High Case Fatality Ratio Research Articles

Infectious disease outbreaks in the African region: overview of events reported to the World Health Organization in 2018.

The WHO African region is characterised by the largest infectious disease burden in the world. We conducted a retrospective descriptive analysis using records of all infectious disease outbreaks formally reported to the WHO in 2018 by Member States of the African region. We analysed the spatio-temporal distribution, the notification delay as well as the morbidity and mortality associated with these outbreaks. In 2018, 96 new disease outbreaks were reported across 36 of the 47 Member States. The most commonly reported disease outbreak was cholera which accounted for 20.8% (n = 20) of all events, followed by measles (n = 11, 11.5%) and Yellow fever (n = 7, 7.3%). About a quarter of the outbreaks (n = 23) were reported following signals detected through media monitoring conducted at the WHO regional office for Africa. The median delay between the disease onset and WHO notification was 16 days (range: 0-184). A total of 107 167 people were directly affected including 1221 deaths (mean case fatality ratio (CFR): 1.14% (95% confidence interval (CI) 1.07%-1.20%)). The highest CFR was observed for diseases targeted for eradication or elimination: 3.45% (95% CI 0.89%-10.45%). The African region remains prone to outbreaks of infectious diseases. It is therefore critical that Member States improve their capacities to rapidly detect, report and respond to public health events.

Seasonal upsurge of pneumococcal meningitis in the Central African Republic

A high incidence of bacterial meningitis was observed in the Central African Republic(CAR) from December 2015 to May 2017 in three hospitals in the northwest ofthe country that are within the African meningitis belt. The majority of cases were caused by Streptococcus pneumoniae (249/328; 75.9%), which occurred disproportionatelyduring the dry season (November-April) with a high case-fatality ratioof 41.6% (95% confidence interval [CI] 33.0, 50.8%). High rates of bacterial meningitis during the dry season in the meningitis belt have typically been caused by Neisseriameningitidis (meningococcal meningitis), and our observations suggest that therisk of contracting S. pneumoniae (pneumococcal) meningitis is increased by thesame environmental factors. Cases of meningococcal meningitis (67/328; 20.4%)observed over the same period were predominantly group W and had a lower casefatality rate of 9.6% (95% CI 3.6, 21.8%). Due to conflict and difficulties in accessingmedical facilities, it is likely that the reported cases represented only asmall proportion of the overall burden. Nationwide vaccination campaignsin the CAR against meningitis have been limited to the use of MenAfriVac, whichtargets only meningococcal meningitis group A. We therefore highlight the need forexpanded vaccine coverage to prevent additional causes of seasonal outbreaks.

Emergence of Localized Serogroup W Meningococcal Disease in the United States - Georgia, 2006-2016.

Several countries in Europe and Australia are reporting an increasing incidence of Neisseria meningitidis serogroup W (NmW) as a consequence of the rapid expansion of a single NmW clone belonging to clonal complex 11 (1–5). Because this clone is reported to be associated with more severe disease, unusual clinical presentations, and a high case fatality ratio (CFR), it is considered a hypervirulent strain (1,6). In the United States, NmW accounts for approximately 5% of meningococcal disease reported each year, and this proportion has remained stable for several years (7). However, localized increases in NmW have been reported, most notably in Florida during 2008–2009 (8). In Georgia, NmW accounted for only 3% of meningococcal disease cases reported during 2006–2013; however, between January 2014 and December 2016, 42% of all reported cases were NmW. Surveillance data from Georgia were analyzed to describe the epidemiology and clinical characteristics of NmW cases, and whole-genome sequencing of NmW isolates was performed for comparison with NmW strains circulating in the United States and worldwide. These data indicate that the U.S. NmW strains might have evolved from the same ancestor as the hypervirulent strain that is circulating globally. Genetic analysis demonstrates that these strains are closely related, which would suggest that genetic variation led to the rise of different strains from the same ancestor. Given the recent global expansion of this potentially hypervirulent NmW lineage, clinicians and public health officials need to remain vigilant in obtaining isolates to monitor changes in circulating strains.

Study of histopathologic patterns of borderline and malignant ovarian tumor

Introduction: Ovarian cancer is the cause of a high case-fatality ratio, and most of the cases are diagnosed in late stages. Aims and objectives: To find the frequency of different types of histomorphological types and their correlation with age, side and size distribution and how it helps in managements of these lesions. Methodology: A retrospective analysis of all malignant ovarian tumours received and processed at the Pathology Department of Hassan institute of medical sciences. Results: The ovarian tumours included 22 borderline and malignant cases. Surface epithelial tumours (Borderline and malignant tumours) was the most common accounting for 56.6%. Next common group was Sex cord stromal tumours constituting 26.1% followed by Germ cell tumours accounting for 17.3%. Conclusion: There was single case of Tertoma, Endometrioid carcinoma and Malignant mixed germ cell tumour constituting 4.3%. Maximum number of cases occurred in 4th decade of life.

Histopathological Pattern and Age Distribution, of Malignant Ovarian Tumor among Sudanese Ladies.

INTRODUCTION:Ovarian cancer is the cause of a high case-fatality ratio, and most of the cases are diagnosed in late stages.OBJECTIVES:To determine the histopathological types, age distribution, and ovarian tumour stages among diagnosed with ovarian cancer at Al - Amal Tower a multi-referral polyclinic of Radiology & Isotope Center Khartoum (RICK), Sudan.METHODS:All histopathology reports patients’ case from January to June 2015 were reviewed. The cancers classified according to federation international of Obstetrics and Gynecology (FIGO).RESULTS:There were 127 cases of ovarian cancers. Surface epithelial cancers were the most common 77.7% (n = 98), followed by sex cord-stromal cancers 11.23% (n = 14), Germ cell tumor 1.6% (n = 2). Metastatic cancers were seen from colon and breast in 6.3% and 3.9 % of cases respectively. Few cases (14%) of ovarian cancers were reported before 40 years of age, after the age of 50 is a sharp increase in the incidence of a tumour. The mean age at presentation was 52.36 ± 14.210 years, there is mean age of menarche 13.59 ± 2.706 years. Very few patients used HRT (1.6%) or had been on ovulation induction treatment (8.7%). Most of patients 39 (30.7%) presented in stage IIIC, and stage 1V 32 (25.2%) indicating a poor prognosis.CONCLUSION:The incidence of different types of ovarian cancers in the present study is similar to worldwide incidence. The surface epithelial tumour is the commonest ovarian cancer, of which serous adenocarcinoma is the commonest and most of our patients present in late stages.

Multi-site cholera surveillance within the African Cholera Surveillance Network shows endemicity in Mozambique, 2011-2015.

BackgroundMozambique suffers recurrent annual cholera outbreaks especially during the rainy season between October to March. The African Cholera Surveillance Network (Africhol) was implemented in Mozambique in 2011 to generate accurate detailed surveillance data to support appropriate interventions for cholera control and prevention in the country.Methodology/Principal findingsAfrichol was implemented in enhanced surveillance zones located in the provinces of Sofala (Beira), Zambézia (District Mocuba), and Cabo Delgado (Pemba City). Data were also analyzed from the three outbreak areas that experienced the greatest number of cases during the time period under observation (in the districts of Cuamba, Montepuez, and Nampula). Rectal swabs were collected from suspected cases for identification of Vibrio cholerae, as well as clinical, behavioral, and socio-demographic variables. We analyzed factors associated with confirmed, hospitalized, and fatal cholera using multivariate logistic regression models.A total of 1,863 suspected cases and 23 deaths (case fatality ratio (CFR), 1.2%) were reported from October 2011 to December 2015. Among these suspected cases, 52.2% were tested of which 23.5% were positive for Vibrio cholerae O1 Ogawa. Risk factors independently associated with the occurrence of confirmed cholera were living in Nampula city district, the year 2014, human immunodeficiency virus infection, and the primary water source for drinking.Conclusions/SignificanceCholera was endemic in Mozambique during the study period with a high CFR and identifiable risk factors. The study reinforces the importance of continued cholera surveillance, including a strong laboratory component. The results enhanced our understanding of the need to target priority areas and at-risk populations for interventions including oral cholera vaccine (OCV) use, and assess the impact of prevention and control strategies. Our data were instrumental in informing integrated prevention and control efforts during major cholera outbreaks in recent years.

Abstract KP01: UNITED KINGDOM COLLABORATIVE TRIAL OF OVARIAN CANCER SCREENING – (UKCTOCS) – EXPLORING THE RESULTS

Abstract The continued high case fatality ratio in ovarian cancer has underpinned efforts to develop a screening strategy that could impact on mortality. In the general population randomised control trial - United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) two screening strategies (multimodal MMS and ultrasound USS) were compared to no screening (control C). Of 202,638 women randomised between April 2001-October 2005, 50,624 MMS; 50,623 USS; and 101,299 C were eligible for analysis. By the end of screening (December 2011) 345,570 MMS and 327,775 USS annual screens were performed. At censorship for the initial mortality analysis on 31st December 2014, there was an overall significant stage shift in invasive epithelial ovarian/tubal/peritoneal cancer in the MMS group compared to C in an ‘intention to screen’ analysis. More detailed analysis has shown this stage shift seen in the MMS group was limited to Type II (high grade serous) ovarian cancers. This was associated with a delayed but not yet statistically significant mortality reduction. Disease specific mortality rates in the C arm were continuing to rise while they appeared to have plateaued in the screen arms. Further follow-up is now underway to confirm the mortality reduction and determine its full extent. Meanwhile a focus on detecting low volume disease using cancer specific markers, novel biospecimens such as endocervical samples, targeted imaging and time series algorithms for interpreting marker profile suggest that a new era in ovarian cancer screening is underway. Citation Format: Usha Menon. UNITED KINGDOM COLLABORATIVE TRIAL OF OVARIAN CANCER SCREENING – (UKCTOCS) – EXPLORING THE RESULTS [abstract]. In: Proceedings of the 11th Biennial Ovarian Cancer Research Symposium; Sep 12-13, 2016; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(11 Suppl):Abstract nr KP01.

Chest Radiograph Findings in Childhood Pneumonia Cases From the Multisite PERCH Study.

Chest radiographs (CXRs) are frequently used to assess pneumonia cases. Variations in CXR appearances between epidemiological settings and their correlation with clinical signs are not well documented. The Pneumonia Etiology Research for Child Health project enrolled 4232 cases of hospitalized World Health Organization (WHO)-defined severe and very severe pneumonia from 9 sites in 7 countries (Bangladesh, the Gambia, Kenya, Mali, South Africa, Thailand, and Zambia). At admission, each case underwent a standardized assessment of clinical signs and pneumonia risk factors by trained health personnel, and a CXR was taken that was interpreted using the standardized WHO methodology. CXRs were categorized as abnormal (consolidation and/or other infiltrate), normal, or uninterpretable. CXRs were interpretable in 3587 (85%) cases, of which 1935 (54%) were abnormal (site range, 35%-64%). Cases with abnormal CXRs were more likely than those with normal CXRs to have hypoxemia (45% vs 26%), crackles (69% vs 62%), tachypnea (85% vs 80%), or fever (20% vs 16%) and less likely to have wheeze (30% vs 38%; all P < .05). CXR consolidation was associated with a higher case fatality ratio at 30-day follow-up (13.5%) compared to other infiltrate (4.7%) or normal (4.9%) CXRs. Clinically diagnosed pneumonia cases with abnormal CXRs were more likely to have signs typically associated with pneumonia. However, CXR-normal cases were common, and clinical signs considered indicative of pneumonia were present in substantial proportions of these cases. CXR-consolidation cases represent a group with an increased likelihood of death at 30 days post-discharge.

The cause-specific morbidity and mortality, and referral patterns of all neonates admitted to a tertiary referral hospital in the northern provinces of Vietnam over a one year period

ObjectiveTo describe the cause-specific morbidity and mortality, and referral patterns of all neonates admitted to a tertiary referral hospital in the northern provinces of Vietnam.DesignA prospective hospital based observational study.SettingThe Neonatal Department, National Hospital of Pediatrics, Hanoi, Vietnam.PatientsAll admissions to the Neonatal Department over a 12 month period.Main outcome measuresCause-specific morbidity and mortality; deaths.ResultsThere were 5064 admissions with the commonest discharge diagnoses being infection (32%) and prematurity (29%). The case fatality ratio (CFR) was 13.9% (n = 703). Infection (38%), cardio/respiratory disorders (27%), congenital abnormalities (20%) and neurological conditions (10%) were the main causes of death. Of all the deaths, 38% had an admission weight ≥2500g. Higher CFR were associated with lower admission weights. Very few deaths (3%) occurred in the first 24 hours of life. Most referrals and deaths came from Hanoi and neighbouring provincial hospitals, with few from the most distant provinces. Two distant referral provinces had the highest CFR.ConclusionsThe CFR was high and few deaths occurred in neonates <24 hours old. The high rates of infection call for an improvement in infection control practices and peripartum antibiotic use at provincial and tertiary level. Understanding provincial hospital capacity and referral pathways is crucial to improving the outcomes at tertiary centres. A quality of care audit tool would enable more targeted interventions and monitoring of health outcomes.

Filoviruses and bats.

While Reston and Lloviu viruses have never been associated with human disease, the other filoviruses cause outbreaks of hemorrhagic fever characterised by person-to-person transmission and high case fatality ratios. Cumulative evidence suggests that bats are the most likely reservoir hosts of the filoviruses. Ecological investigations following Marburg virus disease outbreaks associated with entry into caves inhabited by Rousettus aegyptiacus bats led to the identification of this bat species as the natural reservoir host of the marburgviruses. Experimental infection of R. aegyptiacus with Marburg virus has provided insight into the natural history of filovirus infection in bats that may help guide the search for the reservoir hosts of the ebolaviruses.

Risk factors for death during a resurgence of influenza-A (H1N1) pdm09 in Punjab State in 2013.

In 2013, high mortality from influenza-A (H1N1) pdm09 (pH1N1) was observed in Punjab, India. To describe cases and deaths of 2013 pH1N1 positives, to evaluate the high case fatality ratio and risk factors for pH1N1-associated mortality among the hospitalized cases in Punjab for 2013. A case-control study was conducted and compared those who died from confirmed pH1N1 with those who survived in the hospital between January 1, 2013, and April 30, 2013. Sociodemographic and clinical details were extracted from hospital records and from telephone interviews with controls and next of kin of cases using pretested questionnaires. Logistic regression analysis was performed. A total of 182 laboratory-confirmed pH1N1 cases (99 males and 83 females) were hospitalized in 30 hospitals in Punjab; 42 (23%) patients died. Those who died were significantly more likely to be younger than 50 years of age (adjusted odds ratio [AOR] =10.6, 95% confidence interval [CI] =1.8-21.1), be obese (AOR = 16.7, 95% CI = 1.6-170.7), and have visited more than two health-care facilities before laboratory confirmation (AOR = 25.8, 95% CI = 5.4-121.6). The health-care community should have a high index of suspicion for influenza, and general community should be sensitized about risk factors and to seek medical advice early in the illness.

Severe Fever with Thrombocytopenia Syndrome in South Korea, 2013-2015.

BackgroundSevere fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease that was recently identified in China, South Korea and Japan. The objective of the study was to evaluate the epidemiologic and clinical characteristics of SFTS in South Korea.Methods/Principal FindingsSFTS is a reportable disease in South Korea. We included all SFTS cases reported to the Korea Centers for Disease Control and Prevention (KCDC) from January 2013 to December 2015. Clinical information was gathered by reviewing medical records, and epidemiologic characteristics were analyzed using both KCDC surveillance data and patient medical records. Risk factors for mortality in patients with SFTS were assessed. A total of 172 SFTS cases were reported during the study period. SFTS occurred throughout the country, except in urban areas. Hilly areas in the eastern and southeastern regions and Jeju island (incidence, 1.26 cases /105 person-years) were the main endemic areas. The yearly incidence increased from 36 cases in 2013 to 81 cases in 2015. Most cases occurred from May to October. The overall case fatality ratio was 32.6%. The clinical progression was similar to the 3 phases reported in China: fever, multi-organ dysfunction, and convalescence. Confusion, elevated C-reactive protein, and prolonged activated partial thromboplastin times were associated with mortality in patients with SFTS. Two outbreaks of nosocomial SFTS transmission were observed.ConclusionsSFTS is an endemic disease in South Korea, with a nationwide distribution and a high case-fatality ratio. Confusion, elevated levels of C-reactive protein, and prolonged activated partial thromboplastin times were associated with mortality in patients with SFTS.

Cholera in Cameroon, 2000-2012: Spatial and Temporal Analysis at the Operational (Health District) and Sub Climate Levels.

IntroductionRecurrent cholera outbreaks have been reported in Cameroon since 1971. However, case fatality ratios remain high, and we do not have an optimal understanding of the epidemiology of the disease, due in part to the diversity of Cameroon’s climate subzones and a lack of comprehensive data at the health district level.Methods/FindingsA unique health district level dataset of reported cholera case numbers and related deaths from 2000–2012, obtained from the Ministry of Public Health of Cameroon and World Health Organization (WHO) country office, served as the basis for the analysis. During this time period, 43,474 cholera cases were reported: 1748 were fatal (mean annual case fatality ratio of 7.9%), with an attack rate of 17.9 reported cases per 100,000 inhabitants per year. Outbreaks occurred in three waves during the 13-year time period, with the highest case fatality ratios at the beginning of each wave. Seasonal patterns of illness differed strikingly between climate subzones (Sudano-Sahelian, Tropical Humid, Guinea Equatorial, and Equatorial Monsoon). In the northern Sudano-Sahelian subzone, highest number of cases tended to occur during the rainy season (July-September). The southern Equatorial Monsoon subzone reported cases year-round, with the lowest numbers during peak rainfall (July-September). A spatial clustering analysis identified multiple clusters of high incidence health districts during 2010 and 2011, which were the 2 years with the highest annual attack rates. A spatiotemporal autoregressive Poisson regression model fit to the 2010–2011 data identified significant associations between the risk of transmission and several factors, including the presence of major waterbody or highway, as well as the average daily maximum temperature and the precipitation levels over the preceding two weeks. The direction and/or magnitude of these associations differed between climate subzones, which, in turn, differed from national estimates that ignored subzones differences in climate variables.Conclusions/SignificanceThe epidemiology of cholera in Cameroon differs substantially between climate subzones. Development of an optimal comprehensive country-wide control strategy for cholera requires an understanding of the impact of the natural and built environment on transmission patterns at the local level, particularly in the setting of ongoing climate change.

Epidemiological Trends in Colorectal Cancer in China: An Ecological Study.

Due to the changes in lifestyle and dietary behaviors, the incidence of colorectal cancer (CRC) has been rapidly increasing in China. This study is to present the trends of CRC in China over the past decade. It used a series of nationally representative data, including the National Central Cancer Registry of China, the GLOBOCAN project and the Global Burden of Disease. The age-standardized rate of CRC incidence increased from 12.8 in 2003 to 16.8 per 100,000 in 2011, while the mortality rose from 5.9 to 7.8 per 100,000. The age group most affected by incident CRC cases were those aged 60-74years old, whereas CRC death was most associated with those >74years. Furthermore, the east coast of China presented a higher mortality rate (>15 and 10-14.9 per 100,000 in men and women) than central and west China (5-14.9 and 5-9.9 per 100,000). Compared with other countries worldwide, China indicated lower rates of incidence (14.2 per 100,000), mortality (7.4 per 100,000), and 5-year prevalence (52.7 per 100,000) than most developed countries. However, China had a higher case-fatality ratio (14.0%) and mortality/incidence ratio (52.1%). Lastly, disability-adjusted life years attributed to CRC in China was 224.2 per 100,000. It presents a steady increase in CRC in China over the past decade. It also reveals the domestic diversity of age, gender, and geography and finds the differences between China and developed countries, which may yield insights for national programs and policies.

World Health Organization estimates of the global and regional disease burden of four foodborne chemical toxins, 2010: a data synthesis

Background Chemical exposures have been associated with a variety of health effects; however, little is known about the global disease burden from foodborne chemicals. Food can be a major pathway for the general population’s exposure to chemicals, and for some chemicals, it accounts for almost 100% of exposure. Methods and Findings Groups of foodborne chemicals, both natural and anthropogenic, were evaluated for their ability to contribute to the burden of disease. The results of the analyses on four chemicals are presented here - cyanide in cassava, peanut allergen, aflatoxin, and dioxin. Systematic reviews of the literature were conducted to develop age- and sex-specific disease incidence and mortality estimates due to these chemicals. From these estimates, the numbers of cases, deaths and disability adjusted life years (DALYs) were calculated. For these four chemicals combined, the total number of illnesses, deaths, and DALYs in 2010 is estimated to be 339,000 (95% uncertainty interval [UI]: 186,000-1,239,000); 20,000 (95% UI: 8,000-52,000); and 1,012,000 (95% UI: 562,000-2,822,000), respectively. Both cyanide in cassava and aflatoxin are associated with diseases with high case-fatality ratios. Virtually all human exposure to these four chemicals is through the food supply. Conclusion Chemicals in the food supply, as evidenced by the results for only four chemicals, can have a significant impact on the global burden of disease. The case-fatality rates for these four chemicals range from low (e.g., peanut allergen) to extremely high (aflatoxin and liver cancer). The effects associated with these four chemicals are neurologic (cyanide in cassava), cancer (aflatoxin), allergic response (peanut allergen), endocrine (dioxin), and reproductive (dioxin).

Abstract IA23: Ovarian cancer screening.

Abstract Ovarian cancer is the 5th most common cause of cancer death among women in the UK, with ten-year survival rates of 35%. The continued high case fatality ratio has underpinned efforts to develop a screening strategy that could impact on mortality. In the UK large ovarian cancer screening trials have been completed both in the general (United Kingdom Collaborative Trial of Ovarian Cancer Screening - UKCTOCS) and high-risk (UK Familial Ovarian Cancer Screening Study UKFOCSS) population. Emerging evidence from UKCTOCS is encouraging with the multimodal strategy appearing to have detected double the number of invasive epithelial ovarian/fallopian tube cancer during incidence screening compared to a fixed cut-off for serum CA125 used previously. The key issue is impact on ovarian cancer mortality, which will be available from UKCTOCS in December 2015. Meanwhile new insights into carcinogenesis with a better understanding of the target lesion, improved design of biomarker discovery studies, a focus on detecting low volume disease using cancer specific markers, novel biospecimens such as endocervical samples, targeted imaging and time series algorithms for interpreting marker profile suggests that a new era in ovarian cancer screening is underway. Citation Format: Usha Menon. Ovarian cancer screening. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research: Exploiting Vulnerabilities; Oct 17-20, 2015; Orlando, FL. Philadelphia (PA): AACR; Clin Cancer Res 2016;22(2 Suppl):Abstract nr IA23.

A Case Study: Cholera

The bacterium named Vibrio cholerae is known to be the microorganism causing the deadly disease called as cholera. The first successful isolation of the V. cholerae bacterium occurs as an important instance in the history of medicine on the whole. New, more virulent and drug-resistant strains of V. cholerae continue to emerge, and the frequency of large protracted outbreaks with high case fatality ratios has increased, reflecting the lack of early detection, prevention and access to timely health care. The primary symptoms of cholera are profuse diarrhea (Looseness of bowl movement) and vomiting of clear fluid. Cholera is only one of many types of diarrhoeal disease, but its global importance is underlined by its inclusion in the WHO Communicable Disease Surveillance and Response (CSR) list. A patient who is infected with bacteria V. cholerae (Cholera is caused by the bacterium V. cholera, this bacterium is Gram stain-negative), by eating contaminated food and water and by drink water after watermelon. In most cases cholera can be successfully treated with oral rehydration therapy which is highly effective.

World Health Organization estimates of the global and regional disease burden of four foodborne chemical toxins, 2010: a data synthesis.

Background Chemical exposures have been associated with a variety of health effects; however, little is known about the global disease burden from foodborne chemicals. Food can be a major pathway for the general population's exposure to chemicals, and for some chemicals, it accounts for almost 100% of exposure. Methods and Findings Groups of foodborne chemicals, both natural and anthropogenic, were evaluated for their ability to contribute to the burden of disease. The results of the analyses on four chemicals are presented here - cyanide in cassava, peanut allergen, aflatoxin, and dioxin. Systematic reviews of the literature were conducted to develop age- and sex-specific disease incidence and mortality estimates due to these chemicals. From these estimates, the numbers of cases, deaths and disability adjusted life years (DALYs) were calculated. For these four chemicals combined, the total number of illnesses, deaths, and DALYs in 2010 is estimated to be 339,000 (95% uncertainty interval [UI]: 186,000-1,239,000); 20,000 (95% UI: 8,000-52,000); and 1,012,000 (95% UI: 562,000-2,822,000), respectively. Both cyanide in cassava and aflatoxin are associated with diseases with high case-fatality ratios. Virtually all human exposure to these four chemicals is through the food supply. Conclusion Chemicals in the food supply, as evidenced by the results for only four chemicals, can have a significant impact on the global burden of disease. The case-fatality rates for these four chemicals range from low (e.g., peanut allergen) to extremely high (aflatoxin and liver cancer). The effects associated with these four chemicals are neurologic (cyanide in cassava), cancer (aflatoxin), allergic response (peanut allergen), endocrine (dioxin), and reproductive (dioxin).

Providing nursing care to Ebola virus disease patients: China Ebola Treatment Unit experience.

Providing nursing care to Ebola virus disease patients: China Ebola Treatment Unit experience.

InvasiveSalmonellaDiscussed in Africa Consensus Meeting 2014, Blantyre, Malawi

Invasive<i>Salmonella</i>Discussed in Africa Consensus Meeting 2014, Blantyre, Malawi