Sensitive Surveillance Research Articles

Australian National Enterovirus Reference Laboratory annual report, 2017.

Australia monitors its polio-free status by conducting surveillance for cases of acute flaccid paralysis (AFP) in children less than 15 years of age, as recommended by the World Health Organization (WHO). Cases of AFP in children are notified to the Australian Paediatric Surveillance Unit or the Paediatric Active Enhanced Disease Surveillance System and faecal specimens are referred for virological investigation to the National Enterovirus Reference Laboratory. In 2017, no cases of poliomyelitis were reported from clinical surveillance and Australia reported 1.33 non-polio AFP cases per 100,000 children, meeting the WHO performance criterion for a sensitive surveillance system. Three non-polio enteroviruses, coxsackievirus B1, echovirus 11 and enterovirus A71, were identified from clinical specimens collected from AFP cases. Australia established enterovirus and environmental surveillance systems to complement the clinical system focussed on children and an ambiguous vaccine-derived poliovirus type 2 was isolated from sewage in Melbourne. In 2017, 22 cases of wild polio were reported with three countries remaining endemic: Afghanistan, Nigeria and Pakistan.

Characterizing Environmental Surveillance Sites in Nigeria and Their Sensitivity to Detect Poliovirus and Other Enteroviruses.

BackgroundEnvironmental surveillance (ES) for poliovirus is increasingly important for polio eradication, often detecting circulating virus before paralytic cases are reported. The sensitivity of ES depends on appropriate selection of sampling sites, which is difficult in low-income countries with informal sewage networks.MethodsWe measured ES site and sample characteristics in Nigeria during June 2018–May 2019, including sewage physicochemical properties, using a water-quality probe, flow volume, catchment population, and local facilities such as hospitals, schools, and transit hubs. We used mixed-effects logistic regression and machine learning (random forests) to investigate their association with enterovirus isolation (poliovirus and nonpolio enteroviruses) as an indicator of surveillance sensitivity.ResultsFour quarterly visits were made to 78 ES sites in 21 states of Nigeria, and ES site characteristic data were matched to 1345 samples with an average enterovirus prevalence among sites of 68% (range, 9%–100%). A larger estimated catchment population, high total dissolved solids, and higher pH were associated with enterovirus detection. A random forests model predicted “good” sites (enterovirus prevalence >70%) from measured site characteristics with out-of-sample sensitivity and specificity of 75%.ConclusionsSimple measurement of sewage properties and catchment population estimation could improve ES site selection and increase surveillance sensitivity.

The Scrapie Prevalence in a Goat Herd Is Underestimated by Using a Rapid Diagnostic Test.

Current European surveillance regulations for scrapie, a naturally occurring transmissible spongiform encephalopathy (TSE) or prion disease in sheep and goats, require testing of fallen stock or healthy slaughter animals, and outline measures in the case of confirmation of disease. An outbreak of classical scrapie in a herd with 2500 goats led to the culling of the whole herd, providing the opportunity to examine a subset of goats, take samples, and examine them for the presence of disease-associated prion protein (PrPSc) to provide further information on scrapie test sensitivity, pathology, and association with prion protein genotype. Goats were examined clinically prior to cull, and the brains examined post mortem by Bio-Rad ELISA, a rapid screening test used for active surveillance in sheep and goats, and two confirmatory tests, Western blot and immunohistochemistry. Furthermore, up to 10 lymphoid tissues were examined by immunohistochemistry. Of 151 goats examined, three (2.0%) tested positive for scrapie by ELISA on brain, confirmed by confirmatory tests, and a further five (3.3%) were negative by ELISA but positive by at least one of the confirmatory tests. Only two of these, both positive by ELISA, displayed evident signs of scrapie. In addition, 10 (6.6%) goats, which also included two clinical suspects, were negative on brain examination but had detectable PrPSc in lymphoid tissue. PrPSc was detected most frequently in the medial retropharyngeal lymph node (LN; 94.4% of all 18 cases) and palatine tonsil (88.9%). Abnormal behavior and circling or loss of balance when blindfolded were the best clinical discriminators for scrapie status. None of the goats that carried a single allele in the prion protein gene associated with increased resistance to scrapie (Q211, K222, S146) were scrapie-positive, and the percentage of goats with these alleles was greater than expected from previous surveys. Significantly more goats that were scrapie-positive were isoleucine homozygous at codon 142 (II142). The results indicate that the sensitivity of the applied screening test is poor in goats compared to the confirmatory tests as gold standard, particularly for asymptomatic animals. Sensitivity of surveillance could be improved by testing retropharyngeal LN or palatine tonsil in addition to brain.

Assessment of acute flaccid paralysis surveillance performance in East and Southern African countries 2012 - 2019.

Introduction:polio eradication initiatives started in 1988, this is almost the past 32 years following the WHA resolution 41.8 of eradicating polio by the year 2000. As of 2019, only 3 countries remained to be polio endemic globally, Afghanistan, Pakistan and Nigeria. The east and southern sub-region countries had shown progressive achievement towards polio eradication and to start with the African regional certification. The availability of sensitive AFP surveillance performance is among important strategies in the achievement of polio eradication. We, therefore, decided to conduct this assessment of AFP performance from 2012 to 2019 in the ESA sub-region have evidence documentation and support the certification process of the WHO AFRO region.Methods:we reviewed all reported acute flaccid paralysis (AFP) cases from 19 countries in the ESA sub region with the date of onset of paralysis from 1 January 2012 to 31 December 2019. The data were run to descriptive analysis based on the personal characteristics and AFP surveillance performance indicators parameters.Results:a total of 46,014 AFP cases were reported from 19 countries in the ESA countries who were paralyzed from 1 January 2012 to 31 December 2019. The most affected age group was children aged 0 to 3 years old where 19,740 children with acute paralysis were reported representing 42.9% of the total reported AFP for the period. The overall assessment of the non-polio AFP rate, there is an increase from a rate of 2.7 in 2012 to 3.5 in 2019 per 100,000 population aged less than 15 years, reflects a significant change with a p-value of 0.040 (95% C.I. ranges from 0.035 to 1.564). Furthermore, the percentage of stool adequacy raised from 86.4% in 2012 to 88.5% in 2019, with an observed 2.1% difference and no significant change over the 8 years.Conclusion:we observed an overall increase in the sensitivity of the AFP surveillance performance for the ESA sub-region countries from 2012 to 2019 using the national performance indicators. The COVID-19 pandemic paused an operational challenge for AFP surveillance performances from 2020. A further subnational surveillance performance analysis is suggested.

Surveillance optimisation to detect poliovirus in the pre-eradication era: a modelling study of England and Wales.

Surveillance for acute flaccid paralysis (AFP) cases are essential for polio eradication. However, as most poliovirus infections are asymptomatic and some regions of the world are inaccessible, additional surveillance tools require development. Within England and Wales, we demonstrate how inclusion of environmental sampling (ENV) improves the sensitivity of detecting both wild and vaccine-derived polioviruses (VDPVs) when compared to current surveillance. Statistical modelling was used to estimate the spatial risk of wild and VDPV importation and circulation in England and Wales. We estimate the sensitivity of each surveillance mode to detect poliovirus and the probability of being free from poliovirus, defined as being below a pre-specified prevalence of infection. Poliovirus risk was higher within local authorities in Manchester, Birmingham, Bradford and London. The sensitivity of detecting wild poliovirus within a given month using AFP and enterovirus surveillance was estimated to be 0.096 (95% CI 0.055-0.134). Inclusion of ENV in the three highest risk local authorities and a site in London increased surveillance sensitivity to 0.192 (95% CI 0.191-0.193). The sensitivity of ENV strategies can be compared using the framework by varying sites and the frequency of sampling. The probability of being free from poliovirus slowly increased from the date of the last case in 1993. ENV within areas thought to have the highest risk improves detection of poliovirus, and has the potential to improve confidence in the polio-free status of England and Wales and detect VDPVs.

Measles Outbreak Investigation in Pweto Health Zone—Haut-Katanga Province, DR of the Congo, 2018

Background: Sub-Saharan Africa reports repeated outbreaks of measles, a vaccine-preventable disease, which is notifiable under the Integrated Disease Surveillance and Response (IDSR) strategy in Democratic Republic of Congo (DRC). DRC has reported several outbreaks of measles in the last three years. Poor immunization coverage and weak health systems have been related with measles and other vaccination-preventable diseases’ outbreaks. The DRC has committed to eliminating measles by 2020. In this respect, we investigated one of the outbreaks that occurred in Pweto health zone (HZ), Haut-Katanga province, to describe the outbreak and identify risk factors. Methods: A cross-sectional study was designed to investigate a measles outbreak in Pweto health zone (HZ), Haut-Katanga province. Data entry and analysis were performed using EPI-Info version 7.1.0.6 and MS-Microsoft Excel. Findings: In seven months’ time, four health areas affected by a measles outbreak in Pweto health zone reported 116-suspected cases and 13 deaths. The cumulative attack rate of 42.3/100,000 population and case fatality rate (CFR) of 11.2% were recorded. Of these, 112 (96.5%) cases were ≤15 years of age, and 93 (80.2%) were zero dose of measles vaccine. Although, all age groups were concerned, under five years old were the most affected with 84 cases (72.4%). In response to the outbreak, a response immunization was organized with the support of MSF at the week 25 of the epidemic, when the epidemic curve started to decline. A response immunization involving 46,205 children from 6 to 59 was implemented and overall coverage of 99% (range: 95% - 105%) was achieved. Case management with vitamin A supplementation, active case search, routine immunization improvement and health education were some of the activities carried out to curb the outbreak. Conclusion: This confirmed measles outbreak was caused by failure to vaccinate (80.2% unvaccinated cases). Poor surveillance sensitivity and the community attitude about measles contributed to its spreading. Strengthening routine immunization, improving surveillance system and communication for behaviour change are required.

Comparison of the utility of clinical breast examination and MRI in the surveillance of women with a high risk of breast cancer

To review surveillance magnetic resonance imaging (MRI) and clinical breast examinations (CBE) performed for women at high risk of breast cancer in order to determine recall and cancer-detection rates. Data were collected on all surveillance MRI examinations performed at St James's Hospital in 2016 for women at high risk of developing breast cancer. Data collected included age, indication for MRI, MRI score, ultrasound indications and scores, and histology findings. Ultrasound scores were recorded from CBEs that received a score of ≥3. A total of 385 breast surveillance MRI examinations and CBEs were performed for women at high risk of breast cancer. A recall rate of 11.2% was documented for breast MRI examinations, whereas a recall rate of 6.2% was identified for CBEs. The biopsy rate was 6.2% for MRI and 0.2% for CBE. The cancer detection rate was 1.6% or 16 per 1,000 for MRI screening and 0% for CBE. The high cancer detection rate in the present study supports the unparalleled sensitivity of breast MRI surveillance. Furthermore, the present study did not identify any breast cancers through CBE, suggesting it is not a critical component of the surveillance programme of high-risk women. The current UK guidelines recommending a target recall rate of 7% were not met in the present study or by other studies in the literature, collectively suggesting the guidelines may not be reflective of what is attainable in clinical practice.

Advances in Genomic Profiling and Risk Stratification in Acute Myeloid Leukemia.

To review the current state of molecular and genetic profiling of acute myeloid leukemia (AML) and its implications. Peer-reviewed journal articles. Significant advances in the understanding of the pathology of acute myeloid leukemia have led to refined risk stratification of patients and application of novel targeted therapies based on genetic profiles. Minimal residual disease testing allows for highly sensitive disease surveillance that can be used to predict relapse and assess treatment response. Accurate prognostication and therapeutic decision-making for patients with acute myeloid leukemia is dependent on molecular profiling. Being knowledgeable of the implications of minimal residual disease testing is critical for patient-centered care.

A Collaborative Initiative to Strengthen Sustainable Public Health Capacity for Polio Eradication and Routine Immunization Activities in the Eastern Mediterranean Region.

The many challenges in the Eastern Mediterranean region put the involved countries at risk of polio transmission and affect their ability to meet progress targets in eliminating vaccine-preventable diseases. The Global Health Development (GHD) and Eastern Mediterranean Public Health Network (EMPHNET) are working together on the project “Strengthening sustainable public health capacity in the Eastern Mediterranean region for polio eradication and routine immunization activities” with an overall goal of improving routine immunization, eradicating poliovirus, and controlling/eliminating or eradicating other vaccine-preventable diseases in the Eastern Mediterranean region. The aim of this manuscript is to describe the project and the achievements of GHD/EMPHNET over the last 3 years (2016-2018) to build effective surveillance and immunization systems in the Eastern Mediterranean region through the development of a sustainable and competent public health system to eradicate polio and control/eliminate vaccine-preventable diseases. This project assists the targeted Eastern Mediterranean region countries to build effective surveillance and immunization systems in an effort to expand their capacities to eradicate polio and control/eliminate other vaccine-preventable diseases. The project is streamlined with the Global Polio Eradication Initiative, the Centers for Disease Control and Prevention’s Strategic Framework for Global Immunization 2016-2020, and the Polio Eradication and Endgame Strategic Plan 2013-2018. The project also supports the Global Health Security Agenda by focusing on efforts to accelerate progress toward a world safe and secure from infectious disease threats. Project activities were designed to respond to countries’ needs and assist them in building their institutional and workforce capacity to effectively plan, implement, and evaluate activities to eradicate polio and strengthen routine immunization activities. The project activities covered a set of areas including surveillance of acute flaccid paralysis and other vaccine-preventable diseases, family and community engagement, workforce capacity building, improvement of data quality, management and use of information systems, use of polio assets to control/eliminate other vaccine-preventable diseases, support of countries to develop national strategies, piloting of innovative initiatives, program evaluation and accountability, and immunization strengthening. The project adopts the Global Polio Eradication Initiative strategies for assisting countries to strengthen routine immunization services, maintain highly sensitive acute flaccid paralysis surveillance, and sustain polio eradication functions.

1714. Testing a Novel Clinical Surveillance Case Definition for Invasive Mold Infections

BackgroundInvasive mold infections (IMI) such as aspergillosis and mucormycosis are often fatal among immunosuppressed patients and have caused high-profile outbreaks. Surveillance for IMI is challenging because distinguishing a case from colonization or contamination is complex. The established case definition, Mycoses Study Group (MSG) criteria, lacks sensitivity. Because the need for surveillance remains, we designed a pilot IMI surveillance system within the Georgia Emerging Infections Program. Here, we describe cases identified through this system, using both the MSG criteria and a novel, more sensitive clinical case definition.MethodsTo identify potential IMI cases, we captured fungal cultures positive for mold, histopathology specimens with evidence of fungal tissue invasion, and positive galactomannan results within a 60-day window at three large hospitals in Atlanta during March 2017–2018. We excluded dimorphic fungi and hair and nail specimens. Of 194 potential cases, we selected 24 for complete medical chart review. Two physicians classified cases as proven, probable, or non-case according to MSG criteria. Cases that partially met MSG probable criteria and included antifungal treatment were classified as clinical cases; definitions were mutually exclusive (Figure 1).ResultsOf 24 potential IMI cases, 16 (66%) met an IMI case definition, including 5 proven, 2 probable and 9 clinical cases. Inter-rater agreement was 92%., Most (5/7) MSG cases involved Aspergillus and were more likely to have cancer, a transplant, or other immunosuppression compared with clinical cases (Figure 2 and 3). Clinical cases included conditions not specified in MSG criteria, including burns (1), wounds (1) or eye (4) infections. MSG and clinical cases more often had antifungal treatment (16/16 vs. 1/8) or died (4/16 vs. 0/8) compared with non-cases.ConclusionIn this preliminary analysis of potential IMI cases, most represented true invasive infections, indicating effective exclusion of most colonization. Most of the 16 cases were classified as clinical, however, and would have been missed in a system relying on the MSG criteria alone. Results suggest that a less-specific clinical case definition incorporating antifungal treatment may improve the sensitivity and utility of IMI surveillance. Disclosures All authors: No reported disclosures.

Evaluation of the effectiveness of the surveillance system for tuberculosis in cattle in Spain

In Spain, the eradication of tuberculosis (TB) in cattle has had some setbacks and therefore we need to re-evaluate the current surveillance strategies. The Spanish cattle TB surveillance system consists of three components: a) routine skin testing, b) slaughterhouse surveillance, and c) pre-movement controls. Our objectives were to assess the effectiveness of the whole surveillance system and evaluate the relative contribution of each of those components, both at national and at the province level. The effectiveness was estimated based on both the sensitivity of detection per year and the time until detection. Moreover, we evaluated the impact of different factors on that effectiveness. We used a stochastic model that simulated the spread of Mycobacterium tuberculosis-complex (MTC) infection within cattle herds that was modified to incorporate the three components of TB surveillance. Input data, at the province level, on cattle movements off-farm or the frequency of the routine screening were provided by the Spanish Ministry for Agriculture, Fisheries and Food.Under the current conditions, 96.1% of Spanish herds were detected within one year after their infection (i.e. mean sensitivity of TB surveillance), although that detection took on average 178 days. The surveillance system effectiveness was highly dependent on the routine skin testing, responsible for the detection of almost 90% of the infected herds, while slaughterhouse surveillance and pre-movement controls contributed only to the identification of a small proportion of infected herds. We observed substantial differences in the effectiveness of the surveillance components among Spanish provinces, although in general, the sensitivities were high. The most influential factor on the efficiency of TB detection in Spain was, by far, the frequency of routine controls, followed by the sensitivity of the test used.In a context of reduced funding for cattle TB eradication, the frequency of testing should be adapted based on risk-based surveillance strategies, i.e. efforts should focus on herds more likely to be infected, but also in herds more likely to infect other herds. While slaughterhouse surveillance seems a cost-effective strategy, the use of pre-movement testing at least in areas of low incidence should be further evaluated.

Longitudinal assessment of alpha-fetoprotein for early detection of hepatocellular carcinoma in patients with cirrhosis

Background/aims: Cirrhosis is an important risk factor for hepatocellular carcinoma (HCC), and the surveillance of patients with cirrhosis is, therefore, highly recommended. However, the role of alpha-fetoprotein (AFP) in HCC surveillance is controversial. The aim of this study was to determine the role of AFP in HCC surveillance among patients with cirrhosis.Methods: The study population consisted of 392 patients with cirrhosis. Ultrasound (US) and laboratory tests including AFP were regularly performed to detect HCC development. The cutoff level of AFP for suspicion of HCC was 7 ng/mL.Results: During the median follow-up period of 4.7 (interquartile range, 3.4–5.6) years, HCC developed in 64 (16.3%) patients. Their mean age was 53.6 years, and they were predominantly male (63.5%). For the detection of HCCs, the sensitivity and specificity of US were 56.3% and 100%, respectively. The sensitivity and specificity of AFP were 62.5% and 94.5%, respectively. Using US and AFP in combination increased the sensitivity of surveillance to 89.1% with a specificity of 94.5%. Mean AFP levels were significantly higher in patients with than without HCC at the time of HCC diagnosis, at 6 months and 12 months before the diagnosis. The area under the receiver operating characteristic curve of AFP was highest at the time of HCC diagnosis (0.867), and also was acceptable at 6 months (0.823) and 12 months (0.792) before the diagnosis.Conclusions: These results suggest the complementary use of AFP and US to improve the effectiveness of HCC surveillance in patients with cirrhosis.

Outbreak of measles among persons with secondary vaccine failure, China, 2018

ABSTRACTAlthough the incidence of measles has been dramatically reduced by the highly effective measles vaccine, cases of measles and outbreaks continue to occur in vaccinated population because of immunization failure. We report on an outbreak in which two cases had previous evidence of measles immunity and then one of them transmitted measles infection to an unvaccinated contact. The cases and contacts exposed during the outbreak were investigated. Clinical information and epidemiological information were obtained. Serum samples were collected for measles-specific immunoglobulin M (IgM), immunoglobulin G (IgG) and IgG avidity. Throat swabs were obtained to test for measles virus RNA. Two measles cases (case 1 and case 2) who have received one dose of MCV in past 5 years, and both working at a hospital in Beijing, occurred in 18th and 20nd of January, respectively. Out of the 102 contacts, one additional case (case 3) who had a close, long-term co-exposure with case 1 was reported subsequently. No additional cases of measles occurred among 15 contacts of case 3. The index case was not ascertained through the outbreak review. All three cases had laboratory confirmation of measles infection. Both case 1 and case 2 had high-avidity IgG antibody characteristic of a secondary immune response and developed a modified clinical presentation. This report confirms that a vaccinated individual with documented secondary vaccine failure (SVF) could transmit measles and is the second report since a New York City outbreak (the first report in China). The outbreak represented a series of rare events, so we can conclude that the SVF individuals in the transmission chain of measles are unlikely to threaten measles elimination. The importance of the herd immunity in preventing transmission and sensitive surveillance activities in case of misdiagnosis is emphasized.

Diagnostic Accuracy of Prostate Biopsy for Detecting Cribriform Gleason Pattern 4 Carcinoma and Intraductal Carcinoma in Paired Radical Prostatectomy Specimens: Implications for Active Surveillance.

Prostatic adenocarcinoma with cribriform morphology and/or intraductal carcinoma has higher recurrence and mortality rates after radiation and surgery. While the prognostic impact of these features is well studied, concordance with cribriform morphology and/or intraductal carcinoma on biopsy and prostatectomy has only recently gained attention. Our primary objective was to evaluate the diagnostic performance of biopsy to detect cribriform morphology and/or intraductal carcinoma in paired biopsy and prostatectomy specimens in a large contemporary cohort. Patients who underwent prostate biopsy or had biopsies reviewed prior to prostatectomy at a tertiary hospital between November 2017 and November 2018 were included in study. Sensitivity and specificity were calculated to assess concordance with cribriform morphology and/or intraductal carcinoma on biopsy and prostatectomy. The association of biopsy diagnosed with cribriform morphology and/or intraductal carcinoma with adverse pathology was assessed by multivariable regression. Of the 455 men who underwent prostatectomy 216 (47.5%) had biopsy identified with cribriform morphology and/or intraductal carcinoma. For cribriform morphology and/or intraductal carcinoma the sensitivity and specificity of biopsy was 56.5% and 87.2%, respectively. In men eligible for active surveillance sensitivity was 34.1% and specificity was 88.1%. Magnetic resonance imaging targeted biopsies did not improve sensitivity (53.5%). Cribriform morphology and/or intraductal carcinoma identified on prostatectomy correlated with adverse pathological findings. However, compared to cribriform morphology and/or intraductal carcinoma negative biopsies, biopsies identified with cribriform morphology and/or intraductal carcinoma were not independently associated with adverse pathology. This was likely due to biopsy low sensitivity. In this cohort biopsy was not sensitive for detecting cribriform morphology and/or intraductal carcinoma and this was not improved by magnetic resonance imaging fusion. However, specificity was high, suggesting that when present on biopsy, cribriform morphology and/or intraductal carcinoma may be considered in treatment planning algorithms.

Construction and application of the surveillance system for schistosomiasis transmission risk in Sichuan Province

To build a schistosomiasis transmission risk surveillance system in Sichuan Province, so as to provide technical support for facilitating the progress towards schistosomiasis elimination in the province. The surveillance sites for schistosomiasis transmission risk were assigned in 63 endemic counties (districts) of 11 cities (prefectures) in Sichuan Province. During the period from 2015 through 2018, wild feces contamination, the sources of Schistosoma japonicum infections (fever patients, livestock and wild animals), water infectivity in key settings, snail distribution in key settings, and snail breeding risk (snail importation and spread, floating debris carrying snails and snail breeding in ecological wetlands) were monitored in the surveillance sites. From 2015 to 2018, a total of 1 636 wild faces were detected in Sichuan Province, and 3 faces were positive for S. japonicum, with a 0.18% positive rate; among 3 995 livestock and 59 wild mice monitored, no S. japonicum infection was detected. A total of 49 414 fever patients were monitored in 2018, and 493 were seropositive for S. japonicum infection; then, 445 seropositives were subjected to stool examinations, and no egg-positives were found. From 2010 to 2018, a total of 93 sentinel sites were assigned, and 3 994 sentinel mice were placed for monitoring the water infectivity, with one S. japonicum-infected mouse detected. Between 2015 and 2018, a total of 4 156 key settings were investigated covering an area of 1 998.46 hm2, and 668 settings were detected with snails (16.07%), covering an area of 193.26 hm2; 497 suspected settings with a likelihood of snail importation with plant introduction were monitored from 2017 to 2018, and 65 settings with snails were found with 2 673 snails captured; 593 sites were assigned to collect the floating debris from 2017 to 2018, and 9 191.39 kg floating debris were collected with 186 snails captured; 4 wetlands were monitored for the risk of schistosomiasis transmission from 2013 to 2015, and snail breeding was found in 2 wetlands. No S. japonicum infection was identified in snails captured from all surveillance sites. A sensitive and effective schistosomiasis transmission risk surveillance system has been successfully established in Sichuan Province. There is still a risk of schistosomiasis transmission risk in local areas of Sichuan Province. Therefore, the integrated schistosomiasis control measures with emphasis on the control of the source of S. japonicum infections should be further intensified, and snail monitoring and control and monitoring and control of schistosomiasis in wetlands should be also intensified.

Analisis Implementasi Kebijakan Program Pengendalian Resistensi Antimikroba (PPRA)

Antimicrobial resistance has become a problem in Indonesia. The Ministry of Health has established a policy ofAntimicrobial Resistance (AMR) Control Program in hospitals to resolve the issue. A qualitative case study was conducted at Dr. RSUP Wahidin Sudirohusodo hospital, Makassar in 2018 to analyze the implementation of AMR control program. The data were collected through in-depth interviews and analyzed descriptively. The study showed that policy AMR control program has not be carefully implemented. The function of AMR control program team is to make policies and guidelines for antibiotic use, to make surveillance of germ patterns and antibiotic sensitivity, clinical audits of antibiotic use, to conduct studies/research and to make evaluation that is reported to the Hospital Director. However, this AMR control program has not been optimally implemented due to many challenges such as lack of budget, lack of commitment and internal coordination between the AMR control program team members. Implementation of AMR control program in this hosptal management is not optimal. The Program dissemination and AMR team activities were not evenly distributed. High workload, inadequate infrastructure and antibiotic resistance issues of the referred patients. As a conclusion AMRcontrol program policy in RSUP. Wahidin Sudirohusodo, Makassar, has not been properly disseminated and implemented. Coordination, dissemination and discussion forums on PPRA policies internally and externally with cross-sectoral hospitals are needed to improve antimicrobial resistance control commitment. 
 

The impact of pooling samples on surveillance sensitivity for the megalocytivirus Infectious spleen and kidney necrosis virus.

Movements of large volumes and species varieties make the ornamental fish industry a high-risk pathway for the transfer of aquatic pathogens to new geographical regions and naïve hosts, potentially resulting in emergency disease events. Infectious spleen and kidney necrosis virus (genus Megalocytivirus) is considered exotic to Australia despite documented incursions since 2003. There are current import controls requiring freedom from infection for entry to Australia. The objective was to evaluate the effect of tissue pooling strategies for qPCR testing using a SYBR® assay for freedom from ISKNV at 2% expected prevalence with 95% confidence. Tissue homogenates from apparently healthy imported ornamental fish were tested as individuals and in pools of 5 and 10. Analytical sensitivity of the qPCR assay was reduced by two orders of magnitude when the nucleic acid extraction process was accounted for by spiking the plasmid in fish tissues and compared with molecular grade water. Diagnostic sensitivity of the assay was substantially reduced when testing tissues in pools compared with individual testing. For Population 1 (66% positive for ISKNV with moderate viral loads), surveillance sensitivity was only achieved using individual testing. For Population 2 (100% positive ISKNV with high viral loads), surveillance sensitivity was achieved using 260 fish in pools of 10 for a total of 26 tests or 200 fish in pools of 5 for 40 tests. Surveillance sensitivity could be maximized even when there was a reduction in pooled diagnostic sensitivity compared with diagnostic sensitivity for individual fish by increasing the sample size. Pooled sensitivity was influenced by the prevalence and variable virus load among fish with subclinical infections. Pooled testing is highly effective when the prevalence is >10% which should be informed by prior knowledge or pooling can be used for a screening test to rapidly identify populations with high prevalence.

Optimal Timing of Total Gastrectomy to Prevent Diffuse Gastric Cancer in Individuals With Pathogenic Variants in CDH1

Carriers of pathogenic variants in CDH1 have a high risk of hereditary diffuse gastric cancer (HDGC). Guidelines recommend prophylactic total gastrectomy (PTG) at age 20-30 years, although there is controversy over the optimal age. We developed a simulation model to analyze the effects of PTG at different ages on quality-adjusted life-years (QALYs), cancer mortality, and life expectancy. We used a Markov model of HDGC progression associated with pathogenic variants in CDH1 to simulate outcomes of hypothetical cohorts with different ages at time of PTG (ages 20-79 years). Model inputs including health state transition probabilities, mortality and complication rates, quality of life utility values, and endoscopic surveillance sensitivity were derived from publications. The primary outcome, used to determine the optimal strategy, was age at which PTG yielded the highest QALYs. Secondary outcomes were cancer mortality and unadjusted life-years. Our model found that for men, the optimal age for PTG is 39 years, resulting in 32.01 incremental QALYs, 58.81 life-years (biologic age, 72.81 years), and lifetime cancer mortality of 8.5%. Incorporating endoscopic surveillance prior to PTG decreased cancer mortality to 6.7%, but had lower QALYs (31.59). PTG at age 30 reduced cancer mortality to 3.2%, with 31.45 incremental QALYs. For women, the optimal age for PTG was calculated to be 30 years, with 33.09 incremental QALYs, 66.17 life-years (biologic age, 80.17 years), and lifetime cancer mortality of 1.6%. Addition of endoscopic surveillance did not decrease the risk of HDGC mortality in women. Using a Markov model of HDGC progression associated with pathogenic variants in CDH1 to simulate outcomes, we found the optimal ages for PTG to be 39 years for men and 30 years for women, when QALYs are the primary endpoint. These ages for PTG are older than those of current recommendations.

Progress Toward Measles Elimination - Pakistan, 2000-2018.

In 1997, the 21 countries in the World Health Organization (WHO) Eastern Mediterranean Region* (EMR) passed a resolution during the 41st session of the Regional Committee for the Eastern Mediterranean to eliminate measles† (1). In 2015, this goal was included as a priority in the Eastern Mediterranean Vaccine Action Plan 2016-2020 (2), approved at the 62nd session of the Regional Committee (3). To achieve measles elimination, the WHO Regional Office for the Eastern Mediterranean developed the following four-pronged strategy: 1) achieve ≥95% vaccination coverage with the first dose of measles-containing vaccine (MCV) among children in every district of each country through routine immunization services; 2) achieve ≥95% vaccination coverage with a second MCV dose in every district of each country either through implementation of a routine 2-dose vaccination schedule or through supplementary immunization activities (SIAs)§; 3) conduct high-quality, case-based measles surveillance in all countries; and 4) provide optimal measles clinical case management, including dietary supplementation with vitamin A (4). Pakistan, an EMR country with a population of approximately 200 million, accounts for nearly one third of the overall EMR population. This report describes progress and challenges toward measles elimination in Pakistan during 2000-2018. During the study period, estimated coverage with the first MCV dose (MCV1) increased from 57% in 2000 to 76% in 2017. The second MCV dose (MCV2) was introduced nationwide in 2009, and MCV2 coverage increased from 30% in 2009 to 45% in 2017. During 2000-2018, approximately 232.5 million children received doses of MCV during SIAs. Reported confirmed measles incidence increased from an average of 24.6 per 1 million persons during 2000-2009 to an average of 80.4 during 2010-2018, with peaks in 2013 (230.3) and 2018 (153.6). In 2017 and 2018, the rates of suspected cases discarded as nonmeasles after investigation were 2.1 and 1.5 per 100,000 population, reflecting underreporting of cases. To achieve measles elimination, additional efforts are needed to increase MCV1 and MCV2 coverage, develop strategies to identify and reach communities not accessing immunization services, and increase sensitivity of case-based measles surveillance in all districts.

Environmental Surveillance and Vaccine Derived Polio Virus type 2 Isolation, Gombe State, Nigeria.

Environmental Surveillance and Vaccine Derived Polio Virus type 2 Isolation, Gombe State, Nigeria.