Enhanced Surveillance System Research Articles

Absence of proteinase K-resistant PrP in Korean Holstein cattle carrying potential bovine spongiform encephalopathy-related E211K somatic mutation.

Bovine spongiform encephalopathy (BSE) is a kind of prion disease caused by proteinase K-resistant prion protein (PrPSc ) in cattle. Although BSE has been reported worldwide, BSE-infected cases have never been reported in Korea. In a previous study, we identified BSE-related somatic mutation E211K in 3 Korean Holstein cattle. In Korea, the BSE surveillance system has been established. However, several genetic factors have not been controlled simultaneously thus far. In the present study, we performed enhanced surveillance of prion disease-related factors in Korean cattle, including Holstein cattle and Hanwoo (Korean native cattle), which is widely raised for meat. We investigated the germline mutation E211K at codon 211 of the PRNP gene and analysed genotype, allele and haplotype frequencies of the 23- and 12-bp insertion/deletion polymorphisms of the PRNP gene using direct DNA sequencing. In addition, we investigated linkage disequilibrium (LD) and compared haplotype distributions of polymorphisms among cattle breeds. Furthermore, we carried out BSE diagnosis in the medulla oblongata (MO) of Korean cattle including 3 Korean Holstein cattle carrying somatic mutation E211K using Western blotting analysis. We did not find the E211K mutation in the PRNP gene in any of the Korean cattle and found significantly different genotype, allele and haplotype distributions of the 23- and 12-bp insertion/deletion polymorphisms of the PRNP gene in male Holstein compared with male Hanwoo, female Hanwoo and total Hanwoo. In addition, only male Holstein showed weak LD between 23- and 12-bp insertion/deletion polymorphisms. Furthermore, the PrPSc bands were not detected in all Korean cattle tested. To the best of our knowledge, the enhanced surveillance system of BSE was conducted for the first time in Korean cattle.

Qualitative Risk Analysis of IBR Introduction to Ethiopia via the Legal Importation of Bulls from Netherlands

Infectious bovine rhinotracheitis/infectious pustular vulvovaginitis (IBR/IPV) is a highly contagious viral disease of domestic and wild cattle causing high economic loss in cattle industry. The disease is caused by bovine herpes virus 1 (BoHV-1). BHV-1 is distributed worldwide including the exporting country Netherlands except it has been eradicated from Austria, Denmark, Finland, Sweden, Switzerland and Norway. To know the status of the disease in Ethiopia, 1430 sera samples were collected starting from January 3- 26, 2016 from four regions. However, samples are not yet processed. As part of the genetic improvement of the local breeds, the ministry of livestock and fishery of Ethiopia has already decided to import 120 bulls in March 2016 for semen production. Before the importation this bulls, an import risk assessment of IBR/IPB was conducted with the objective of assessing the risk of introduction of BHV1 to Ethiopia through the importation of infected bulls from Netherlands. Hence, hazard identification conclusion revealed the introduction of BHV1 or its abortifacient strains are regarded as potential hazards. Following the entry of infected bulls, the likelihood establishment and transmission of IBR to formerly imported breed and indigenous cattle was indicated to be high. The overall likelihood occurrence of IBR following the importation of infected bulls was assessed to be high. Potentially exotic strains of bovine herpes viruses would cause significant health impact in susceptible cattle including illness, abortion, stillbirth, neonatal death and calf mortality thereby leading to high economic losses in cattle industry. However there would little effect on people and environment. The overall level of consequence of IBR was assessed to be minor. In general, the overall risk of IBR occurrence following the importation of infected bull was estimated from moderate to high. However, this risk can be mitigated if bulls intended for importation are sourced from IBR/IPB free country and healthy check-up and detection capacity of infected animals at entry point of Ethiopia is intensified, the awareness of animal health workers and farm owners about IBR is raised with enhanced surveillance system and diagnostic capacity of the BHV1 in the importing country.

An evaluation of enhanced surveillance of hospitalised COVID-19 patients to inform the public health response in Victoria.

Public health surveillance is crucial for supporting a rapid and effective response to public health emergencies. In response to the coronavirus disease (COVID-19) pandemic, an enhanced surveillance system of hospitalised COVID-19 patients was established by the Victorian Department of Health and Human Services (DHHS) and the Victorian Healthcare Associated Infection Surveillance System Coordinating Centre. The system aimed to reduce workforce capacity constraints and increase situational awareness on the status of hospitalised patients. The system was evaluated, using guidelines from the United States Centers for Disease Control and Prevention, against eight attributes: acceptability; data quality; flexibility; representativeness; simplicity; stability; timeliness; and usefulness. Evidence was generated from stakeholder consultation, participant observation, document review, systems review, issues log review and audits. Data were collected and analysed over a period of up to three months, covering pre- and post-implementation from March to June 2020. This system was rapidly established by leveraging established relationships and infrastructure. Stakeholders agreed that the system was important but was limited by a reliance on daily manual labour (including weekends), which impeded scalability. The ability of the system to perform well in each attribute was expected to shift with the severity of the pandemic; however, at the time of this evaluation, when there were an average 23 new cases per day (0.3 cases per 100,000 population per day), the system performed well. This enhanced surveillance system was useful and achieved its key DHHS objectives during the COVID-19 public health emergency in Victoria. Recommendations for improvement were made to the current and future systems, including the need to plan alternatives to improve the system's scalability and to maintain stakeholder acceptability.

Persistent Hepatitis E virus infection across England and Wales 2009-2017: Demography, virology and outcomes.

The first clinical case of persistent HEV infection in England was reported in 2009. We describe the demography, virology and outcomes of patients identified with persistent HEV infection in England and Wales between 2009 and 2017. A series of 94 patients with persistent HEV infection, defined by HEV viraemia of more than 12weeks, was identified through routine reference laboratory testing. Virology, serology and clinical data were recorded through an approved PHE Enhanced Surveillance System. Sixty-six cases (70.2%) were transplant recipients, 16 (17.0%) had an underlying haematological malignancy without stem cell transplantation, six (6.4%) had advanced HIV infection, five (5.3%) were otherwise immunosuppressed, and one patient (1.1%) had no identified immunosuppression. Retrospective analysis of 46 patients demonstrated a median 38weeks of viraemia before diagnostic HEV testing. At initial diagnosis, 16 patients (17.0%) had no detectable anti-HEV serological response. Of 65 patients treated with ribavirin monotherapy, 11 (16.9%) suffered virological relapse despite undetectable RNA in plasma or stool at treatment cessation. Persistent HEV infection remains a rare diagnosis, but we demonstrate that a broad range of immunocompromised patients are susceptible. Both lack of awareness and the pauci-symptomatic nature of persistent HEV infection likely contribute to significant delays in diagnosis. Diagnosis should rely on molecular testing since anti-HEV serology is insufficient to exclude persistent HEV infection. Finally, despite treatment with ribavirin, relapses occur even after cessation of detectable faecal shedding of HEV RNA, further emphasising the requirement to demonstrate sustained virological responses to treatment.

Prevalence and antimicrobial resistance of Salmonella recovered from pig-borne food products in Henan, China

Foodborne disease is one of the most important public health issues worldwide. Food of animal origin is considered as the main vehicle of transmission to humans. Pigs are carriers of numerous foodborne pathogens, including Salmonella which is linked to pork related infection and leads to significant public health concerns, particularly with emerging antimicrobial-resistant clones. Therefore, a continued and enhanced surveillance system of antimicrobial resistance (AMR) pathogens on animal-borne food is essential. This study aims to investigate the prevalence, serovars, and antimicrobial susceptibility pattern of Salmonella isolated from pig-borne food in Henan Province, China. The Salmonella isolates identification were subjected to microbiological culture and PCR assay with positive isolates were assayed for serotyping by slide agglutination test and antimicrobial resistance susceptibility by MIC test. Collectively, a total of 1441 pork and visceral pig products between March and October in 2019 were collected from retail market, we found that 219 (15.1%) were positive for Salmonella isolates from liver (n = 83), bile (n = 19) and pork (n = 117). The highest prevalence of positive Salmonella isolates was observed 25.86% in liver (n = 83/321), followed by 21.84% in bile (n = 19/87), and 11.33% in pork (n = 117/1033). Seventeen different serovars were identified and classified into five serogroups. The most prevalent identified serovar was S. Derby (32.87%), followed by S. Rissen (25.57%) and S. Goldcoast (10.50%). We also found high resistance rate against tetracycline (96.5%), sulfisoxazole (96.3%), followed by amoxicillin (85.2%), ampicillin (84.4%), and streptomycin (83.7%), respectively. An additional investigation of multi-drug resistance pattern (MDR ≥3 antimicrobial classes) indicated that serovar Indiana (n = 13) showed the highest MDR (ACSSuT-AMC-CIP) prevalence (100%), followed by Goldcoast and Derby. Collectively, this study showed considerable diversity among Salmonella isolates in the pig-borne food and highlighted a high prevalence and emerging foodborne MDR clones may increase the frequency of therapeutic failure in the clinical settings.

TBE in Italy

Italy is considered a low-incidence country for tick-borne encephalitis (TBE) in Europe.1 Areas at higher risk for TBE in Italy are geographically clustered in the forested and mountainous regions and provinces in the north east part of the country, as suggested by TBE case series published over the last decade.2-5 A national enhanced surveillance system for TBE has been established since 2017.6 Before this, information on the occurrence of TBE cases at the national level in Italy was lacking. Both incidence rates and the geographical distribution of the disease were mostly inferred from endemic areas where surveillance was already in place, ad hoc studies and international literature.1

Sociodemographic and clinical risk factors for paediatric typical haemolytic uraemic syndrome: retrospective cohort study

ObjectivesHaemolytic uraemic syndrome (HUS) following Shiga toxin-producing Escherichia coli (STEC) infection is the the most common cause of acute renal failure among children in the UK. This study explored differential...

Epidemiological profile of meningitis in Iran before pentavalent vaccine introduction

BackgroundNo reliable and comprehensive study has been published on the incidence and epidemiological profile of meningitis in Iran from 2008 to 2014, before pneumococcal conjugate vaccine (PCV) and pentavalent vaccine (DTPw-Hep B-Hib (PRP-T) vaccine (pentavac) (adsorbed)) introduction. The present study aimed to portray the epidemiological profile of meningitis in Iran from 2008 to 2014.MethodsData on meningitis cases aged from 1 day to 110 years were extracted from national notifiable diseases surveillance system from March 2008 to December 2014 in Iran. A total number of 48,006 cases of suspected meningitis were identified and 1468 cases of which met the criteria for diagnosis-confirmed meningitis. Of 1468 cases, 1352 patients were included in the study.ResultsThe great number of cases reported from urban areas. Moreover, males were more predominant than females (58.51% vs. 33.81%) in total. The estimated annual incidence rate of meningitis varied from 0.28/100000 in 2008 to 0.09/100000 in 2014. Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis were the most leading pathogens causing bacterial meningitis, accounted for 266(23.44%), 145(12.78%), 95(8.37%) of cases, respectively. Each of the three bacterial species showed a descending trend. The majority of infected subjects are children under five years.ConclusionsUnlike the decreasing trend of meningitis and high percentage of cultures with negative results, according to World Health Organization recommendation PCV introduction into routine immunization is evident. Implementing an enhanced surveillance system to provide high quality data on epidemiological profile of meningitis in Iran is necessary.

A Fully Integrated Real-Time Detection, Diagnosis, and Control of Community Diarrheal Disease Clusters and Outbreaks (the INTEGRATE Project): Protocol for an Enhanced Surveillance System.

BackgroundDiarrheal disease, which affects 1 in 4 people in the United Kingdom annually, is the most common cause of outbreaks in community and health care settings. Traditional surveillance methods tend to detect point-source outbreaks of diarrhea and vomiting; they are less effective at identifying low-level and intermittent food supply contamination. Furthermore, it can take up to 9 weeks for infections to be confirmed, reducing slow-burn outbreak recognition, potentially impacting hundreds or thousands of people over wide geographical areas. There is a need to address fundamental problems in traditional diarrheal disease surveillance because of underreporting and subsequent unconfirmed infection by patients and general practitioners (GPs); varying submission practices and selective testing of samples in laboratories; limitations in traditional microbiological diagnostics, meaning that the timeliness of sample testing and etiology of most cases remains unknown; and poorly integrated human and animal surveillance systems, meaning that identification of zoonoses is delayed or missed.ObjectiveThis study aims to detect anomalous patterns in the incidence of gastrointestinal disease in the (human) community; to target sampling; to test traditional diagnostic methods against rapid, modern, and sensitive molecular and genomic microbiology methods that identify and characterize responsible pathogens rapidly and more completely; and to determine the cost-effectiveness of rapid, modern, sensitive molecular and genomic microbiology methods.MethodsSyndromic surveillance will be used to aid identification of anomalous patterns in microbiological events based on temporal associations, demographic similarities among patients and animals, and changes in trends in acute gastroenteritis cases using a point process statistical model. Stool samples will be obtained from patients’ consulting GPs, to improve the timeliness of cluster detection and characterize the pathogens responsible, allowing health protection professionals to investigate and control outbreaks quickly, limiting their size and impact. The cost-effectiveness of the proposed system will be examined using formal cost-utility analysis to inform decisions on national implementation.ResultsThe project commenced on April 1, 2013. Favorable approval was obtained from the Research Ethics Committee on June 15, 2015, and the first patient was recruited on October 13, 2015, with 1407 patients recruited and samples processed using traditional laboratory techniques as of March 2017.ConclusionsThe overall aim of this study is to create a new One Health paradigm for detecting and investigating diarrhea and vomiting in the community in near-real time, shifting from passive human surveillance and management of laboratory-confirmed infection toward an integrated, interdisciplinary enhanced surveillance system including management of people with symptoms.International Registered Report Identifier (IRRID)DERR1-10.2196/13941

Improving the quality of neonatal data capture and clinical care at a tertiary-care hospital in Uganda through enhanced surveillance, training and mentorship

ABSTRACTIntroduction: Accurate documentation of neonatal morbidity and mortality is limited in many countries in sub-Saharan Africa. This project aimed to establish a surveillance system for neonatal conditions as an approach to improving the quality of neonatal care.Methods: A systematic data capture and surveillance system was established at Jinja Regional Referral Hospital, Uganda using a standardised neonatal medical record form which collected detailed individual patient level data. Additionally, training and mentorship were conducted and basic equipment was provided.Results: A total of 4178 neonates were hospitalised from July 2014 to December 2016. Median (IQR) age on admission was one day (1–3) and 48.0% (1851/3859) were male. Median (IQR) duration of hospitalisation was 17 days (IQR 10–40) and the longest duration of hospitalisation was 47 days (IQR 41–58). The majority were referrals from government health facilities (54.4%, 2012/3699), though 30.6% (1123/3669) presented as self-referrals. Septicaemia (44.9%, 1962/4371), prematurity (21.0%, 917/4371) and birth asphyxia (19.1%, 833/4371) were the most common diagnoses. The overall mortality was 13.8% (577/4178) and the commonest causes of death included septicaemia (26.9%, 155/577), prematurity (24.3%, 140/577), birth asphyxia (21.0%, 121/577), hypothermia (9.9%, 57/577) and respiratory distress (8.0%, 46/577). The majority of deaths (51.5%, 297/577) occurred within the first 24 h of hospitalisation although a significant proportion of deaths also occurred after 7 days of hospitalisation (24.1%, 139/577). A modest decrease in mortality and improvement in clinical outcome were observed.Conclusion: Improvement in neonatal data capture and quality of care was observed following establishment of an enhanced surveillance system, training and mentorship.Abbreviations: aOR: adjusted odds ratio; CHRP: Centre for Health research and Programmes; HC: health centre; HMIS: Health Management Information System; JRRH: Jinja Regional Referral Hospital; NMRF: neonatal medical record form; PMTCT: prevention of mother-to-child transmission of HIV; UPA: Uganda Paediatric Association

A public health enhanced surveillance system for a mass gathering event.

From June 7 to June 9, 2018, a G7 Summit was held in the Canadian province of Quebec. This international political mass gathering event posed a number of potential risks to public health. To assess three additional monitoring strategies to detect public health threats during a mass gathering event. In addition to routine public health monitoring, a partnership was created and three monitoring strategies were put in place three days before, during and six days after the G7 event: the analysis of data on the presenting complaint and discharge diagnosis from 11 emergency departments in the area using the logical Early Aberration Reporting System; the daily polling of key health partners with an online questionnaire; and the analysis of calls to Info-Santé, a government-run telephone consultation service for the public regarding health and social issues. Emergency room data produced 78 alerts from the presenting complaints and 39 alerts from the discharge diagnoses. Of these 117 alerts, two were investigated (one in the respiratory and one in the neurological-muscular categories) and no other interventions were required. With a few exceptions, all of the health partners completed the online survey each day and no signal of concern was generated. Compared with historical data, no increase or differences in calls to Info-Santé were detected during the monitoring period. The three additional monitoring strategies developed to detect events of public health importance during the 2018 G7 Summit in Quebec were successful in gathering timely data for analysis. Close collaboration and good participation from the different partners were essential to this project. However, because no public health event occurred, it was not possible to determine whether the enhanced surveillance system had sufficient speed and sensitivity for timely detection and response.

A public health enhanced surveillance system for a mass gathering event

A public health enhanced surveillance system for a mass gathering event

Surveillance for Lyme disease in Canada: 2009-2015

ObjectiveThis study aims to describe incidence over time, geographic and seasonal distribution, demographic and clinical characteristics of Lyme disease cases in Canada.IntroductionLyme disease (LD), a multisystem infection that is manifested by progressive stages (1), is emerging in central and eastern provinces of Canada due to northward expansion of the geographic range of Ixodes scapularis, the main vector in these regions (2). In 2004, approximately 40 human cases of LD were reported in Canada. In 2009, LD disease became nationally notifiable, with provincial and territorial health departments reporting clinician-diagnosed cases to the Public Health Agency of Canada (PHAC). This study summarizes seven years (2009-2015) of national surveillance data for LD in Canada.MethodsNational Lyme disease surveillance data is collected through two surveillance systems, the Canadian National Disease Surveillance System (CNDSS) and the Lyme disease enhanced surveillance system (LDES). The CNDSS collects only demographic data (age and sex), and information on episode date and case classification. The LDES system captures additional data, including: possible geographic location of infection (for both locally acquired and travel-related cases); clinical manifestations; and results of laboratory testing. Nine provinces out of ten participate to LDES that means they provide a part of or all the data elements of this surveillance system. The 2009 national Lyme disease case definition (3) that distinguishes confirmed and probable cases (Table 1) is used to classify and report cases diagnosed by clinicians.This study describes the incidence over time, seasonal and geographic distribution, demographic and clinical characteristics of reported LD cases. Logistic regression was used to explore variations among age groups, sex and year of reporting clinical manifestations to better understand potential demographic risk factors for the occurrence of LD. Different models were used with as outcomes absence or presence of: erythema migrans (early Lyme disease), neurologic and cardiac symptoms and multiple erythema, migrans (early disseminated Lyme disease); and arthritis (late disseminated Lyme disease). The most parsimonious multivariate models were sought by backward elimination of nonsignificant variables until all factors in the model were significant (P<0.05).ResultsThe number of reported LD cases increased more than six-fold, from 144 in 2009 to 917 in 2015, mainly due to an increase in infections acquired in Canada. For the provinces participating into the LDES system, the month of illness onset for Lyme disease cases acquired in Canada was available for 2010 cases. Most cases were reported during the summer months of June (20.7%), July (35.4%) and August (17.3%) (Figure 1). An increase in incidence of LD was observed in provinces from Manitoba eastwards (Figure 2). This is consistent with our knowledge of range expansion of the tick vectors in this region. In the western provinces the incidence has remained low and stable. All cases reported by Alberta, Saskatchewan and Newfoundland and Labrador were acquired outside of the province, either elsewhere in Canada or abroad. There was a bimodal distribution for LD by age with peaks at 5–9 and 45–74 years of age (Figure 3). The most common presenting symptoms were a single erythema migrans rash (74.2%) and arthritis (35.7%) (Figure 4). In the multivariate analysis for clinical manifestations, children aged 0–9 years had a greater number of cases reported as early LD (erythema migrans only) than patients aged 10–19 and 30–39 years (P<0.05). For early disseminated manifestations, young adults 20–29 years of age reported more neurologic manifestations, cardiac manifestations or multiple erythema migrans than the reference age group of 0–9 years (P<0.05). For late disseminated manifestations, children under 15 years of age were more frequently reported as having arthritis than other age groups.ConclusionsLyme disease incidence continues to increase in Canada as does the geographic range of ticks that carry the LD bacteria. This increasing of LD incidence might also be due to changing in knowledge, attitudes, and practices of clinicians who diagnose the disease and or of the public health workers who collect and report the data. Ongoing surveillance, preventive strategies as well as early disease recognition and treatment will continue to minimize the impact of LD in Canada.

Evaluation of a phased pneumococcal conjugate vaccine introduction in Mongolia using enhanced pneumonia surveillance and community carriage surveys: a study protocol for a prospective observational study and lessons learned

BackgroundStreptococcus pneumoniae causes substantial morbidity and mortality among children. The introduction of pneumococcal conjugate vaccines (PCV) has the potential to dramatically reduce disease burden. As with any vaccine, it is important to evaluate PCV impact, to help guide decision-making and resource-allocation. Measuring PCV impact can be complex, particularly to measure impact on one of the most common and significant diseases caused by the pneumococcus, namely pneumonia. Here we outline the protocol developed to evaluate the impact of 13-valent PCV (PCV13) on childhood pneumonia in Mongolia, and a number of lessons learned in implementing the evaluation that may be helpful to other countries seeking to undertake pneumonia surveillance.MethodsFrom 2016 PCV13 was introduced in a phased manner into the routine immunisation programme with some catch-up by the Government of Mongolia. We designed an evaluation to measure vaccine impact in children aged 2–59 months with hospitalised radiological pneumonia as a primary outcome, with secondary objectives to measure impact on clinically-defined pneumonia, nasopharyngeal carriage of S. pneumoniae among pneumonia patients and in the community, and severe respiratory infection associated with RSV and/or influenza. We enhanced an existing hospital-based pneumonia surveillance system by incorporating additional study components (nasopharyngeal swabbing using standard methods, C-reactive protein, risk factor assessment) and strengthening clinical practices, such as radiology as well as monitoring and training. We conducted cross-sectional community carriage surveys to provide data on impact on carriage among healthy children.DiscussionEstablishing a robust surveillance system is an important component of monitoring the impact of PCV within a country. The enhanced surveillance system in Mongolia will facilitate assessment of PCV13 impact on pneumonia, with radiological confirmed disease as the primary outcome. Key lessons arising from this evaluation have included the importance of establishing a core group of in-country staff to be responsible for surveillance activities and to work closely with this team; to be aware of external factors that could potentially influence disease burden estimates; to be flexible in data collection processes to respond to changing circumstances and lastly to ensure a consistent application of the pneumonia surveillance case definition throughout the study period.

Lessons Learned from Enhancing Sentinel Surveillance for Cholera in Post-Earthquake Nepal in 2016.

.A major earthquake in 2015 that struck Nepal created a favorable environment for the rapid spread of infectious diseases. In anticipation of a cholera outbreak in 2016, UNICEF, Johns Hopkins University, and the Group for Technical Assistance, Nepal, collaborated to assist the government of Nepal to strengthen early warning surveillance, laboratory-based diagnosis, and field investigation. This article outlines the challenges and lessons learned in cholera prevention and control based on the authors’ experiences in 2016. Priorities for the future plan should include sustaining the enhanced surveillance system for acute gastroenteritis and cholera, rolling out a rapid diagnostic test, and ensuring rapid and systematic epidemiological investigation and environmental testing.

Evaluation of Ebola virus disease surveillance system in Tonkolili District, Sierra Leone.

IntroductionThe Ebola Virus Disease (EVD) epidemic devastated West Africa, with Sierra Leone recording over 50% of the 28,610 cases across the three most affected countries. Enhanced surveillance system was developed for improved identification of cases and response in Sierra Leone. Here, we evaluated the surveillance system to determine its strengths and challenges in meeting the set objectives.MethodsThe EVD surveillance system in Tonkolili District, Sierra Leone, was assessed using the CDC updated guidelines for evaluating public health surveillance. In particular, the simplicity, stability, acceptability, flexibility, representativeness, sensitivity, positive predictive value and data quality of the system were assessed using EVD surveillance data and information from key informant interviews with program stakeholders.ResultsThe EVD surveillance system in Tonkolili District provided information and data on disease trends and outbreak report through official and rumours sources. Case definitions were well understood by participants, with willingness to continue surveillance activities after the EVD outbreak. Standardized data collection tools were in place and data communication was clear with feedback to surveillance units at all levels. The EVD surveillance was not operated within the Integrated Disease Surveillance and Response framework (IDSR). Data completeness was about 91%, consistency existed but data quality was poor (incompletely filled data and missing data existed). Regarding timeliness, samples arrived designated laboratory within 24 - 48 hours in 174 (84.9%). Sensitivity of the surveillance system was 88.5%. Predictive value positive was 25.8%. The stability was questionable since the government of Sierra Leone were not fully in charge of the system.ConclusionWhile the simplicity of the EVD surveillance system in Tonkolili District facilitated its implementation, users suggested that the system did not meet expectations in terms of timeliness, flexibility and acceptability. There was a need to channel efforts towards integrating EVD surveillance into the IDSR. Data completeness and timeliness needed more attention. The District Health Management Team need to take ownership of the surveillance system for sustainability.

2555. Predicting Risk of Breakthrough Invasive Pneumococcal Disease in Children After 13-Valent Pneumococcal Conjugate Vaccination

BackgroundThirteen-valent-pneumococcal conjugate vaccine (PCV13) replaced PCV7 in the childhood immunization schedule in Massachusetts beginning in April 2010. We evaluated the predictors of vaccine-type (VT) invasive pneumococcal infection (IPD) occurrence despite vaccination.MethodsCases of IPD in children <18 years of age were detected through an enhanced surveillance system in MA since 2001. All cases and Streptococcus pneumoniae (SP) isolates are submitted to Department of Public Health (MDPH) and parents/physicians are interviewed for confirmation of demographic and clinical data. All available isolates are serotyped by Quellung reaction. Children who received any dose of PCV7 were excluded from this study. We used 4-layer, feed-forward, neural network with backpropagation learning algorithm, random forest algorithm with 150 classification trees, and extreme gradient boosting (XGBoost) algorithm based on boosted trees with over than 200 iterations to make prediction about risk of nonvaccine serotype (NVST) causing IPD.ResultsOverall, 144 IPD cases have been identified between April 1, 2010, and March 31, 2017, and 27 (19%) were VT IPD. Compared with children with complete PCV13 vaccination, IPD among those with incomplete immunization was more likely to be due to VT (9%, 95% CI 4–18% vs. 19%, 95% CI 10–31%, respectively). Despite complete immunization, 80 of 144 (55.6%) of all IPD in >60 months was breakthrough IPD (Figure 1). Among children with ≥1 comorbid condition and incomplete PCV13, 4 of 18 (22%) IPD were due to VT. Children with incomplete vaccination and pneumonia were most likely (11/17, 65%) to have VT; however, bacteremia without focus cases with incomplete vaccination were most likely (44/45, 3%) to have NVST (Figure 2). Our algorithm performs with 85% accuracy and 92% precision scores.ConclusionIPD due to VT after PCV13 vaccination mostly occurs in older children with incomplete PCV13 immunization, among those with underlying comorbidity, and among those who present with pneumococcal pneumonia. Evaluating the immune response following PCV13 vaccination in children with comorbidity could increase our understanding of breakthrough pneumococcal infections despite vaccination with PCV13. Disclosures All authors: No reported disclosures.

1430. Evolving Impact of 13-Valent Pneumococcal Conjugate Vaccine on Invasive Pneumococcal Disease

BackgroundThe 13-valent pneumococcal conjugate vaccine (PCV13) replaced PCV7 in the childhood immunization schedule in Massachusetts (MA) beginning in April, 2010. We describe the current epidemiology of invasive pneumococcal disease (IPD) in Massachusetts (MA) children after introduction of PCV13.MethodsCases of invasive pneumococcal disease (IPD) in children <18 years of age were detected through an enhanced surveillance system in MA since 2001. All cases in children and Streptococcus pneumoniae (SP) isolates, when available, are submitted to Department of Public Health (MDPH) and parents/physicians are interviewed for confirmation of demographic and clinical data. All available isolates are confirmed as SP, serotyped by Quellung reaction.ResultsThere were 351 IPD cases in MA children from April 1, 2010 to September 31, 2017, and 36 (10.3%) were in infants <6 months; 42 (12.0%) in children between 6 and 12 months; 63 (18.0%) in toddlers 12–24 months; 102 (29.1%) in children aged 2–5 years, and 108 (30.8%) were in children aged ≥5 years. Incidence of IPD declined to 6.8/105 children (95% CI 2.6–11.1) in 2015/2016 period which represents a 72.1% decline compared with 2010/2011 (24.4/105, 95% CI 16.3–32.5) (figure). However, in 2016/2017, IPD incidence increased to 10.4/105 children (95% CI 5.2–15.7). The most common clinical presentation was bacteremia (62.9%), followed by pneumonia (30.5%) and CNS disease (6.6%). Among, 103 (32.6%) children with ≥1 comorbidity, asthma (13.2%), hematologic malignancy (12.1%), prematurity (9.9%) and sickle cell disease (9.9%) were the most common comorbidities. He overall mortality rate was 5.1%. Isolates from 308 (89.3%) were available for serotyping; vaccine serotypes (VST) were identified in 106 (33.3%) IPD cases [19A (46.2%), 7F (19.9%), 3 (17.9%), 19F (10.4%), 6A (2.8%), 14, 18C, 5 (0.9% each). Serotypes 15BC (13.7%), 22F (12.6%) and 33F (11.8%) were the most common nonvaccine serotypes (NVST).ConclusionInvasive pneumococcal disease identified in the post-PCV13-era is primarily caused by NVSTs, specifically serotypes 15BC, 33F and 22F; and disproportionately observed in children with comorbid conditions. Continued surveillance is necessary to determine the impact of PCV13, as well as track potential changes in disease incidence and character due to NVST. Disclosures All authors: No reported disclosures.

Completeness of a Maternal and Perinatal Mortality Enhanced Surveillance System in Pakistan: Evidence from Capture–Recapture Methods

Objectives An enhanced surveillance system that integrated health information systems and extended surveillance to previously uncovered areas to capture all births, perinatal and maternal deaths in a rural district of Pakistan was established in 2015, and this study uses capture-recapture methodology to assess completeness. Methods Births and deaths collected by the survey were matched with the data captured by the enhanced surveillance system. Capture-recapture methodology was used to estimate the total number of births and deaths, measure the degree of underestimation, and adjust mortality rates. Results Of all births, 99% were captured by the enhanced surveillance system. Ninety percent of neonatal deaths and 86% of early neonatal deaths were recorded. The recorded neonatal mortality rate was 40 per 1000 live births (95% CI 35-44), and after adjustment for under-enumeration was 42 per 1000 live births (95% CI 37-46). Recorded rates underestimated neonatal mortality by 5% and perinatal mortality by 7%. Five stillbirths were recorded by the survey and all were matched to recorded stillbirths. The one maternal death recorded by the survey was matched with the maternal death captured by the enhanced surveillance system. The maternal mortality ratio prior to adjustment for under-enumeration was 247 per 100,000 live births (95% CI 147-391), whereas after adjustment it was 246 per 100,000 live births (95% CI 146-389). Conclusion Application of capture-recapture methods to the enhanced surveillance system indicated a high completeness of birth and death recording by the surveillance system.

Syndromic Surveillance on the Mental Health Impact of Political Rallies in Charlottesville, Virginia

ObjectiveTo describe the impact of civil unrest on the mental health of a community in near real-time using syndromic surveillance.IntroductionAs part of a wide-spread community discussion on the presence of monuments to Confederate Civil War figures, the Charlottesville city council voted to remove a statue of General Robert E. Lee.1 Multiple rallies were then held to protest the statue’s removal. A Ku Klux Klan (KKK) rally on July 8, 2017 (MMWR Week 27) and a Unite the Right rally on August 12, 2017 (MMWR Week 32) held in Charlottesville both resulted in violence and media attention.2,3 The violence associated with the Unite the Right rally included fatalities connected to motor vehicle and helicopter crashes.Syndromic surveillance has been used to study the impact of terrorism on a community’s mental health4 while more traditional data sources have looked at the impact of racially-charged civil unrest.5 Syndromic surveillance, however, has not previously been used to document the effect of racially-charged violence on the health of a community.MethodsThe Virginia Department of Health (VDH) analyzed syndromic surveillance data from three emergency departments (EDs) in the Charlottesville area (defined to include Charlottesville city and Albemarle county), regardless of patient residence following the Unite the Right rally. Visits to these EDs between January 1 and September 2, 2017 were analyzed using the Enhanced Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) and Microsoft SQL 2012. Encounters were identified as acute anxiety-related visits based on an International Classification of Diseases, Tenth Revision (ICD-10) discharge diagnosis beginning with ’F41’. Analyses were conducted using the ESSENCE algorithm EWMA 1.2 and SAS 9.3.ResultsThe greatest number of visits with a primary diagnosis of anxiety in 2017 (N=20) was observed in MMWR week 34 (August 20-26). This represented a statistically significant increase over baseline with a p-value of 0.01.By race, a significant increase over baseline in visits with a primary diagnosis of anxiety was observed among blacks or African Americans. The largest volume of visits was observed in MMWR week 33 with a total of 8 identified visits or 1.8% of total ED visit volume. The increase in visits for anxiety observed in weeks 33-35 was 2.2 times greater among blacks or African Americans than it was among whites, p = 0.016, 95% CI [1.14, 4.16].ConclusionsPrevious work done in Virginia to identify ED visits related to anxiety included only chief complaint criteria in the syndrome definition. Due to a change in how one ED in the Charlottesville area reported data during the study period, this syndrome definition could not be applied. In order to remove any potential data artifacts, only those visits with an initial diagnosis of anxiety were included in the analysis. The resulting syndrome definition likely underestimated the occurrence of anxiety in the Charlottesville area, both because it lacked chief complaint information and because syndromic surveillance does not include data on visits to mental health providers outside of EDs. This analysis presents a trend over time rather than a true measure of the prevalence of anxiety.This analysis, while conservative in its inclusion criteria, still identified an increase in visits for anxiety, particularly among blacks or African Americans. In today’s political environment of race-related civil unrest, a way to measure the burden of mental illness occurring in the community can be invaluable for public health response. In Charlottesville, the identification of a community-wide need for mental health support prompted many local providers to offer their services to those in need pro-bono.6References1 Suarez, C. (2017, February 6). Charlottesville City Council votes to remove statue from Lee Park. The Daily Progress. Retrieved from http://bit.ly/2wYOHhv2 Spencer, H., &amp; Stevens, M. (2017, July 8). 23 Arrested and Tear Gas Deployed After a K.K.K. Rally in Virginia. The New York Times. Retrieved from http://nyti.ms/2tCiBGU3 Hanna, J., Hartung, K., Sayers, D., &amp; Almasy, S. (2017, August 13). Virginia governor to white nationalists: ‘Go home … shame on you’. CNN. Retrieved from http://cnn.it/2vvAGHt4 Vandentorren, S., Paty, A. C., Baffert, E., Chansard, P., Caserio-Schönemann, C. (2016, February). Syndromic surveillance during the Paris terrorist attacks. The Lancet (387(10021), 846-847. doi:10.1016/S0140-6736(16)00507-95 Yimgang, D. P., Wang, Y., Paik, G., Hager, E. R., &amp; Black, M. M. Civil Unrest in the Context of Chronic Community Violence: Impact on Maternal Depressive Symptoms. American Journal of Public Health 107(9), 1455-1462. doi:10.2105/AJPH.2017.3038766 DeLuca, P. (2017, August 19). Downtown Charlottesville Library Offers Free Counseling. NBC29.com. Retrieved from http://bit.ly/2yIzHbl