Public Health Investigation Research Articles

Mapping pediatric A&E respiratory presentations with air quality

IntroductionWest Belfast Partnership Board undertook a collaborative public health investigation to explore what if any correlation exists between air quality and children from the Falls Divis area presenting to RBHSC with a respiratory condition.
 BackgroundAn analysis of Emergency Department Attendances showed monthly trend in 2015/16 differed from previous years with a peak in November 2015 which was 27% higher than the number of attendances in November of 2014. The overall increase in 2015/16 across the 4 main paediatric categories was 10%. The increase for respiratory was 34% higher. West Belfast accounted for 32% (248n) of this spike.
 There exists a compelling case for linkage between air quality and a range of conditions which is socially patterned. Falls and Divis area appears in the top 3 areas of multiple deprivation.
 ApproachWe identified periods of elevated paediatric presentation at A&E with repository compliant and mapped over air quality monitoring data from the same period in the Falls Divis area; Factoring potential incubation time between exposure to potential harmful air pollutants.
 ConclusionBased upon a review of air quality data no causal link was established between air quality and periods of elevated presentation of children at A&E with respiratory evident.

Use of Rapid Online Data Collection during a Large Community Enteric Outbreak in Toronto, Canada

ObjectiveTo describe the use of an online survey tool to rapidly collect data from a large community outbreak of enteric illness in Toronto, Canada.IntroductionIn the early morning of Friday January 20, 2017, Toronto Public Health (TPH) was notified of several reports of acute vomiting, diarrhea, and stomach pain/cramps among students living in residence at a post-secondary institution in Toronto, Canada. A public health investigation was initiated and it was quickly determined that a large number of students and visitors to the campus were affected. Following considerable media coverage, TPH began receiving an overwhelmingly high volume of reports from ill individuals who lived, visited, or worked at the college campus and had experienced gastrointestinal illness.MethodsGastroBusters – an established online foodborne illness reporting tool was quickly adapted to support the outbreak investigation. GastroBusters was rapidly updated to include a screening question allowing ill individuals connected with the outbreak location to self-identify and report their symptoms, onset dates and times, and food histories to TPH securely online. The necessary updates were developed, tested, and implemented in less than one hour. Ill individuals were directed to the GastroBusters website – tph.to/gastrobusters - by college administrators and through media messaging. Those who were ill and reported to TPH through other methods (e.g., by phone) were interviewed by TPH investigators to collect comparable data, which were entered by staff into an online survey that mirrored the structure of the GastroBusters questions. These two data sets were merged and descriptive analyses were conducted using MS Excel and SAS v9.2.ResultsIn total, 354 reports associated with the outbreak were received by TPH - 232 who self-reported through GastroBusters, and 122 reported through other methods who were interviewed by TPH. Use of GastroBusters allowed ill individuals to report at a time convenient to them - 204 (88%) reports were submitted outside of TPH's business hours. As well, by providing ill individuals a method to self-report, TPH was able to rapidly collect, analyze and interpret data over the weekend while minimizing use of TPH staff resources. A summary report was available on Monday January 23, 2017 by 9:00 am, describing 236 confirmed and probable cases whose data were collected via both online surveys (GastroBusters and TPH data collection tool), between Friday and Sunday evenings. These data supported the hypothesis that the source of illness for the outbreak was likely norovirus; this was later confirmed through laboratory results.ConclusionsThis investigation provides a successful example of how an existing online reporting system for foodborne illness can be used for rapid data collection during a large-scale community enteric outbreak, where the exposed population could not be easily defined and the source of illness was unknown. Advantages of using this approach included: 1) rapid and robust data collection resulting in prompt analysis, and 2) efficient use of public health resources given the volume of reports otherwise processed by a public health investigator. Moreover, the investigation coincided with a weekend when there are fewer staff available and large amounts of overtime costs would have been accrued. TPH is currently developing standards for the use of similar tools in the future.

Enhanced Surveillance of Heat-Related Illness in Pinal County

ObjectiveUsing a syndromic surveillance system to understand the magnitude and risk factors related to heat-related illness (HRI) in Pinal County, AZ.IntroductionExtreme heat is a major cause of weather-related morbidity and mortality in the United States (US).1 HRI is the most frequent cause of environmental exposure-related injury treated in US emergency departments.2 More than 65,000 emergency room visits occur for acute HRI each summer nationwide.3 In Arizona, HRI accounts for an estimated 2,000 emergency room patients and 118 deaths each year.4 As heat-related illness becomes increasingly recognized as a public health issue, local health departments are tasked with building capacity to conduct enhanced surveillance of HRI in order to inform public health preparedness and response efforts. In Pinal County, understanding the magnitude and risk factors of HRI is important for informing prevention efforts as well as developing strategies to respond to extreme heat.MethodsTo gain a better understanding of the magnitude of HRI in Pinal County, historical cases were reviewed from hospital discharge data (HDD) from 2010-2016. Cases were included if the discharge record included any ICD codes consistent with HRI (ICD-9 codes 992 or ICD-10 codes T67 or X30) and if the patient’s county of residence was Pinal County. Recent HRI cases during the summer of 2017 were identified using the National Syndromic Surveillance Program BioSense Platform. The ESSENCE syndromic surveillance tool within the BioSense Platform includes data reported by local hospitals. This data can be used to detect abnormal activity for public health investigation. HRI cases were identified in ESSENCE based on ICD-10 codes and chief complaint terms according to a standardized algorithm developed by the Council of State and Territorial Epidemiologists.1 Both emergency department and admitted patients with a HRI were abstracted from HDD and ESSENCE. To assess HRI risk factors for the summer of 2017, a survey instrument was developed. Survey questions included the nature and location of the HRI incident, potential risk factors, and knowledge and awareness of HRI. Cases were identified in ESSENSE on a weekly basis from May 1, 2017-September 12, 2017, and follow up phone interviews were conducted with eligible cases. For HRI cases eligible for interview, three attempts were made to contact the patient by phone. Cases were excluded if the patient was incarcerated, deceased, or did not have a HRI upon medical record review. An exploratory analysis was performed for the data from HDD, ESSENCE, and interviews.ResultsPinal County Public Health Services District identified 1,321 HRI cases from 2010-2016, an average of 189 per year. Hospital discharge data suggest HRI cases are more likely to occur in males between the ages of 20-44 years old (27%). It is also notable that a sharp increase in HRI cases is observed each year in mid-to-late June, with an estimated 14% of annual cases occurring during the third week of June. Further analysis of HDD showed 31% of cases received medical treatment in Casa Grande in central Pinal County. Between May 1st and September 12th of 2017, 161 HRI cases were detected using ESSENCE. Of which 149 cases were determined to be HRI; 22 cases did not have contact information, and 4 cases were ineligible due to incarceration or death. A total of 31 HRI cases were interviewed out of the eligible 123 ESSENSE cases (25% response rate). Interview data indicated occupational exposure to extreme heat as a major risk factor for HRI. Additional risk factors reported during interviews included exposure to extreme heat while at home or traveling, although interview results are not representative due to a small sample size (n=31).ConclusionsSyndromic surveillance combined with interviews and a review of HDD provides an informative approach for monitoring and responding to HRI. Data suggest Pinal County should expect an increase in HRI cases by mid-June each year, typically coinciding with the first National Weather Service Extreme Heat Warning of the season. Preliminary results suggest that cases occur more frequently in working males ages 20-44 years old in occupations that expose workers to extreme heat conditions. Additional information is needed to assess risk factors for HRI among vulnerable populations in Pinal County who were not represented in this study, including individuals who are homeless, undocumented, elderly, or in correctional facilities. Future areas for improvement include improving the phone interview script to include English and Spanish language versions and performing medical record abstractions on all HRI cases. Enhanced syndromic surveillance is recommended to provide information on risk factors for HRI to inform prevention efforts in Pinal County.

Travel and Triage: Pilot project to detect infections after medical tourism procedures

Objective: Medical notes provide a rich source of information that can be used as additional supporting information for healthcare-associated infection (HAI) investigations. The medical notes from 10 New Jersey (NJ) emergency departments (ED) were searched to identify cases of surgical-site infections (SSI).Introduction: EpiCenter, NJ’s statewide syndromic surveillance system, collects ED registration data. The system uses chief complaint data to classify ED visits into syndrome categories and provides alerts to state and local health departments for surveillance anomalies.After the 2014 Ebola outbreak in West Africa, the New Jersey Department of Health (NJDOH) started collecting medical notes including triage notes, which contain more specific ED visit information than chief complaint, from 10 EDs to strengthen HAI syndromic surveillance efforts.In 2017, the NJDOH was aware of one NJ resident whose surgical site was infected following a cosmetic procedure outside of the US. This event triggered an intensive data mining using medical notes collected in EpiCenter. The NJDOH staff searched one week of medical notes data in EpiCenter with a specific keyword to identify additional potential cases of surgical-site infections (SSI) that could be associated with medical tourism.Methods: The NJ resident whose surgical site was infected following a cosmetic procedure outside of the US was interviewed by NJDOH staff for details about their procedure. First, the patient’s interview results were reviewed to prepare a set of SSI and travel related keywords to be used in performing data mining in medical notes collected in EpiCenter. The interviewed patient had tummy tuck and liposuction surgeries; therefore, it was decided to search for “tummy tuck” as a keyword in EpiCenter. The medical notes from August 31, 2017 through September 8, 2017 were reviewed to identify patients who developed SSI following a cosmetic procedure outside of the US.Results: The search yielded 8 ED visits, one of which was identified as possible surgical site infection. The medical notes details indicated that the ED patient, a 21-year old female who had abdominoplasty (tummy tuck) and liposuction surgeries about a month prior, presented with post-surgical complaints such as pain, surgical dehiscence, and purulent drainage at the surgery site. Chief complaint text for the same ED patient indicated the patient had headache and dizziness which were less specific than medical notes.The NJDOH staff contacted the ED to obtain additional information regarding the infection. The lab results from the ED showed that the patient was identified as having a post-surgery infection, which prompted public health to follow-up whether it was an HAI.Conclusions: The limitation for this project was that the keyword search was conducted only on one week of data. The timeframe was kept short to pilot testing the keyword identified. The Centers for Disease Control and Prevention suggests clinicians should consider nontuberculous mycobacteria (NTM) infections in the differential diagnosis for all people who have wound infections after surgery abroad, including surgery that has occurred weeks to months previously (1). Future studies will explore larger data sets with additional keywords (e.g. country and organism) to see if potential cases can be identified as possible HAI and/or outbreak that will lead to public health investigations.

Quantitative HPLC–MS/MS analysis of toxins in soapberry seeds: Methylenecyclopropylglycine and hypoglycin A

Methylenecyclcopropylglycine (MCPG) and hypoglycin A (HGA) are naturally occurring amino acids found in various soapberry (Sapindaceae) fruits. These toxins have been linked to illnesses worldwide and were recently implicated in Asian outbreaks of acute hypoglycemic encephalopathy. In a previous joint agricultural and public health investigation, we developed an analytical method capable of evaluating MCPG and HGA concentrations in soapberry fruit arils as well as a clinical method for the urinary metabolites of the toxins. Since the initial soapberry method only analyzed the aril portion of the fruit, we present here the extension of the method to include the fruit seed matrix. This work is the first method to quantitate both MCPG and HGA concentrations in the seeds of soapberry fruit, including those collected during a public health investigation. Further, this is the first quantitation of HGA in litchi seeds as well as both toxins in mamoncillo and longan seeds.

Public health opportunities and challenges in the provision of partner notification services: the New England experience

BackgroundPartner notification services (PNS) are recommended by the Centers for Disease Control and Prevention as a public health intervention for addressing the spread of HIV and other sexually transmitted diseases (STDs). Barriers and facilitators to the partner notification process from a public health perspective have not been well described.MethodsIn 2015, a coalition of New England public health STD directors and investigators formed to address the increasing STD prevalence across the region (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) and to promote communication between state STD programs. To evaluate barriers and facilitators of PNS programs, a survey was administered to representatives from each state to describe PNS processes and approaches.ResultsOf the six PNS programs, Connecticut, Maine, Massachusetts, Vermont, and New Hampshire had combined HIV and STD PNS programs; Rhode Island’s programs were integrated but employed separate disease intervention specialists (DIS). All states performed PNS for HIV and syphilis. Maine, New Hampshire and Vermont performed services for all gonorrhea cases. Rhode Island, Connecticut, and Massachusetts performed limited partner notification for gonorrhea due to lack of resources. None of the six states routinely provided services for chlamydia, though Maine and Vermont did so for high-priority populations such as HIV co-infected or pregnant individuals. Across all programs, clients received risk reduction counseling and general STD education as a component of PNS, in addition to referrals for HIV/STD care at locations ranging from Planned Parenthood to community- or hospital-based clinics. Notable barriers to successful partner notification across all states included anonymous partners and index cases who did not feel comfortable sharing partners’ names with DIS. Other common barriers included insufficient staff, inability of DIS to identify and contact partners, and index cases declining to speak with DIS staff.ConclusionsIn New England, state health departments use different strategies to implement PNS programs and referral to STD care. Despite this, similar challenges exist across settings, including difficulty with anonymous partners and limited state resources.

Reporting the methods used in public health research and practice.

The methods section of a scientific article often receives the most scrutiny from journal editors, peer reviewers, and skeptical readers because it allows them to judge the validity of the results. The methods section also facilitates critical interpretation of study activities, explains how the study avoided or corrected for bias, details how the data support the answer to the study question, justifies generalizing the findings to other populations, and facilitates comparison with past or future studies. In 2006, the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Programme began collecting and disseminating guidelines for reporting health research studies. In addition, guidelines for reporting public health investigations not classified as research have also been developed. However, regardless of the type of study or scientific report, the methods section should describe certain core elements: the study design; how participants were selected; the study setting; the period of interest; the variables and their definitions used for analysis; the procedures or instruments used to measure exposures, outcomes, and their association; and the analyses. Specific requirements for each study type should be consulted during the project planning phase and again when writing begins. We present requirements for reporting methods for public health activities, including outbreak investigations, public health surveillance programs, prevention and intervention program evaluations, research, surveys, systematic reviews, and meta-analyses.

Survey on the Use of Whole-Genome Sequencing for Infectious Diseases Surveillance: Rapid Expansion of European National Capacities, 2015-2016.

Whole-genome sequencing (WGS) has become an essential tool for public health surveillance and molecular epidemiology of infectious diseases and antimicrobial drug resistance. It provides precise geographical delineation of spread and enables incidence monitoring of pathogens at genotype level. Coupled with epidemiological and environmental investigations, it delivers ultimate resolution for tracing sources of epidemic infections. To ascertain the level of implementation of WGS-based typing for national public health surveillance and investigation of prioritized diseases in the European Union (EU)/European Economic Area (EEA), two surveys were conducted in 2015 and 2016. The surveys were designed to determine the national public health reference laboratories’ access to WGS and operational WGS-based typing capacity for national surveillance of selected foodborne pathogens, antimicrobial-resistant pathogens, and vaccine-preventable diseases identified as priorities for European genomic surveillance. Twenty-eight and twenty-nine out of the 30 EU/EEA countries participated in the survey in 2015 and 2016, respectively. National public health reference laboratories in 22 and 25 countries had access to WGS-based typing for public health applications in 2015 and 2016, respectively. Reported reasons for limited or no access were lack of funding, staff, and expertise. Illumina technology was the most frequently used followed by Ion Torrent technology. The access to bioinformatics expertise and competence for routine WGS data analysis was limited. By mid-2016, half of the EU/EEA countries were using WGS analysis either as first- or second-line typing method for surveillance of the pathogens and antibiotic resistance issues identified as EU priorities. The sampling frame as well as bioinformatics analysis varied by pathogen/resistance issue and country. Core genome multilocus allelic profiling, also called cgMLST, was the most frequently used annotation approach for typing bacterial genomes suggesting potential bioinformatics pipeline compatibility. Further capacity development for WGS-based typing is ongoing in many countries and upon consolidation and harmonization of methods should enable pan-EU data exchange for genomic surveillance in the medium-term subject to the development of suitable data management systems and appropriate agreements for data sharing.

Canadian Public Health Laboratory Network position statement: Non-culture based diagnostics for gastroenteritis and implications for public health investigations.

As clinical laboratories transition to using culture-independent detection test (CIDT) panels for cases of acute gastroenteritis, culture of clinical specimens is becoming less common. The reduction in bacterial cultures available for public health activities is expected to hinder surveillance and outbreak response by public health laboratories at the local, provincial, national and international levels. These recommendations are intended to serve as guidelines for the implementation of CIDT panels in frontline laboratories in Canada. The United States of America has already seen a significant reduction in culture of stool specimens despite the Association of Public Health Laboratories recommendation to perform reflex culture on positive CIDT specimens. Priority public health organisms addressed in these Canadian guidelines include Shiga toxin-producing Escherichia coli, Shigella and Salmonella and, under regional circumstances, other organisms such as Campylobacter jejuni/coli and Yersinia enterocolitica. These recommendations suggest active engagement between primary diagnostic laboratories and provincial public health laboratories to determine the workflow and protocols for reflex or parallel culture. Consequently, notifiable disease definitions will also need modification, with consultation of all stakeholders. Stakeholders need to work together to enhance recovery of bacterial isolates with best practices used for stool transport and storage.

Canadian Public Health Laboratory Network position statement: Nonculture based diagnostics for gastroenteritis and implications for public health investigations

Canadian Public Health Laboratory Network position statement: Nonculture based diagnostics for gastroenteritis and implications for public health investigations

Analysis of population-level determinants of legionellosis: spatial and geovisual methods for enhancing classification of high-risk areas

BackgroundAlthough the incidence of legionellosis throughout North America and Europe continues to increase, public health investigations have not been able to identify a common exposure in most cases. Over 80% of cases are sporadic with no known source. To better understand the role of the macro-environment in legionellosis risk, a retrospective ecological study assessed associations between population-level measures of demographic, socioeconomic, and environmental factors and high-risk areas.MethodsGeographic variability and clustering of legionellosis was explored in our study setting using the following methods: unadjusted and standardized incidence rate and SaTScan™ cluster detection methods using default scanning window of 1 and 50% as well as a reliability score methodology. Methods for classification of “high-risk” census tracts (areas roughly equivalent to a neighborhood with average population of 4000) for each of the spatial methods are presented. Univariate and multivariate logistic regression analyses were used to estimate associations with sociodemographic factors: population ≥ 65 years of age, non-white race, Hispanic ethnicity, poverty, less than or some high school education; housing factors: housing vacant, renter-occupied, and built pre-1950 and pre-1970; and whether drinking water is groundwater or surface water source.ResultsCensus tracts with high percentages of poverty, Hispanic population, and non-white population were more likely to be classified as high-risk for legionellosis versus a low-risk census tract. Vacant housing, renter-occupied housing, and homes built pre-1970 were also important positively associated risk factors. Drinking water source was not found to be associated with legionellosis incidence.DiscussionCensus tract level demographic, socioeconomic, and environmental characteristics are important risk factors of legionellosis and add to our understanding of the macro-environment for legionellosis occurrence. Our findings can be used by public health professionals to target disease prevention communication to vulnerable populations. Future studies are needed to explore the exact mechanisms by which these risk factors may influence legionellosis clustering.

Public Health and Law Enforcement Joint Investigation of Unknown Suspicious Substances and Potential Threat Evaluations, Minnesota, 2007-2016.

From the Field is a semi-regular column that explores what it means to be a local health professional on the front lines of an emergency. Typically, National Association of County and City Health Officials (NACCHO) members share their stories of preparing for and responding to disasters, epidemics, and other major health issues. This month's column features a submission from a state health department that describes their experience in investigating white powder incidents. Through exploring the analysis of the challenges faced and the solutions developed, readers can learn how these public health champions keep their communities safe even in extreme situations. Readers may submit topics of interest to the column's editor, Meghan McGinty, PhD, MPH, MBA, at mmcginty@naccho.org.

Familial Creutzfeldt-Jakob Disease Cluster Among an African American Family.

Familial Creutzfeldt-Jakob disease (fCJD) results from inheritance of mutations in the prion protein gene. Confirming fCJD diagnosis is essential for informing persons of their potential hereditary risk and for genetic counseling to support personal decisions for genetic testing and family planning. We describe a case of fCJD that was linked to a large cluster of African Americans with fCJD identified through a public health investigation, including 8 confirmed cases and 13 suspected cases involving 7 generations in 1 family. Genetic counseling is an important component of fCJD management for families coping with genetic prion diseases.

Ecological niche modeling and distribution of Ornithodoros hermsi associated with tick-borne relapsing fever in western North America.

Tick-borne relapsing fever in western North America is a zoonosis caused by the spirochete bacterium, Borrelia hermsii, which is transmitted by the bite of infected Ornithodoros hermsi ticks. The pathogen is maintained in natural cycles involving small rodent hosts such as chipmunks and tree squirrels, as well as the tick vector. In order for these ticks to establish sustained and viable populations, a narrow set of environmental parameters must exist, primarily moderate temperatures and moderate to high amounts of precipitation. Maximum Entropy Species Distribution Modeling (Maxent) was used to predict the species distribution of O. hermsi and B. hermsii through time and space based on current climatic trends and future projected climate changes. From this modeling process, we found that the projected current distributions of both the tick and spirochete align with known endemic foci for the disease. Further, global climate models predict a shift in the distribution of suitable habitat for the tick vector to higher elevations. Our predictions are useful for targeting surveillance efforts in areas of high risk in western North America, increasing the efficiency and accuracy of public health investigations and vector control efforts.

Opioid Overdose Outbreak - West Virginia, August 2016.

On August 15, 2016, the Mayor's Office of Drug Control Policy in Huntington, West Virginia, notified the Cabell-Huntington Health Department (CHHD) of multiple calls regarding opioid overdose received by the emergency medical system (EMS) during 3 p.m.-8 p.m. that day. A public health investigation and response conducted by the West Virginia Bureau for Public Health (BPH) and CHHD identified 20 opioid overdose cases within a 53-hour period in Cabell County; all cases included emergency department (ED) encounters. EMS personnel, other first responders, and ED providers administered the opioid antidote naloxone to 16 (80%) patients, six of whom were administered multiple doses, suggesting exposure to a highly potent opioid. No patients received referral for recovery support services. In addition to the public health investigation, a public safety investigation was conducted; comprehensive opioid toxicology testing of clinical specimens identified the synthetic opioid fentanyl* and novel fentanyl analogs, including carfentanil,† which had been used by patients who overdosed in Huntington. Results of these two investigations highlight the importance of collaboration between public health and public safety agencies to provide in-depth surveillance data from opioid overdose outbreaks that involve high-potency fentanyl analogs. These data facilitated a public health response through increased awareness of powerful opioid substances requiring multiple naloxone doses for reversal, and improved patient linkage to recovery support services and a harm reduction program from the ED after opioid overdose.

Whole-Genome Sequencing for National Surveillance of Shigella flexneri.

National surveillance of Shigella flexneri ensures the rapid detection of outbreaks to facilitate public health investigation and intervention strategies. In this study, we used whole-genome sequencing (WGS) to type S. flexneri in order to detect linked cases and support epidemiological investigations. We prospectively analyzed 330 isolates of S. flexneri received at the Gastrointestinal Bacteria Reference Unit at Public Health England between August 2015 and January 2016. Traditional phenotypic and WGS sub-typing methods were compared. PCR was carried out on isolates exhibiting phenotypic/genotypic discrepancies with respect to serotype. Phylogenetic relationships between isolates were analyzed by WGS using single nucleotide polymorphism (SNP) typing to facilitate cluster detection. For 306/330 (93%) isolates there was concordance between serotype derived from the genome and phenotypic serology. Discrepant results between the phenotypic and genotypic tests were attributed to novel O-antigen synthesis/modification gene combinations or indels identified in O-antigen synthesis/modification genes rendering them dysfunctional. SNP typing identified 36 clusters of two isolates or more. WGS provided microbiological evidence of epidemiologically linked clusters and detected novel O-antigen synthesis/modification gene combinations associated with two outbreaks. WGS provided reliable and robust data for monitoring trends in the incidence of different serotypes over time. SNP typing can be used to facilitate outbreak investigations in real-time thereby informing surveillance strategies and providing the opportunities for implementing timely public health interventions.

Examining the structure and behavior of Afghanistan’s routine childhood immunization system using system dynamics modeling

PurposeThe purpose of this paper is to demonstrate how public health and systems science methods can be combined to examine the structure and behavior of Afghanistan’s routine childhood immunization system to identify the pathways through which health system readiness to deliver vaccination services may extend beyond immunization outcomes.Design/methodology/approachUsing findings from an ecological study of Afghanistan’s immunization system and a literature review on immunization program delivery, the routine immunization system was mapped using causal loop diagrams. Next, a stock-and-flow diagram was developed and translated to a system dynamics (SD) model for a system-confirmatory exercise. Data are from annual health facility assessments and two cross-sectional household surveys. SD model results were compared with measured readiness and service outcomes to confirm system structure.FindingsReadiness and demand-side components were associated with improved immunization coverage. The routine immunization system was mapped using four interlinking readiness subsystems. In the SD model, health worker capacity and demand-side factors significantly affected maternal health service coverage. System readiness components affected their future measures mostly negatively, which may indicate that the reinforcing feedback drives current system-structured behavior.Originality/valueThe models developed herein are useful to explore the potential impact of candidate interventions on service outcomes. This paper documents the process through which public health and systems investigators can collaboratively develop models that represent the feedback-driven behavior of health systems. Such models allow for more realistically addressing health policy and systems-level research questions.

Outbreak of Influenza A(H7N2) Among Cats in an Animal Shelter With Cat-to-Human Transmission-New York City, 2016.

We describe the first case of cat-to-human transmission of influenza A(H7N2), an avian-lineage influenza A virus, that occurred during an outbreak among cats in New York City animal shelters. We describe the public health response and investigation.

Blood borne virus testing of 2250 patients in an unusual, repeated dental patient notification exercise: challenges faced and lessons learnt

ObjectivesThe objectives of this study were to ascertain the risk created for patients of two dental practices where infection control was found to be inadequate, and if the risk was deemed to be significant, initiate an investigation involving notification and blood borne virus (BBV) testing to establish if any patient-to-patient BBV transmissions had occurred as a result of these infection control breaches. Study designA case study. MethodsA public health investigation and patient notification. Investigations involved practice inspections, staff interviews and examination of invoices. The practices were not fully cooperative during the investigation and provided misleading information regarding the allegations. This led to two patient notification exercises, as more serious breaches were uncovered following the first notification exercise. Risk assessments of BBV transmission likelihood were undertaken and informed the nature of the advice given to patients. ResultsThe health board wrote to 5100 patients informing them of the situation. BBV testing was offered in the second notification exercise and 2250 patients opted to be tested for HIV, hepatitis B and hepatitis C. There were no new cases of HIV or hepatitis B but less than five patients were found to be positive for hepatitis C. None of these cases were proven to have contracted their infection as a result of the dental infection control lapses. ConclusionsThis incident was unusual in that the practice was found to be repeatedly and knowingly putting patients at risk, and attempts were made to cover up breaches during the investigation. In future, health boards would benefit from a risk assessment tool to aid decision making regarding notification exercises, and whether testing is indicated where risk to patients is low. This would help ensure that notification exercises do more good than harm.

Inquiring into the Gaps of Campylobacter Surveillance Methods.

Campylobacter is one of the most common pathogen-related causes of diarrheal illnesses globally and has been recognized as a significant factor of human disease for more than three decades. Molecular typing techniques and their combinations have allowed for species identification among members of the Campylobacter genus with good resolution, but the same tools usually fail to proceed to subtyping of closely related species due to high sequence similarity. This problem is exacerbated by the demanding conditions for isolation and detection from the human, animal or water samples as well as due to the difficulties during laboratory maintenance and long-term storage of the isolates. In an effort to define the ideal typing tool, we underline the strengths and limitations of the typing methodologies currently used to map the broad epidemiologic profile of campylobacteriosis in public health and outbreak investigations. The application of both the old and the new molecular typing tools is discussed and an indirect comparison is presented among the preferred techniques used in current research methodology.