Epidemiological Principles Research Articles

COVID-19 Highlights Critical Need for Public Health Data Modernization to Remain a Priority.

COVID-19 Highlights Critical Need for Public Health Data Modernization to Remain a Priority.

Harmonized One Health Trans-Species and Community Surveillance for Tackling Antibacterial Resistance in India: Protocol for a Mixed Methods Study

BackgroundIndia has the largest burden of drug‑resistant organisms compared with other countries around the world, including multiresistant and extremely drug‑resistant tuberculosis and resistant Gram‑negative and Gram‑positive bacteria. Antibiotic resistant bacteria are found in all living hosts and in the environment and move between hosts and ecosystems. An intricate interplay of infections, exposure to antibiotics, and disinfectants at individual and community levels among humans, animals, birds, and fishes triggers evolution and spread of resistance. The One Health framework proposes addressing antibiotic resistance as a complex multidisciplinary problem. However, the evidence base in the Indian context is limited.ObjectiveThis multisectoral, trans-species surveillance project aims to document the infection and resistance patterns of 7 resistant-priority bacteria and the risk factors for resistance following the One Health framework and geospatial epidemiology.MethodsThis hospital- and community-based surveillance adopts a cross-sectional design with mixed methodology (quantitative, qualitative, and spatial) data collection. This study is being conducted at 6 microbiology laboratories and communities in Khurda district, Odisha, India. The laboratory surveillance collects data on bacteria isolates from different hosts and their resistance patterns. The hosts for infection surveillance include humans, animals (livestock, food chain, and pet animals), birds (poultry), and freshwater fishes (not crustaceans). For eligible patients, animals, birds and fishes, detailed data from their households or farms on health care seeking (for animals, birds and fishes, the illness, and care seeking of the caretakers), antibiotic use, disinfection practices, and neighborhood exposure to infection risks will be collected. Antibiotic prescription and use patterns at hospitals and clinics, and therapeutic and nontherapeutic antibiotic and disinfectant use in farms will also be collected. Interviews with key informants from animal breeding, agriculture, and food processing will explore the perceptions, attitudes, and practices related to antibiotic use. The data analysis will follow quantitative (descriptive and analytical), qualitative, and geospatial epidemiology principles.ResultsThe study was funded in May 2019 and approved by Institute Ethics Committees in March 2019. The data collection started in September 2019 and shall continue till March 2021. As of June 2020, data for 56 humans, 30 animals and birds, and fishes from 10 ponds have been collected. Data analysis is yet to be done.ConclusionsThis study will inform about the bacterial infection and resistance epidemiology among different hosts, the risk factors for infection, and resistance transmission. In addition, it will identify the potential triggers and levers for further exploration and action.International Registered Report Identifier (IRRID)DERR1-10.2196/23241

Principles of studying low-level neurotoxic exposures in children: using the Seychelles Child Development Study of methyl mercury as a prototype

Epidemiological studies to determine the impact of low level toxic exposure on child development are important in guiding clinical and public health action. However, carrying out such studies and interpreting their findings presents a number of significant challenges to the investigators. First, they must find a cohort with suitable exposure, select a biomarker that will accurately determine the level of exposure and determine the endpoints that are most likely to detect subtle differences in neurodevelopment. Following that, the logistics of the study must be organised and collaboration established with the local population and health authorities. To accurately interpret the data, they must also accurately determine covariates that impact child development. After the data are collected, interpreting the findings presents a further challenge. Throughout this process, the study must adhere to fundamental epidemiological principles and clearly defined statistical approaches. This paper discusses those principles and uses the Seychelles Child Development Study to show how one epidemiological study addressed them.

The epidemiology of moral bioenhancement

In their 2008 paper, Persson and Savulescu suggest that for moral bioenhancement (MBE) to be effective at eliminating the danger of ‘ultimate harm’ the intervention would need to be compulsory. This is because those most in need of MBE would be least likely to undergo the intervention voluntarily. By drawing on concepts and theories from epidemiology, this paper will suggest that MBE may not need to be universal and compulsory to be effective at significantly improving the collective moral standing of a human populace and reducing the threat of ultimate harm. It will identify similarities between the mechanisms that allow biological contagions (such as a virus) and behaviours (such as those concerned with ethical and unethical actions) to develop, spread, and be reinforced within a population. It will then go onto suggest that, just as with the epidemiological principle of herd immunity, if enough people underwent MBE to reach a minimum threshold then the incidence and spread of immoral behaviours could be significantly reduced, even in those who have not received MBE.

An assessment of the Armenian national midwifery curriculum as per international standards

Abstract Background Literature suggests increasing evidence that incompetent midwifery education results in poor quality of care. The study compared and evaluated the level of compliance of the Armenian national criterion on midwifery with the global competency standards and developed recommendations for improvement. Methods The study team conducted a document review using a standardized checklist, which was adapted from the International Confederation of Midwives (ICM) core assessment tools. The document review explored if the main knowledge and skills/ability related elements of each ICM competency were separately covered by different modules of the national criterion using a scoring system with categories: not met, partially met, fully met and unspecified. Results Although the national criterion did not have specifically defined competencies, most of the elements required by the ICM were present as specific learning outcomes under different modules of the criterion. Midwifery program curriculum was described as intensive with unnecessarily heavy workload. Additionally, the document review reviled that most of the learning outcome defined in modules of the national criterion focused more on theoretical knowledge rather than practical skills and abilities. Overall, the ICM required competency in provision of care during pregnancy was the most comprehensively covered one in the national criterion, while the competency in facilitation of abortion related care was the lowest covered. National criterion did not highlight the importance of topics such as women's rights and health, principles of epidemiology, statistical methods of research, cultural, local and ethical beliefs. Conclusions The systematic comparison of the national criterion with internationally recognized essential competencies demonstrates significant gaps. The study team recommends revisions to the national criterion to make it competency based. Key messages Midwifery education criteria in Armenia did not reflect internationally accepted midwifery competency’s fundamental philosophy and values. Given the shortcomings of the current national midwifery education criterion, a comprehensive revision of the competencies of midwives in Armenia should be considered.

Metabolic disease testing on farms: epidemiological principles

Background: Although many clinical metabolic diseases have been successfully controlled in modern dairy herds, subclinical metabolic diseases are often prevalent and associated with significant economic losses. Given the absence of...

An action research to improve social health insurance coverage of Philippines’ informal sector

Abstract Background PhilHealth, the social health insurance (SHI) agency of the Philippines, still does not sufficiently cover the informal sector workers (ISWs) - or the “missing middle”. Previous approaches had limited success. The impetus for finding solutions to protect the missing middle still remains. Methods A multi-component action research was done to address the complex social problem. Literature review and interviews were conducted to understand the nature of ISWs. National survey data was analyzed for factors affecting the ISWs' membership and retention in SHI. Findings were triangulated to construct evidence-based and context-rich marketing personas to understand PhilHealth's target clients. Using Human-Centered Design Thinking (HCDT), solutions that aim to address the low retention of ISWs in health insurance (HI) were proposed. Results The exact nature of ISWs is still unknown. Costly insurance premiums, poor knowledge of SHI, low perceived value of SHI, and inconvenient payment mechanisms contribute to low participation in SHI. Every additional 1000 PHP (∼20 USD) income increases odds of being an active member by 4%. Those who access private facilities are 2.8 times more likely to be active members. Those who perceive themselves to be sickly were 52% more likely to drop-out of the insurance. The results were fed into the HCDT process producing four prototypes: 1) solutions that explore partnership of PhilHealth with other organizations, 2) use of mobile application platforms for payment and member status updates, 3) automated algorithm to identify and calculate fair premiums, and 4) integration of money-saving strategies. Conclusions The government needs to step-up current efforts to extend health financial risk protection for the ISWs. PhilHealth can take advantage of the research results by testing the prototypes produced, and by adopting the HCDT process to improve their service and coverage for the informal sector. Key messages This government-funded project integrated principles of public health, epidemiology, health financing, participatory governance, and implementation research to address a complex social problem. The results provide a better understanding of the informal sector workers’ nature and needs with regards health insurance and can help PhilHealth improve coverage of informal sector workers.

Abstract IA23: Opportunities and lessons learned from the Cancer Research Network

Abstract Using health care systems data for research and care improvement is of intense interest. The now widespread availability of electronic health records (EHRs) holds great promise for population sciences cancer research. Founded in 1999, the Cancer Research Network (CRN) is a consortium of a dozen research groups affiliated with US integrated health care systems. CRN health care systems are pioneers in use of data systems to document and inform administrative and clinical aspects of health care. In addition to administrative (e.g., claims) data, the clinical databases of CRN health systems capture details of care that have generally not been available until the advent of EHRs. In most CRN health systems, such databases have been in use since at least the mid-1990s, with adoption of EHRs in the mid-2000s. CRN researchers developed the Virtual Data Warehouse (VDW) common data model to facilitate collaborative, multi-institution research. The VDW, with standardized data tables, variable names, and formats implemented at each participating research group, enables efficient multi-institution research collaborations. From a cancer research perspective, the VDW is also one of the only EHR-based common data models with tumor registry data of comparable quality to that of the SEER Program. Infusion medication data are also available in the VDW, and inclusion of results of clinical genetic and molecular tests is in development. The VDW is updated regularly, monthly or more frequently in most CRN institutions for most data domains. Advantages of conducting cancer research in the CRN setting include the ability to identify a “denominator” population, and the capture of primary and specialty care. Retention of health plan enrollees is high in CRN health systems, enabling longitudinal research. In most US health care settings, the population eligible to receive care cannot be identified, and data may be available for some, but not all, episodes of care. For example, tertiary-care cancer centers may have details on cancer treatment, but not information from primary care or other specialty care encounters. However, it is important to use caution because EHR data result from clinical encounters and associated activity and are not collected for research purposes; missingness is unlikely to be random and confounding by indication is an analytic and interpretational issue. Collaborative, efficient use of these data also requires navigating regulatory concerns. The federated nature of the VDW minimizes HIPAA-related privacy concerns, while agreed-upon human subjects and data use procedures facilitate collaborations. The CRN provides unparalleled opportunities for research across the full range of the cancer experience, from primary prevention to end of life, incorporating data from EHRs and other clinical and administrative databases. Use of these data and adherence to epidemiologic principles in the design of studies and their analysis and interpretation can greatly advance knowledge to decrease the burden of cancer. Citation Format: Lawrence H. Kushi, Jeffrey S. Brown, Diana S.M. Buist, Jessica Chubak, V. Paul Doria-Rose, Kathleen M. Mazor. Opportunities and lessons learned from the Cancer Research Network [abstract]. In: Proceedings of the AACR Special Conference on Modernizing Population Sciences in the Digital Age; 2019 Feb 19-22; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(9 Suppl):Abstract nr IA23.

Хроническая ишемия мозга: обзор публикаций, патогенетические подходы к терапии

Chronic сеrebral ischemia is one of the leading causes of morbidity, mortality and disability in the Republic of Kazakhstan. According to the data from Ministry of Healthcare of the Republic of Kazakhstan, the overall morbidity of the country’s population due to diseases of the circulatory system registered in health care organizations has increased almost three times from 1998 to 2017 over the past 20 years. According to world publications, on average, the incidence of Chronic сеrebral ischemia in the world is relatively high among the elderly, occurring in two-thirds of people over 65 years of age. It is also observed in 50% of people aged 50 to 65 years and in 25% of people aged 45 to 50 years. Purpose. To review of epidemiological data, risk factors, causes, pathogenetic mechanisms, diagnostic algorithms and principles of treatment of Chronic сеrebral ischemia. Material and methods. The literature review on Chronic сеrebral ischemia data was conducted using the Pubmed search engine in Medline electronic databases from 2009 to 2019. Results and discussion. A total of 45 research papers were included. This review examines epidemiological data, risk factors, causes, pathogenetic mechanisms, diagnostic algorithms and principles of therapy for Chronic сеrebral ischemia disease. In the etiopathogenesis of Chronic сеrebral ischemia, a significant part is played by the combination of risk factors known as vascular comorbidity and being the main cause of deaths. Vascular comorbidity is characterized by the involvement into a single pathological process of all risk factors that form Chronic сеrebral ischemia, which lead to a change in cerebral circulation with hypoxia of the brain substance and a cascade of biochemical changes, and subsequently results in diffuse, multi-focal changes in the brain substance. In a case of comorbidity of the atherosclerotic process with dyslipidemia, narrowing of the lumen of the arteries with an increase in the permeability of their wall membranes can be observed, with further damage to the endothelium, activation of synthesis by leukocytes, platelets, endotheliocytes of chemotaxis factors, kinins, growth factors, with the accumulation of active oxygen, peroxidation with the formation of oxidative stress. Chronic сеrebral ischemia therapy with vascular comorbidity, in which all risk factors are В тексте переправлены стилистические и ортографические ошибки. involved in a single pathological process, provides the prevention of polypragmasia, and the assignment of certain pathogenetic drugs aimed at the same pathogenesis that leads to the formation of Chronic сеrebral ischemia. Conclusion. It is most rational to use an antioxidant/antihypoxant in therapy. Such pathogenetic drugs include antioxidant therapy. Among other antioxidants/antihypoxants used in routine practice, Mexidol (ethylmethylhydroxypyridine succinate) is characterized with the strongest evidence base. Keyword: chronic brain ischemia, chronic cerebral circulatory insufficiency, vascular comorbidity, ethylmethylhydroxypyridine succinate, Mexidol.

Demonstrating the Benefits of Predictive Bayesian Dose-Response Relationships Using Six Exposure Studies of Cryptosporidium parvum.

A conventional dose-response function can be refitted as additional data become available. A predictive dose-response function in contrast does not require a curve-fitting step, only additional data and presents the unconditional probabilities of illness, reflecting the level of information it contains. In contrast, the predictive Bayesian dose-response function becomes progressively less conservative as more information is included. This investigation evaluated the potential for using predictive Bayesian methods to develop a dose-response for human infection that improves on existing models, to show how predictive Bayesian statistical methods can utilize additional data, and expand the Bayesian methods for a broad audience including those concerned about an oversimplification of dose-response curve use in quantitative microbial risk assessment (QMRA). This study used a dose-response relationship incorporating six separate data sets for Cryptosporidium parvum. A Pareto II distribution with known priors was applied to one of the six data sets to calibrate the model, while the others were used for subsequent updating. While epidemiological principles indicate that local variations, host susceptibility, and organism strain virulence may vary, the six data sets all appear to be well characterized using the Bayesian approach. The adaptable model was applied to an existing data set for Campylobacter jejuni for model validation purposes, which yielded results that demonstrate the ability to analyze a dose-response function with limited data using and update those relationships with new data. An analysis of the goodness of fit compared to the beta-Poisson methods also demonstrated correlation between the predictive Bayesian model and the data.

Covid-19 on the Alert: The Delay in Question – Commentary

A scientist, who elaborates on the ongoing pandemic, will rarely miss the opportunity to mention an epidemiological principle based on the consensus. As a rule, he adheres, like a majority of his colleagues, to the credo that, if an alarm is given that will lead to a flare-up of COVID-19, a lag of 2-3 weeks will necessarily intervene between the heralding incident(s) and the outburst. The present commentary is meant to find out, whether the above concept may be validated, and if we can determine the nature of these gaps and of their causes.

From R<sub>0</sub> to the Herd: A Review of <em>The Rules of Contagion</em>, by Adam Kucharski

Adam Kucharski. 2020. The Rules of Contagion: Why Things Spread--and Why They Stop; (London: Profile Books, Ltd.). Hardback ISBN 978-17-88-16019-3. E-book ISBN 978-17-82-83430-4. Kucharski's well-timed Rules of Contagion provides an introduction to the mathematical and epidemiological principles behind contagious phenomenon. While the author's primary expertise stems from work on biological epidemics, the book points to examples from a wide range of fields including finance, psychology, computer science, and criminology. As such, selections of the book could be used by faculty in a wide range of classes to show how our recent experience with a viral epidemic might add to our understanding of a diverse set of questions. While the book points to models behind epidemiological work, those who want an explicit treatment will need to draw that material from other available sources.

Evidence about the Chest CT diagnostic performance in the pandemic of SARS-CoV-2 infection: A smooth takeoff and hard landing.

According to all guidelines, the unique criterion for the diagnosis of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the viral nucleic acid test by reverse transcription polymerase chain reaction (RT-PCR). That should always guide the isolation decision and the management conduction [1]. SARS-CoV-2 related pneumonia may manifest after 2 to 4 days following the coronavirus infection. Typical computed tomography (CT) feature of coronavirus (COVID-19) lung disease is the bilateral , peripheric or diffuse and patchy ground-glass opacities(GGO) with consolidations. Several other signs such as crazy paving pattern , interstitial thickening, reversed-halo or microvascular embolisms are less likely described and may evoke COVID-19 pneumonia in an appropriate context. The chest CT could be initially normal. The GGO have tendency of quick evolution till the seventh day and stabilize later till the 20th day of the COVID-19 infection. Lung lesions in severe cases involve more lung segments with larger sized GGO. the interlobular septal thickening and consolidations are constant. The pleural effusion and pneumothorax were rarely described [2]. The lack of sensitivity, insufficient stability, and relatively long processing time of RT-PCR gave a considerable place for the chest CT in the daily practice of COVID-19 patients. Several reports found exciting the confrontation between the CT and the RT-PCR results. The sensitivity of CT features in highly pandemic areas could reach 97%. The earlier CT chest signs and the improvement of pulmonary lesions before RT-PCR negativity made some authors recommend the CT chest as diagnostic screening tool [3-5]. However, we still believe that the recommendation of the CT as a new diagnostic tool could not be based only on likelihood ratios and temporary concordance with the reference gold standard test. The respect of the basic epidemiologic principles is always mandatory to enhance the conclusion’s value. These recommendations were not born from blinded comparison with the refence test such in controlled randomized trials. To avoid time-lead bias many studies did not consider other potential bias especially the confusion and the selection. Moreover, the CT result did not influence the decision of proceeding to the reference test in all the previous reports. In this pandemic era, a chest CT examination will include not only additional cost for personal protective equipment (PPE) and sterilization but also more risk for the radiology department staff [6]. The chest CT could be used to select patients candidate for RT-PCR. Its value in the management and the follow up of pulmonary lesions cannot be overstated. It could play a role in clinical decision making when the gold standard test is not available in highly pandemic areas. Most of the radiology societies all over the world were not recommending the CT as diagnostic test especially in large scale screening. The few metaanalysis available have discordant conclusions about the topic. Upcoming evidence-based reports should contribute more to that [7,8].

COVID-19 Trends and Forecast in the Eastern Mediterranean Region With a Particular Focus on Pakistan.

First reported in China, the coronavirus responsible for coronavirus disease 2019 (COVID-19) has spread to 213 countries and territories around the world as of April 26, 2020. This study was designed to explore COVID-19 trends in the Eastern Mediterranean Region (EMR), with a particular focus on Pakistan. Daily reports and updates from the Ministry of National Health Services Regulations and Coordination COVID-19 Pakistan and the European Centre for Disease Prevention and Control were collected and study-specific data were extracted and analyzed. Our analysis revealed that, as of April 26, 2020, a total of 22 countries and territories in the EMR have reported COVID-19 cases. Iran had the highest number of cases (89,329) followed by Saudi Arabia (16,299), Pakistan (12,723), and the United Arab Emirates (9,813). Egypt (7.1%), Iran (6.3%), and Iraq (4.9%) had high case fatality rates; Lebanon (3.4%) and Pakistan (2.1%) had moderate case fatality rates; Saudi Arabia and the United Arab Emirates had low case fatality rates of 0.8% and 0.7%, respectively. Iran (76.3%) and Iraq (69.4 %) had the highest recovery rate followed by Pakistan (22.5%), the United Arab Emirates (19.2%), and Saudi Arabia (13.6%). If the current trend continues, based on the susceptible, infected, recovered (SIR) epidemiological model, we predict that EMR countries might experience a surge in the number of COVID-19 cases, resulting in as many as 2.12 million cases in Iran, 0.58 million in Saudi Arabia, and 0.51 million in Pakistan by June 20, 2020. Pakistan is the most populated country in the EMR and was the third most-affected country in terms of the number of cases with moderate case fatality and recovery rates. We predict that Pakistan’s weak healthcare system would not be able to sustain care if there is an explosive increase in the number of cases due to insufficient and inconsistent disease prevention and control policies. The best strategy for mitigating the COVID-19 pandemic is to strictly follow recommendations based on epidemiological principles.

Imaging Publications in the COVID-19 Pandemic: Applying New Research Results to Clinical Practice.

Online supplemental material is available for this article.

The epidemiologist and the pandemic

Like Cholera outbreak of London in 1854, Spanish flu in 1920 or many other pandemic and epidemics thereafter including the current pandemic of COVID 19, it has again reminded to the world about the role of epidemiologist and epidemiological principles in controlling any such event where there is no cure available and thus saving the mankind. It points towards the urgent need of strengthening our public health infrastructure. This should be started with recruitment of competent epidemiologists on priority at district, state and country level. We should make use of full potential of members of IPHA and IAPSM mainly by providing data and help in policy making. This would help in developing capacity for timely action in best interest of our population for any threat of outbreak, epidemic or pandemic in current scenario and in future.

Trauma informed education for specialist practice

Trauma experienced in childhood and adolescence can have a lifelong impact upon an individual's physical and mental health. Therefore, the integration of trauma-informed education, within SCPHN training programmes was considered, in order to ensure school nurses, have the essential knowledge and skills, required to effectively deliver trauma-informed care within their role in practice. This involved utilising a combination of theoretical frameworks such as life-course epidemiology, psychosocial epidemiology and trauma-informed principles in conjunction with a variety of pedagogies such as social constructivism, experiential learning and a strengths-based approach.

The Application of Epidemiology for Categorising DNS Cyber Risk Factors

This Epidemiology can be applied to cybersecurity as a novel approach for analysing and detecting cyber threats and their risks. It provides a systematic model for the analysis of likelihood, consequence, management, and prevention measures to examine malicious behaviours like disease. There are a few research studies in discrete cybersecurity risk factors; however, there is a significant research gap on the analysis of collective cyber risk factors and measuring their cyber risk impacts. Effective cybersecurity risk management requires the identification and estimation of the probability of infection, based on a comprehensive range of historical and environmental factors, including human behaviour and technology characteristics. This paper explores how an epidemiological principle can be applied to identify cybersecurity risk factors. These risk factors comprise both human and machine behaviours profiled as risk factors. This paper conducts a preliminary analysis of the relationships between these risk factors utilising Domain Name System (DNS) data sources. The experimental results indicated that the epidemiological principle can effectively examine and estimate cyber risk factors. The proposed principle has a great potential in enhancing new machine learning-enabled intrusion detection solutions by utilising this principle as a risk assessment module of the solutions.

Chinese consensus on the diagnosis and management of adult candidiasis

In this consensus we mainly present the etiology, epidemiology, risk factors, microbiology, clinical diagnosis and general principles of treatment, as well as the detailed diagnosis and treatment of common candidiasis. Though mucocutaneous candidiasis such as oral, esophageal and vulvovaginal infections are known as non-invasive diseases, they are included in this consensus, considering their high prevalence and the potential to be the source of systematic infections.In order to be accordant with the practical situation in China, new technologies and drugs that have not been well developed or routinely applied are not recommended in this consensus. As to the differences from foreign guidelines, we address the explanations. Individualized treatment and management should be administrated based on the specific underlying conditions, organism distribution and drug resistance profile of Candida species.

A Review of Vaccine Efficacy Measures

To fully understand the assessments of vaccine efficacy and safety, the crucial information needed for regulatory approval, one must understand the principles of vaccine epidemiology. In this review article, we go through some of the key concepts in vaccine epidemiology