Epidemic Investigation Research Articles

Lessons learnt from malaria epidemics in the Islamic Republic of Iran

The Islamic Republic of Iran is in the pre-elimination phase of malaria control, but malaria epidemics are still a concern in the south of the country. This retrospective study presents the epidemiological characteristics and predisposing factors of 60 of the malaria epidemics reported in Sistan va Baluchestan province during 2005-09. A zero-truncated negative binomial model was used to investigate the relation between predictor variables and the total number of malaria cases. Malaria epidemics occurred mainly in the southern part of the province, mostly between July and October, peaking in August. Most malaria epidemics were small-scale (68.3% were < 100 cases) and short (51.7% lasted < 1 month). Plasmodium falciparum was present in 46.7% of the epidemics. An increase in the rainfall rate as well as population movements were the most significant predisposing factors. The results may help inform an epidemic investigation and reporting system as the country approaches the malaria elimination phase.

Mycobacterium massilienseoutbreak after intramuscular injection, South Korea

SUMMARY We conducted an epidemic investigation to discover the route of transmission and the host factors of an outbreak of post-injection abscesses. Of the 2984 patients who visited a single clinic, 77 cases were identified and 208 age- and sex-matched controls were selected for analysis. Injected medications per se were not found to be responsible, and a deviation from safe injection practice suggested the likelihood of diluent contamination. Therefore the injected medications were classified according to whether there was a need for a diluent, and two medications showed a statistically significant association, i.e. injection with pheniramine [adjusted odds ratios (aOR) 5·93, 95% confidence interval (CI) 2·97-11·87] and ribostamycin (aOR 47·95, 95% CI 11·08-207·53). However, when considered concurrently, pheniramine lost statistical significance (aOR 8·71, 95% CI 0·44-171·61) suggesting that normal saline was the causative agent of this outbreak. Epidemiological evidence strongly suggested that this post-injection outbreak was caused by saline contaminated with Mycobacterium massiliense without direct microbiological evidence.

The past, present, and future of public health surveillance.

This paper provides a review of the past, present, and future of public health surveillance—the ongoing systematic collection, analysis, interpretation, and dissemination of health data for the planning, implementation, and evaluation of public health action. Public health surveillance dates back to the first recorded epidemic in 3180 B.C. in Egypt. Hippocrates (460 B.C.–370 B.C.) coined the terms endemic and epidemic, John Graunt (1620–1674) introduced systematic data analysis, Samuel Pepys (1633–1703) started epidemic field investigation, William Farr (1807–1883) founded the modern concept of surveillance, John Snow (1813–1858) linked data to intervention, and Alexander Langmuir (1910–1993) gave the first comprehensive definition of surveillance. Current theories, principles, and practice of public health surveillance are summarized. A number of surveillance dichotomies, such as epidemiologic surveillance versus public health surveillance, are described. Some future scenarios are presented, while current activities that can affect the future are summarized: exploring new frontiers; enhancing computer technology; improving epidemic investigations; improving data collection, analysis, dissemination, and use; building on lessons from the past; building capacity; enhancing global surveillance. It is concluded that learning from the past, reflecting on the present, and planning for the future can further enhance public health surveillance.

Investigation of hospital epidemics and guidelines for the management of suspected cases of measles and invasive meningococcal disease

RésuméLes épidémies de maladies infectieuses en établissement de soins doivent être précocement détectées et contrôlées. La bonne connaissance des étapes de l’enquête d’investigation, des outils de cette enquête et du rôle des acteurs hospitaliers permet d’organiser une prise en charge efficace de l’épidémie. L’épidémie est également une opportunité formidable pour identifier les brèches du système de santé, et mettre en place des actions de formation et d’éducation.

A worldwide investigation of tuberculosis epidemics

We analyse the tuberculosis (TB) epidemics of 211 countries with a view to proposing more efficient and targeted TB control strategies. Countries are classified by how their TB case notification rates have evolved over time and the age distribution of those suffering from active TB disease in 2008. Further analysis of key statistics associated with each of the countries shows the impact of different indicators. As expected, HIV is a key driver of TB epidemics and affects their age-distribution and their scale. The level of development of a country and its wealth also vary with the shape and scale of a country's TB epidemic. Immigration has an influence on the shape of TB epidemics, which is particularly pronounced in highly developed countries with low levels of TB disease in the native population. We conclude by proposing how the TB control programme in each country analysed should prioritise its efforts.

Epidemic Optic Neuropathy Is Evident in the Somalian Population

Optic neuropathy epidemics have proven to be a serious public health problem around the world. Recently, documented outbreaks have occurred in Cuba and Tanzania, with almost identical clinical presentation. Investigations of both epidemics have implicated nutritional deficiencies as part of a multifactorial etiology, and thus, it is proposed that there may be many undetected epidemics in other food-deprived nations. Somalia, a country subject to prolonged droughts and civil war, may be at particular risk of nutritional deficits. We conducted a case series in Mogadishu, the Somalian capital, with the aim of identifying and characterizing any cases of epidemic optic neuropathy. Cases were recruited at the Al-Noor Eye Hospital, Mogadishu, between 2002 and 2004. Individuals were screened by trained ophthalmic nurses, and a full ophthalmic examination was undertaken by an experienced ophthalmologist. Patients also completed a lifestyle questionnaire to identify any common risk factors. One hundred five acute cases of optic neuropathy were identified. Progression from hyperemia to pallor of the optic discs and greatest visual loss occurred over the first month. Our findings are similar to those reported in the Tanzanian epidemic, including involvement of young patients (mean age: 24 ± 5.3 years) and evidence of peripheral neuropathy. Epidemic levels of optic neuropathy are evident in Somalia. The extent of visual loss in the first month emphasizes the need to initiate treatment early in the course of the disease. Training and establishing health surveillance systems in community clinics may form a central component to this strategy.

Modelling the initial phase of an epidemic using incidence and infection network data: 2009 H1N1 pandemic in Israel as a case study.

This paper presents new computational and modelling tools for studying the dynamics of an epidemic in its initial stages that use both available incidence time series and data describing the population's infection network structure. The work is motivated by data collected at the beginning of the H1N1 pandemic outbreak in Israel in the summer of 2009. We formulated a new discrete-time stochastic epidemic SIR (susceptible-infected-recovered) model that explicitly takes into account the disease's specific generation-time distribution and the intrinsic demographic stochasticity inherent to the infection process. Moreover, in contrast with many other modelling approaches, the model allows direct analytical derivation of estimates for the effective reproductive number (R(e)) and of their credible intervals, by maximum likelihood and Bayesian methods. The basic model can be extended to include age-class structure, and a maximum likelihood methodology allows us to estimate the model's next-generation matrix by combining two types of data: (i) the incidence series of each age group, and (ii) infection network data that provide partial information of 'who-infected-who'. Unlike other approaches for estimating the next-generation matrix, the method developed here does not require making a priori assumptions about the structure of the next-generation matrix. We show, using a simulation study, that even a relatively small amount of information about the infection network greatly improves the accuracy of estimation of the next-generation matrix. The method is applied in practice to estimate the next-generation matrix from the Israeli H1N1 pandemic data. The tools developed here should be of practical importance for future investigations of epidemics during their initial stages. However, they require the availability of data which represent a random sample of the real epidemic process. We discuss the conditions under which reporting rates may or may not influence our estimated quantities and the effects of bias.

Epidemiological features of a GIS-supported investigation of cholera outbreak in Abeokuta, Nigeria

This study seeks to assess the epidemiological features of a GIS supported investigation of a cholera outbreak in Abeokuta. Abeokuta, the capital city of Ogun State, Southwestern Nigeria with an area of 1256 km2 and a population of 605, 451 people had an outbreak of cholera from 20th November, 2005 to 1st of January, 2006. The outbreak affected the Abeokuta North Local Government area where the municipal waterworks is located. Municipal water consumption was found to be associated with illness [McNemar’s Chi square (X2 = 20.5; p < 0.001) and Odds ratio 10]. The epidemiological surveillance data showed a total of one hundred and fifteen cases and 11 deaths with case fatality rate of 9.6%. Male specific and female specific case fatality rates were 11.9 and 7.1%, respectively. The age group of 15 years and above accounted for 68.3% of the cases and 90.9% of the deaths. Post epidemic environmental investigation showed progressive contamination along distribution points. Cholera is still a major cause of morbidity and mortality among youth and ageing population in Nigeria. Key words: Cholera, epidemiological studies, outbreak investigation, Vibrio cholerae, Abeokuta, Nigeria.

Analysis on surveillance outcome of Kaschin-Beck disease from national monitoring region in Xinghai county of Qinghai province from 2003 to 2008

Objective To master the prevalence trend of Kaschin-Beck disease in Xinghai county (Shanglujuan and X.ialujuan village of Tangnaihai township) from 2003 to 2008 in order to understand changes of selenium level of internal and external environments. Methods According to monitoring method on national Kaschin-Beck disease,we carried out epidemical investigation,clinical examination and X-ray photograph on school children aged 7-12 in Xinghai county,a monitoring region,and collected samples of hair and grain. The content of selenium was detected by 2,3-naphthalene fluorescence. Results From 2003 to 2008,in Shanglujuan village,the prevalence rate of clinic examination was fluctuating between 0(0/34)-17.14%(6/35); the detectable rate of X-ray examination was fluctuating between 11.11% (3/27)-20.59% (7/34),the prevalence rates of metaphysis and extremities were fluctuating between 0 (0/27)-13.21%(7/53) and 2.63% (1/38)-11.43% (4/35). In Xialujuan village,the prevalence rate of clinic examination was fluctuating between 2.94% (1/34)-13.33% (6/45); the detectable rate of X-ray examination was fluctuating between 26.67% (12/45)-43.63%(24/55),the prevalence rate of metaphysis and extremities were fluctuating between 8.33% (6/72)-26.47% (9/34) and 13.33% (6/45)-38.18% (21/55). The selenium contents in hair samples were (139.92±92.27),(134.98±63.77)μg/kg respectively in Shanglujuan and Xialujuan village in 2003; the selenium contents in grain samples were (12.90± 7.18),(14.58±9.90)μg/kg respectively in Shanglujuan and Xialujuan village in 2005. Conclusions The prevalence state of Kaschin-Beck disease in national monitoring region is rigid and pathogenetic factors of Kaschin-Beck disease are active. Selenium levels of internal and external environments are low in this region. Key words: Kaschin-Beck disease; X-rays; Selenium; Epidemiology

Epidemic investigation of the jaundice outbreak in girdharnagar, ahmedabad, gujarat, India, 2008.

Background:Since 1976, seven outbreaks of hepatitis E occurred in Ahmedabad. Clusters of jaundice cases were reported on June 19, 2008, by a civic center, Girdharnagar ward, Ahmedabad.Objectives:The objectives were as follows: (1) to identify the etiological agent, source of outbreak, and mode of transmission; (2) to propose a control measure based on the outbreak investigation.Materials and Methods:We defined a case as an acute illness with (a) a discrete onset of symptoms and (b) jaundice or elevated serum aminotransferase levels, from March to September 2008 in the households of the Girdharnagar ward. We collected data through a door-to-door survey and hospital records. We described the outbreak in terms of time, place, and person. We collected laboratory investigation reports of case patients admitted to the civil hospital. To test our hypothesis we conducted a retrospective cohort study to find out the relative risk for hepatitis. We conducted environment investigation to find out the source of contamination of water supply.Results:A total 233 case patients of hepatitis were identified with the attack rate of 10.9/1000 population. Cases were reported in all the age groups with a higher attack rate in the age group of 20-29 years (18.5/1000). Out of 17 case patients, 16 were positive for the hepatitis E IgM antibody. The attack rate was two times more among those who were exposed to the leaking pipeline than the non-exposed (RR=2.3, 95% CI 1.76, 2.98). Environmental investigation also confirmed the sewage contamination of drinking water in the distribution system.Conclusion:The outbreak was due to hepatitis E virus. We recommended a temporary alternative water supply, repair of the leakages, and water quality surveillance.

SNR analysis: molecular investigation of an anthrax epidemic

BackgroundIn Italy, anthrax is endemic but occurs sporadically. During the summer of 2004, in the Pollino National Park, Basilicata, Southern Italy, an anthrax epidemic consisting of 41 outbreaks occurred; it claimed the lives of 124 animals belonging to different mammal species. This study is a retrospective molecular epidemiological investigation carried out on 53 isolates collected during the epidemic. A 25-loci Multiple Locus VNTR Analysis (MLVA) MLVA was initially performed to define genetic relationships, followed by an investigation of genetic diversity between epidemic strains through Single Nucleotide Repeat (SNR) analysis.Results53 Bacillus anthracis strains were isolated. The 25-loci MLVA analysis identified all of them as belonging to a single genotype, while the SNR analysis was able to detect the existence of five subgenotypes (SGTs), allowing a detailed epidemic investigation. SGT-1 was the most frequent (46/53); SGTs 2 (4/53), 3 (1/53) 4 (1/53) and 5 (1/53) were detected in the remaining seven isolates.ConclusionsThe analysis revealed the prevalent spread, during this epidemic, of a single anthrax clone. SGT-1 - widely distributed across the epidemic area and present throughout the period in question - may, thus, be the ancestral form. SGTs 2, 3 and 4 differed from SGT-1 at only one locus, suggesting that they could have evolved directly from the latter during the course of this epidemic. SGT-5 differed from the other SGTs at 2-3 loci. This isolate, thus, appears to be more distantly related to SGT-1 and may not be a direct descendant of the lineage responsible for the majority of cases in this epidemic. These data confirm the importance of molecular typing and subtyping methods for in-depth epidemiological analyses of anthrax epidemics.

The clinical characteristics of primary biliary cirrhosis in China: a systematic review

To summarize the clinical features, diagnosis and treatment of patients with primary biliary cirrhosis (PBC) in China. Systematic analysis of clinical characteristics by searching the Chinese literatures. From 1955 to 2007, 2740 PBC patients were reported in 103 papers (duplicated reports were deleted). The detailed information of 985 patients from 16 papers were collected. Female : male was 6.82:1. The age range was 42 to 56.2-year-old. The time from onset to diagnosis was 12 to 98.4 months. The most common symptoms were fatigue (72.40%), jaundice (67.41%), anorexia (68.58%) and pruritus (45.60%). 20% patients were asymptomatic at onset. The most frequent physical signs were splenomegaly (57.53%), hepatomegaly (43.56%) and ascites (18.45%). Serum alkaline phosphatase (ALP) and gamma glutamyl transpeptidase (GGT) levels were markedly elevated in most of these patients. The immunological marks of AMA and M2 were positive in 88.98% and 82.65% patients, respectively. The most common comorbidity were Sjögren syndrome (9.14%), rheumatoid arthritis (3.95%) and diabetes type II (2.54%). Of the 507 patients treated with ursodeoxycholic acid (UDCA), 345 patients got complete or partial clinical biochemical response. The common complications were gastrointestinal bleeding (41.67%) and liver failure (41.67%). Liver transplantation was the only effective way for the treatment of the end-stage liver disease. The clinical feature of primary biliary cirrhosis in China was similar to the overseas literatures. Further research should focus on epidemic investigation, early diagnosis, long term follow up of asymptomatic patients, immunological mechanism and the efficacy of liver transplantation.

Welcome to Epidemiology and Health

The Korean Society of Epidemiology publishes a scholarly journal titled 'Korean Journal of Epidemiology', which announces and discusses the results of epidemiological studies from the past 30 yr. Since its first publication in 1979, the journal has contributed to the advancement of epidemiology as well as the prevention and control of disease, and the promotion of health in Korea.In 2009, the editorial board has decided to publish the journal in English to contribute internationally, and change the journal's name. The new name of the journal is 'Epidemiology and Health'.The abstract and full text of articles will be published as an open access online journal, which will be posted onto the homepage (http://www.e-epih.org/) in real time for anyone in the world to access free of charge. Our editorial policy is that 'Epidemiology and Health' is open to every researcher in fields related to epidemiology, regardless of membership, his or her major and nationality.Editorials, lectures, review papers, original articles, epidemic and case investigations, brief communications and letters will be published to generate active discussion through the journal along with the publication of the papers.'Epidemiology and Health' welcomes articles from various fields of epidemiology, such as 1) infectious diseases epidemiology, 2) chronic diseases epidemiology, 3) nutritional epidemiology, 4) clinical epidemiology, 5) pharmacoepidemiology, 6) genetic or molecular epidemiology, 7) social epidemiology, 8) environmental or occupational epidemiology, 9) epidemiological methods and biostatistics, 10) disease prevention and control, 11) health promotion and, 12) all other fields related to epidemiology.

‘The gloomy forebodings of this dread disease’, climate, famine and sleeping sickness in East Africa

Identifying the nature of the association between climate, environmental, socio‐economic and political context and disease remains a major challenge, yet a better comprehension of the linkages is imperative if predictive models to guide public health responses are to be devised. Our understanding of the relationships could be improved through investigations of historical epidemics. In this paper we draw on a range of published and unpublished documents to explore the complex relationship between climate, environmental change and epidemic disease (re)emergence in East Africa, and Uganda in particular. This is a region which has experienced climate variability at a range of temporal and spatial scales, but which also has a long history of episodic epidemic disease. We focus on the late nineteenth and early twentieth centuries – a time of social, economic and political reordering in East Africa associated with European colonial intervention, but also a period which witnessed a variety of climatic, ecological and disease events. It will be argued that these developments coalesced, creating a set of spatially distinctive social and environmental conditions which fostered the emergence and prolongation of one of the most deadly episodes of disease in East African history, the sleeping sickness epidemic of c.1900–20.

Real-time PCR assay for sensitive organ detection and epidemic investigation of Turbot reddish body iridovirus

AbstractA rapid and sensitive real-time polymerase chain reaction (PCR) assay coupled with SYBR Green I chemistry was developed for the quantitative detection of Turbot reddish body iridovirus (TRBIV) isolated from farmed turbot (Scophthalmus maximus). A 152 bp DNA fragment from the TRBIV major capsid protein (MCP) gene was involved in the real-time PCR (RT-PCR) assay using the Roter Gene 3000 sequence detection system. The PCR mixture contained a fluorescent dye, SYBR Green I, which exhibited fluorescence enhancement when bound to double-stranded (ds) DNA. The enhancement of fluorescence was proportional to the initial concentration of the template DNA. The positive control plasmid, pUCm-T/TRBIV MCP, containing the target sequence, was quantified to make a standard curve for sample detection after serial tenfold dilution. Linear coefficient correlations between the cycle threshold (CT) value and logarithmic positive plasmid concentration were close to one (R2=0.9952) and the detection limit of the assay was 102 copies of positive plasmids. The quantitative detection of virus in different tissues from TRBIV-infected fish showed that the spleen and kidney contained the largest number of viral particles (5.23×106 and 2.18×106 viral genome copies/mg tissue, respectively), while no viral DNA was detected in the muscular tissue. The molecular epidemic investigation of TRBIV showed that many cultured turbots were infected and TRBIV has become epidemic in turbot farms located along the Shandong peninsula. The virus number varied from 1.27×102 to 2.33×106 viral genome copies/mg tissue in spleens of infected turbot. These results suggest that the RT-PCR assay reported here can be used as a rapid, sensitive and quantitative method for TRBIV.

The US Obesity “Epidemic”: Metaphor, Method, or Madness?

In 2000, US Secretary of Health and Human Services Secretary Tommy Thompson mobilized the US public health infrastructure to deal with escalating trends of excess body weight. A cornerstone of this effort was a report entitled The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. The report stimulated a great deal of public discussion by utilizing the distinctive public health terminology of an epidemic to describe the growing prevalence of obesity in the US population. We suggest that the ensuing controversy was fueled in part by the report’s ambiguous usage of the evocative term “epidemic.” In some passages, the report seems to use “epidemic” in a literal sense, suggesting that rising prevalence of excess body weight should be defined technically as a disease outbreak. Other passages of the report present the same key term metaphorically, leaving readers with the impression that the epidemic language is invoked primarily for rhetorical effect. Here, we explore dynamics and implications of both interpretations. This analysis sheds light on the ongoing public argument about the appropriate societal response to steadily increasing body sizes in the US population; likewise, it capitalizes on the accumulated knowledge that the field of public health has garnered from combating diverse historic epidemics. Our interdisciplinary approach deploys critical tools from the fields of rhetoric, sociology and epidemiology. In particular, we draw from metaphor theory and public address scholarship to elucidate how the Call to Action frames public deliberation on obesity. We turn to the applied public health literature to develop a reading of the report that suggests a novel approach to the problem—application of the Epidemic Investigation protocol to streamline the public health response and reframe the public argument about obesity.

Multi-Virulence-Locus Sequence Typing Identifies Single Nucleotide Polymorphisms Which Differentiate Epidemic Clones and Outbreak Strains ofListeria monocytogenes

A recently developed multi-virulence-locus sequence typing (MVLST) method showed improved discriminatory power for subtyping genetically diverse Listeria monocytogenes isolates and identified epidemic clone II isolates associated with two recent U.S. multistate listeriosis outbreaks. To evaluate the ability of MVLST to distinguish other epidemic clones and outbreak strains of L. monocytogenes, 58 outbreak-related isolates from 14 outbreaks and 49 unrelated isolates were analyzed. Results showed that MVLST provided very high discriminatory power (0.99), epidemiological concordance (1.0), stability, and typeability. MVLST accurately identified three previously known epidemic clones (epidemic clones I, II, and III) and redefined another epidemic clone (epidemic clone IV) in serotype 4b of L. monocytogenes. A set of 28 single nucleotide polymorphisms (SNPs) differentiated all epidemiologically unrelated isolates. A subset of 16 SNPs differentiated all epidemic clones and outbreak strains. Phylogenetic analysis showed congruence between MVLST clusters, serotypes, and previously defined genetic lineages of L. monocytogenes. SNPs in virulence genes appear to be excellent molecular markers for the epidemiological investigation of epidemics and outbreaks caused by L. monocytogenes.

Lab Based surveillance of Dengue Hemorrhagic Fever during 2006 Epidemic in Lahore

Dengue haemorrhagic fever (DHF) is an acute viral disease which is worldwide in distribution. It is caused by four serotypes of Dengue viruses, members of falaviviruses, which are immunologically distinct and does not provide cross protectivity. A lab based surveillance was started on the indication of disease occurrence in Lahore. This epidemic investigation comprises 395 suspected DHF patients with IgG and IgM captured ELISA against Dengue virus 2 and serotype, Lab based data derived from the provincial referral Lab present in a public hospital of Lahore. Among the suspected patients 65.2% (n=257) were male and 34.8% (n=137) were female. There were 38.2% (n=151) patients non-reactive while 28.4% (n=112) were exposed to Dengue virus and 33.4%(n=132) were confirmed dengue patients. It was noted that epidemic started from mid of august and get terminated in the mid of January while the secular trends show that most of (60-70%) cases occur in November as per recorded.

Low dose radiation on lens of x-ray workers

目的 探讨低剂量辐射对晶状体的损伤及剂量与效应的关系.方法 对1996年和2005年绵阳市医用X线工作者的晶状体进行了流行病学调查,并检测和统计了个人受照累积剂量.结果 调查组晶状体浑浊与对照组比较均有随着工龄的增长而增高,差异有统计学意义(P＜0.005).晶状体浑浊的部位,两组均以后皮质浑浊者为最多,差异有统计学意义(P＜0.001).晶状体的浑浊均随累积剂量的增加而增加,但在累积剂量小于20msv的各组中,2005年调查组晶状体浑浊率呈下降趋势.结论 低剂量辐射致晶状体的浑浊是随着工龄的增长和累积剂量的增加而增加,损伤的部位以后皮质为主.故必须加强放射防护。

National survey of the status of infection surveillance and control programs in acute care hospitals with more than 300 beds in the Republic of Korea

This study was conducted to assess the status of infection surveillance and control programs (ISCPs) and to analyze the trends associated with ISCP implementation since the first program was established in Korea in 1991. A questionnaire modified from the Study on the Efficacy of Nosocomial Infection Control was mailed 4 times nationwide to acute care hospitals (n = 164) with more than 300 beds between June and October 2003. Eighty-five hospitals participated (52%). The mean number of beds (649) in the responding hospitals was significantly greater than in nonresponding hospitals. Of the participating hospitals, 92% had educational functions, 40% to 90% used hand hygiene resources, and 100% had infection control committees; 86% had infection control doctors, 98% had infection control nurses (ICNs), 89% employed only 1 ICN, and 59% employed an ICN only part-time; 68% performed surveillance, undertaking 2.7 epidemic investigations per year and 8.4 teaching programs per year; 88% undertook needlestick prevention programs; 58% performed regular air culture; and 64% discarded ineffective ISCPs. Annual trends analysis of ISCPs indicated that accreditation and legislation impact strongly on Korean ISCPs. The figures for ISCPs in this study indicate that improvements have been made since the 1990s. Legislation and accreditation have strongly influenced ISCPs. Much consideration should be given to the weaknesses in Korean ISCPs: surveillance, insufficient hand hygiene resources, and shortage of ICNs.