Taiwan CDC Research Articles

Resurgence of pertussis in Taiwan during 2009-2015 and its impact on infants.

Pertussis incidence markedly decreased due to universal vaccination, but outbreaks had been noted worldwide in recent decade. This study was conducted to know the epidemiology of pertussis and its impact on infants in Taiwan. Epidemiologic parameters for confirmed pertussis cases were collected from the Taiwan Centers for Disease Control. The incidence of each age group over years was calculated using population data. We also did retrospective reviews of laboratory-confirmed pertussis cases in NTUH to analyze clinical characteristics and disease severity. A total of 668 confirmed pertussis cases were obtained from the Taiwan CDC open database between 2003 and 2017. There was higher incidence during the period 2009-2015, with a mean incidence of 0.27 cases per 100,000 population, about 2-fold increase compared with mean incidence of 0.12 cases per 100,000 population during the period 2003-2008. Infants accounted for the highest proportion of all cases (49.8%), with mean incidence of 16.1 cases per 100,000 people per year during 2009-2015, and a trend of increase was found from 2003 to 2015. In NTUH, a total of 17 laboratory-confirmed pertussis cases were diagnosed during 2012-2016, and 14 cases were young infants. Among them, 9 infants had been admitted to intensive care unit and 2 infant needed invasive ventilator support. There was a resurgence of pertussis during 2009-2015 and it had significant impact on infants. Young infants with pertussis may be severe and need intensive care, so preventive strategy may be advocated for them.

Impact of prior pulmonary tuberculosis in treatment outcomes of HCAP and CAP patients in intensive care units.

It is controversial whether healthcare-associated pneumonia (HCAP) belongs to a unique clinical entity or it shares common characteristics with community-acquired pneumonia (CAP). The impact of prior pulmonary tuberculosis (PTB) in clinical presentation and treatment outcome of ICU-admitted CAP and HCAP patients also remains unknown. We report a nationwide, multi-center, retrospective study. ICU-admitted CAP and HCAP patients from six medical centers in Taiwan were enrolled for analysis. Patients were defined as either CAP or HCAP cases, and with and without prior PTB, according to the database of Taiwan CDC. The disease severity, microbiologic characteristics, and treatment outcomes between CAP and HCAP patients with or without prior PTB were compared and analyzed. A total of 414 ICU-admitted patients, including 176 CAP cases and 238 HCAP cases were included for analysis during the study period. In both CAP and HCAP subgroups, the pneumonia severities, proportions of organ dysfunction, and microbiologic characteristics were similar between patients with and without prior PTB. In survival analysis, patients with prior PTB had higher 30-day mortality than those without prior PTB (38.9% vs. 16.5%, p=0.021) in the CAP population. Multivariate analysis revealed that a history of prior PTB was an independent clinical factor associated with higher 30-day mortality rate in CAP patients (HR=4.45, 95% CI: 1.81-10.98, P=0.001). History of prior PTB is an independent clinical factor for increased 30-day mortality rate in ICU-admitted CAP patients, but not in ICU-admitted HCAP patients.

Translational Venomics: Third-Generation Antivenomics of Anti-Siamese Russell's Viper, Daboia siamensis, Antivenom Manufactured in Taiwan CDC's Vaccine Center.

The venom proteome of Siamese Russell’s viper from Taiwan, alongside complementary in vivo lethality neutralization assay and in vitro third-generation antivenomics assessment of the preclinical efficacy of the homologous antivenom manufactured in Taiwan CDC’s Vaccine Center, are here reported. Taiwanese Russell’s viper venom proteome comprised 25 distinct gene products, with the heterodimeric PLA2 viperotoxin-F representing the most abundant toxin (47.5% of total venom proteome). Coagulation FV-activating serine proteinase (RVV-V, 14%), the PIV-SVMP activator of FX (RVV-FX, 8.5%), and less abundant toxins from nine protein families, make up its venom proteome. Venom composition-pathology correlations of D. siamensis envenomings in Taiwan are discussed. The lethal effect of Taiwanese D. siamensis venom was 0.47 mg/g mouse. Antivenomics-guided assessment of the toxin recognition landscape of the Taiwanese Russell’s viper antivenom, in conjunction with complementary in vivo neutralization analysis, informed the antivenom’s maximal toxin immunorecognition ability (14 mg total venom proteins/vial), neutralization capacity (6.5 mg venom/vial), and relative content of lethality neutralizing antibodies (46.5% of the toxin-binding F(ab’)2 antibodies). The antivenomics analysis also revealed suboptimal aspects of the CDC-Taiwan antivenom. Strategies to improve them are suggested.

Using an Open GIS Framework and Epidemiological Intelligence for Dengue Surveillance

Objective: In this paper we designed one cross-platform surveillance system to assist dengue fever surveillance, outbreak investigation and risk management of dengue fever.Introduction:In the 2015 dengue outbreak in Taiwan, 43,784 people were infected and 228 died, making it the nation’s largest outbreak ever. Facing the increasing threat of dengue, the integration of health information for prevention and control of outbreaks becomes very important. Based on past epidemics, the areas with higher incidence of dengue fever are located in southern Taiwan. Without a smart and integrated surveillance system, the information on case distribution, high risk areas, mosquito surveillance, flooding areas and so on is fragmented. The first-line public health workers need to check all this information through different systems manually. When outbreaks occurred, paper-based outbreak investigation forms had to be prepared and filled in by public health workers. Then, they needed to enter part of this information into Taiwan CDC’s system. Duplicated work occurred and cost lots of labor time during the epidemic period. Therefore, we choose one rural county, Pingtung County, with scarce financial resources, to set up a new dengue surveillance system.Methods: We designed a web-based cross-platform system based on an open geographical information system (GIS) framework including Openlayers, Javascript, PHP, MySQL and open data from government open data in Taiwan. There were seven epidemiological intelligence functions within the system including risk management, outbreak investigation, planning controlled areas, intelligent detection of high-risk areas, useful tools for decision making, historical epidemics, and system management. The website was developed by responsive web design which can let public health workers check information and fill in the investigation form by any devices.Results: The system was promptly set up in June 2016. With first-line public health workers’ efforts and the help of the surveillance system, there were no indigenous dengue fever cases after the system was implemented. There were sporadic imported cases from south-east Asia. The dengue surveillance system achieved three major improvements: integration of all decision support information; digitalization and automation of outbreak investigation; and planning the control areas. The results on outbreak investigation and mosquito surveillance can directly transfer to Taiwan CDC’s database by Web Application Programming Interface (API). It can avoid duplicated work for disease surveillance.Conclusions: Through introducing the new dengue surveillance system into local health departments, first-line public health workers can update all epidemic information at the same time. During epidemic periods, it can provide demographic, epidemiological, environmental, and entomological information for decision making. During non-epidemic periods, it can highlight the high risk areas for enhanced surveillance to reduce the risk of outbreaks.

A Foodborne Outbreak Associated with School Lunch Program in a School - New Taipei City, Taiwan, November 2016

On November 4, 2016, Taiwan CDC was notified of a foodborne outbreak in two schools whose lunch served by the same caterer and 361 of 1,686 students who consumed school lunch were ill. We conducted a case-control study among 9th grade students and teachers in School A and defined cases as people who ate lunch on November 1, 2, or 3 and developed diarrhea or abdominal pain within 72 hours after consuming. We performed univariate analysis to identify associated food items. Stools from ill students, food handlers, and food samples were collected to test for common foodborne pathogens. Food distribution process was reviewed. Fifty-four cases consumed lunch on November 3 were sick and median incubation period was 10 hours. Compared with 125 controls, consuming pork slices with mashed garlic (OR 17.58, 95% CI 1.04-297.80) and grapes (OR 2.13, 95% CI 1.06-4.31) were associated with illness, but only the former was served to both schools. Specimens of leftovers and stool from one food handler were tested positive for Bacillus cereus, but specimens from ill students were culture-negative. It took at least 2 hours from foods cooked before to be served. We recommend school caterer should review food distribution process to ensure food safety.

Seasonal Patterns of Japanese Encephalitis and Associated Meteorological Factors in Taiwan.

The persistent transmission of Japanese encephalitis virus (JEV) in Taiwan necessitates exploring the risk factors of occurrence of Japanese encephalitis (JE). The purpose of this study was to assess the relationship between meteorological factors and the incidence of JE in Taiwan. We collected data for cases of JE reported to the Taiwan Centers for Disease Control (Taiwan CDC) from 2000 to 2014. Meteorological data were obtained from the Taiwan Central Weather Bureau. The relationships between weather variability and the incidence of JE in Taiwan were determined via Poisson regression analysis and a case-crossover methodology. During the 15-year study period, a total of 379 cases of JE were reported. The incidence of JE showed significant seasonality, with the majority of cases occurring in summertime (for oscillation, p < 0.001). The number of JE cases started to increase at temperatures of 22 °C (r2 = 0.88, p < 0.001). Similarly, the number of JE cases began to increase at a relative humidity of 70–74% (r2 = 0.75, p < 0.005). The number of JE cases was positively associated with mean temperature and relative humidity in the period preceding the infection. In conclusion, the occurrence of JE is significantly associated with increasing temperature and relative humidity in Taiwan. Therefore, these factors could be regarded as warning signals indicating the need to implement preventive measures.

Clinical and epidemiological characteristics in hospitalized young children with acute gastroenteritis in southern Taiwan: According to major pathogens.

Acute gastroenteritis (AGE) can be caused by a wide array of pathogens, including bacteria, viruses, and parasites. A prospective study to investigate the epidemiology and clinical presentation in young children hospitalized with AGE was conducted in a medical center in southern Taiwan. Patients aged less than 5 years who was hospitalized due to AGE in National Cheng Kung University Hospital were enrolled from July 2014 to June 2016. The demographic information, clinical features and laboratory data were collected by chart reviews, and stool samples were sent to Centers of Disease Control, Taiwan (Taiwan CDC) for a panel of pathogen identification consisting of two viruses, nine bacteria, and five parasites. Totally 441 patients were enrolled in this study. Salmonella spp. was the leading cause of disease (21.8%), followed by norovirus (17.0%), Clostridium difficile (9.5%), and rotavirus (9.3%). Norovirus identification rate was the highest among patients less than 6 months of age, while Salmonella was highest among patients between 2 and 3 years old. Patients with Salmonella infection frequently presented with fever, lethargy, bloody stool, and elevated serum level of C-reactive protein (CRP); norovirus and rotavirus infection frequently presented with vomiting. Salmonella gastroenteritis also resulted in longer hospitalization and more frequent antibiotics administration. C. difficile could be isolated from both gastroenteritis patients and control children. Salmonella spp. was the most common pathogen of AGE in hospitalized children in southern Taiwan during 2014-2016, followed by norovirus and rotavirus. Further monitoring of epidemiology characteristics among cardinal pathogens of pediatric gastroenteritis is necessary.

Risk and Outbreak Communication: Lessons from Taiwan's Experiences in the Post-SARS Era.

In addition to the impact of a disease itself, public reaction could be considered another outbreak to be controlled during an epidemic. Taiwan's experience with SARS in 2003 highlighted the critical role played by the media during crisis communication. After the SARS outbreak, Taiwan's Centers for Disease Control (Taiwan CDC) followed the WHO outbreak communication guidelines on trust, early announcements, transparency, informing the public, and planning, in order to reform its risk communication systems. This article describes the risk communication framework in Taiwan, which has been used to respond to the 2009-2016 influenza epidemics, Ebola in West Africa (2014-16), and MERS-CoV in South Korea (2015) during the post-SARS era. Many communication strategies, ranging from traditional media to social and new media, have been implemented to improve transparency in public communication and promote civic engagement. Taiwan CDC will continue to maintain the strengths of its risk communication systems and resolve challenges as they emerge through active evaluation and monitoring of public opinion to advance Taiwan's capacity in outbreak communication and control. Moreover, Taiwan CDC will continue to implement the IHR (2005) and to promote a global community working together to fight shared risks and to reach the goal of “One World, One Health.”

Stockpile Model of Personal Protective Equipment in Taiwan.

The Taiwan Centers for Disease Control (Taiwan CDC) has established a 3-tier personal protective equipment (PPE) stockpiling framework that could maintain a minimum stockpile for the surge demand of PPE in the early stage of a pandemic. However, PPE stockpiling efforts must contend with increasing storage fees and expiration problems. In 2011, the Taiwan CDC initiated a stockpile replacement model in order to optimize the PPE stockpiling efficiency, ensure a minimum stockpile, use the government's limited funds more effectively, and achieve the goal of sustainable management. This stockpile replacement model employs a first-in-first-out principle in which the oldest stock in the central government stockpile is regularly replaced and replenished with the same amount of new and qualified products, ensuring the availability and maintenance of the minimum stockpiles. In addition, a joint electronic procurement platform has been established for merchandising the replaced PPE to local health authorities and medical and other institutions for their routine or epidemic use. In this article, we describe the PPE stockpile model in Taiwan, including the 3-tier stockpiling framework, the operational model, the components of the replacement system, implementation outcomes, epidemic supports, and the challenges and prospects of this model.

Epidemiological Features of Japanese Encephalitis in Taiwan from 2000 to 2014.

The incidence of Japanese encephalitis (JE) decreased sharply after the national vaccination program was implemented in Taiwan in 1968. However, cases of JE still occur. The purpose of this study was to assess the epidemiology and vaccination policy for JE in Taiwan. We analyzed the data on JE cases reported to the Taiwan Centers for Disease Control (Taiwan CDC) between 2000 and 2014. During the 15-year study period, a total of 4,474 cases were reported to the Taiwan CDC. Of these, 379 (8.5%) were classified as confirmed cases, and 4,095 (91.5%) were classified as suspected cases. The incidence of JE ranged from 0.59 to 1.61 per 1,000,000 people and peaked in 2007. Men had a higher incidence of JE than women (1.37 versus 0.84 per 1,000,000; P = 0.03). Patients who were 40-59 years of age had a higher incidence than did patients younger than 20 years (1.82 versus 0.23; P < 0.001). Patients who lived in the eastern region of Taiwan had the highest incidence rate of JE (P < 0.001). Compared with those who were not vaccinated with the JE vaccine, patients who received four doses of JE vaccine had a lower risk of suffering from death and/or hospitalization (adjusted odds ratio: 0.26; 95% confidence interval: 0.08-0.90; P = 0.04). JE is still a public health problem in Taiwan, and monitoring JE via diagnostic testing to determine the best vaccination program along with enforcing JE vaccine boosters for adults is necessary to eliminate JE in Taiwan.

Risk Assessment on Zika Virus Infection in Taiwan

The geographical distribution of Zika virus has spread explosively since 2015. In February 2016, WHO declared that the clusters of microcephaly and neurological disorders reported in Brazil and French Polynesia constituted a Public Health Emergency of International Concern (PHEIC). Evolving Zika virus epidemic and scientific evidence of a causal link between Zika virus and neurological disorders, adding to that competent mosquito vectors had inhabited in Taiwan, a few Asian countries are Zika endemic, and frequent travelling between countries in America, Southeast Asia and Taiwan, posed a threat to Taiwan that prompted the risk assessment. We estimated the probability and population-level impact of Zika virus disease in Taiwan by referring to risk assessments on Zika virus disease, the international risk assessment framework and algorithm, viral characteristics, global epidemiology, disease severity and other information currently available. To date, the evidence indicated that sporadic cases of Zika are expected in the future. The likelihood of Zika clusters reported in Taiwan depending on the evolution of Zika in Southeast Asia. The sickness is usually mild while the impact on infected pregnant women about their fetuses developing brain abnormalities and patients developing neurological complications should be monitored. Infection prevention measures are recommended for the general population and for pregnant women in particular including protection themselves from exposure to mosquitos and sexual contact with an infected partner. Pregnant women and women who are planning to become pregnant should consider delaying travel to areas with Zika. Travelers should wait a month to donate blood and take strict safe-sex precautions after visiting Zika-prone areas. Zika virus disease is notifiable and Taiwan CDC has activated the agency-level command center for Zika to strengthen preparedness and response efforts, including healthcare system preparedness planning, prevention of Zika importation, border quarantine and vector control.

Border Quarantine Measures to Prevent Ebola at Taoyuan International Airport in 2014

On 8 August, 2014, the World Health Organization (WHO) declared the Ebola virus disease outbreak in West Africa as a Public Health Emergency of International Concern (PHEIC). In response, Taiwan Centers for Disease Control (Taiwan CDC) established the ＂Ebola Virus Disease Emergency Response Task Force＂. This report addressed how Taoyuan International Airport implemented these policies from Taiwan CDC. The measures included: providing the latest update of health information for travelers, preparedness and drills at the airport, screening incoming passengers from Ebola-affected countries in West Africa. All passengers arriving by flights from Europe and Dubai were required to complete the blue ＂Ebola Declaration Form＂. Immigration officers would request the presence of a Taiwan CDC’s quarantine officer when travelers from Ebola-affected countries were passing through immigration. These border quarantine measures will serve as a reference in the future on how to prevent the spread of diseases into the country.

HIV in Taiwan: 2014 Statistics Overview

Taiwan CDC received 2,236 reports of new HIV infections in year 2014. With 8 cases less than year 2013, this number of new reports showed the first decline trend since 2009. Among the cumulative 28,710 cases, 26,892 (93.7%) were male, 1,818 (6.3%) were female, with sex ratio of 14.8:1. Among the 2,236 new cases in year 2014, 2,176 (97.3%) were male and 60 (2.7%) were female, with sex ratio of 36.3:1; the sex ratio was reduced compared to year 2013. Among the cumulative cases, 92.9% were aged 15-49 years old; while among the new cases in year 2014, 979 (43.8%) were aged 25-34 years old, followed by 15-24 years old (658 cases [29.4%]). Southern and Taipei regions showed increasing trend (8.3% and 2.9%, respectively) compared to year 2013, but the other regions showed declining trend. Among the cumulative cases, the main risk category for HIV infections was sexual contacts (74.9%), followed by drug injection users (23.8%). Among those within the sexual contacts risk category, 75.3% were men who have sex with men (MSM). This article summarized the national HIV trends, analyzed data by adopting the UNAIDS goals and WHO's Second Generation Surveillance concepts, determined the risk factors, and compared to international countries, to better promote national strategy and control of HIV in Taiwan.

A No-Notice Drill of Hospital Preparedness in Responding to Ebola Virus Disease in Taiwan.

The Ebola virus was first discovered in 1976, but the outbreak of Ebola virus disease that began in Guinea, West Africa, in December 2013 shocked the world. It is the largest and most severe epidemic of Ebola virus disease to date. The US Centers for Disease Control and Prevention confirmed that inadequate implementation of the policy of acquiring travel history led to a delay in identifying the first imported Ebola virus disease case. The Taiwan Centers for Disease Control developed a no-notice drill that used a simulated patient to assess hospitals' emergency preparedness capacity in responding to Ebola virus disease. Despite the fact that regular inspection shows that more than 90% of regional hospitals and medical centers inquired about patients' travel history, occupation, contact history, and cluster information, the no-notice drill revealed that more than 40% of regional hospitals and medical centers failed to ask emergency room patients about these factors. Therefore, to assist in inquiries about travel history, occupation, contact history, and cluster information in emergency triage and outpatient settings, the Taiwan CDC revised the criteria for hospital infection control inspection. It requested that hospitals issue appropriate reminders and implement process control mechanisms to block diagnostic processes in instances in which healthcare workers do not inquire about travel history, occupation, contact history, and cluster information. Furthermore, the Taiwan CDC will continue no-notice inspections in order to strengthen hospitals' infection control measures and reduce the risk of infectious disease transmission in the healthcare system.

Using prediction markets of market scoring rule to forecast infectious diseases: a case study in Taiwan.

BackgroundThe Taiwan CDC relied on the historical average number of disease cases or rate (AVG) to depict the trend of epidemic diseases in Taiwan. By comparing the historical average data with prediction markets, we show that the latter have a better prediction capability than the former. Given the volatility of the infectious diseases in Taiwan, historical average is unlikely to be an effective prediction mechanism.MethodsWe designed and built the Epidemic Prediction Markets (EPM) system based upon the trading mechanism of market scoring rule. By using this system, we aggregated dispersed information from various medical professionals to predict influenza, enterovirus, and dengue fever in Taiwan.ResultsEPM was more accurate in 701 out of 1,085 prediction events than the traditional baseline of historical average and the winning ratio of EPM versus AVG was 64.6 % for the target week. For the absolute prediction error of five diseases indicators of three infectious diseases, EPM was more accurate for the target week than AVG except for dengue fever confirmed cases. The winning ratios of EPM versus AVG for the confirmed cases of severe complicated influenza case, the rate of enterovirus infection, and the rate of influenza-like illness in the target week were 69.6 %, 83.9 and 76.0 %, respectively; instead, for the prediction of the confirmed cases of dengue fever and the confirmed cases of severe complicated enterovirus infection, the winning ratios of EPM were all below 50 %.ConclusionsExcept confirmed cases of dengue fever, EPM provided accurate, continuous and real-time predictions of four indicators of three infectious diseases for the target week in Taiwan and outperformed the historical average data of infectious diseases.

Applying the Modified Delphi Technique to Develop the Role of HIV Case Managers and Essential Nursing Competencies in HIV Care

Since 2005, the Taiwan Centers for Disease Control (Taiwan CDC) initiated an HIV case management program in AIDS-designated hospitals to provide integrative services and risk-reduction counseling for HIV-infected individuals. In light of the increasingly complex and highly specialized nature of clinical care, expanding and improving competency-based professional education is important to enhance the quality of HIV/AIDS care. The aim of this study was to develop the essential competency framework for HIV care for HIV case managers in Taiwan. We reviewed essential competencies of HIV care from Canada, the United Kingdom, and several African countries and devised descriptions of the roles of case managers and of the associated core competencies for HIV care in Taiwan. The modified Delphi technique was used to evaluate the draft framework of these roles and core competencies. A total of 15 HIV care experts were invited to join the expert panel to review and rank the draft framework. The final framework consisted of 7 roles and 27 competencies for HIV case managers. In Round 1, only 3 items did not receive consensus approval from the experts. After modification based on opinions of the experts, 7 roles and 27 competencies received 97.06% consensus approval in Round 2 and were organized into the final framework for HIV case managers. These roles and associated core competencies were: HIV Care Expert (9 competencies), Communicator (1 competency), Collaborator (4 competencies), Navigator (2 competencies), Manager (4 competencies), Advocate (2 competencies), and Professional (5 competencies). The authors developed an essential competency framework for HIV care using the consensus of a multidisciplinary expert panel. Curriculum developers and advanced nurses and practitioners may use this framework to support developments and to ensure a high quality of HIV care.

First Report of an Infant Intestinal Botulism Case in A Recent Decade in Taiwan

On 20^(th) January 2015, a 5-month-old girl was notified, and later known as a laboratory-confirmed infant botulism in a medical center in Tainan. It is the first report of an infant intestinal botulism patient in Taiwan in the recent decade. As the tests to the five suspicious food samples were all negative, the source of infection remains uncertain. There are a number of experiences to be shared from the investigation: 1. Blood draws in infants are limited so that it would have taken more than once to collect blood samples from an infant for Botulism tests; 2. Since only Equine Botulinum Antitoxin is available in Taiwan, clinicians should balance between potential risk of hypersensitivity and therapeutic outcome. Accordingly, the workbook provided by Taiwan CDC on prevention and control of infant botulism might need to be amended; 3. In order to collect epidemiological data, it is very important to support family members psychologically, as they feel sorry and guilty for the incidence.

Laboratory Biosafety for Testing of Ebola Virus Disease in Taiwan

Since the first case of Ebola virus disease (EVD) was found in Guinea in West Africa in December 2013, it spread rapidly to neighboring countries in Africa. Until July 2014, it extended more severe. The Taiwan Centers for Disease Control (Taiwan CDC) has been concerning for international Ebola outbreak and prepared for responding to the cross-border suspected case. In September 2014, Taiwan CDC announced the ＂Guidance on laboratory biosafety for handling specimens from patients under investigation for Ebola virus disease (EVD) and pathogens＂ and required the Health department in each county to inspect preparedness status of the laboratory department in the hospitals and to report the preparation results by October 2014. Unfortunately, a nurse from Spain and two from U.S. were infected with Ebola virus when caring for patients in October 2014. The incidence has prompted many countries to review and modify the personnel protection measures when managing EVD patients. Taiwan CDC also accorded the latest international guidelines to revise the guidance for laboratory biosafety, and required laboratories and hospitals that are authorized to test of EVD infection by law to practice drill exercises in case of infection incidents or accidents in laboratory. Taiwan CDC has now prepared well in laboratory biosafety to respond to the international Ebola outbreak. Ensure that laboratory personnel and healthcare workers are well protected to provide strong support when testing of infectious diseases.

The association between the incidence of mumps and meteorological parameters in Taiwan

Mumps is caused by a paramyxovirus. It is an acute, but mild infectious disease. However, approximately 10% of patients with mumps can develop severe meningoencephalitis, disability, and death. Seasonal patterns in mumps vary across countries, but the reasons for this phenomenon remain unclear. The aim of this study was to assess the role of meteorological factors on mumps infection. We investigated the relationships between weather variability and the incidence of mumps in Taiwan using a Poisson regression analysis and case-crossover methodology. Between 2006 and 2011, 6,612 cases of mumps were reported to the Centers for Disease Control, Taiwan (Taiwan CDC). The incidence of mumps showed a significant seasonality in summertime (for oscillation, P < 0.001). The number of mumps started to increase at temperatures of 20°C (r2 = 0.73, P < 0.001), and the case count of mumps began to decline when the temperatures were higher than approximately 25°C (r2 = 0.24, p = 0.04), producing an inverted V-shaped relationship. Similarly, the number of mumps began to increase at a vapor pressure of 5–9 hPa (r2 = 0.87, P < 0.005) and decreased at a vapor pressure higher than 25–29 hPa (r2 = 0.21, p = 0.05). The number of mumps cases was positively associated with temperature and vapor pressure in the preceding period of the infection. In conclusion, this study showed that the occurrence of mumps is significantly associated with increasing temperature and vapor pressure in Taiwan. Therefore, these factors could be regarded as warning signals indicating the need to implement preventive measures.

Cost-Benefit Analysis of Chest X-ray Screening in Specific Populations

The target populations of Taiwan CDC chest X-ray (CXR) screening program varied over the past decade. In this article, costs and benefits of CXR screening on these populations were analyzed, including people in mountainous districts and economically disadvantaged people. Cost-benefit analysis of CXR screening was done by comparison of screening list from local health bureaus during 2011-2012 to list of nationwide tuberculosis (TB) cases detected in 2012 by active case finding in mountainous districts and economically disadvantaged people, respectively. TB case detection rates were similar in both years among mountainous people and not related to CXR examination in previous year, both exceeded 4-times than the national rate (previous examination status unknown, 289.4/100,000; previously unexamined, 230.8/100,000; and previously examined, 248.6/100,000). TB detection rate from CXR screening in disadvantaged people during 2010-2012 was 2X higher than national average (91.0/100,000 in 2010; 205.7/100,000 in 2011 and 113.2/100,000 in 2012). CXR screening strategy was proven to be very successful and cost-effective in active case finding among either mountainous or economically disadvantaged people, and should be continuously endorsed by Taiwan CDC to reduce the burden of TB in these high-risk populations.