environmental conditions such as relative humidity, air temperature, wind speed, and type of soil, as well as presence or absence of animal traces inside the bunkers were documented. Results: TBRF-like clinical symptoms in the patients included: tick bite scars, fever (37.5-39.2°C), rash, tachycardia, hypotension, myalgia, cough, headache, cervical lymphadenopathy and nausea. Microscopic search for B. persica in blood smears was performed in three patients and was negative. Out of the 255 Ornithodoros tholozani ticks collected from the bunker, 198 were analyzed and 2 (1%) were infected with B. persica. To determine if tick infestation in military bunkers is a common phenomenon, we surveyed nine additional military bunkers located in four different geographical areas for the presence of soft ticks. Only one additional bunker was infested with two O. tholozani ticks, both negative for B. persica. Presence of earth that probably helped sustain a relatively big tick population was observed on the floor in the highly infested bunker. Environmental treatment with lambda-cyhalothrin at 9.7% was performed and showed efficacy with no ticks recovered in the infested bunker 124 days after intervention. Conclusion: This study shows that military bunkers may harbor soft ticks infected with B. persica and entrance into bunkers should be considered as a risk for acquiring this infection like entrance into natural caves and archeological ruins.