Applicability of evidence-based practice in public health: risk assessment on Q fever under an ongoing outbreak

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Assessing the risk of a community outbreak of hepatitis A on blood safety in Latvia, 2008

Post-transfusion hepatitis A virus (HAV) infection worldwide is considered a sporadic event. An outbreak of HAV infection occurred in Latvia between the end of 2007 and throughout 2008 with more than 2,800 confirmed cases reported over a 13-month period (incidence of 123 per 100,000 population). The majority of reported HAV infection cases were in people over 18 years of age and in people living in the capital city, Riga. We estimated that the crude risk for HAV contamination of whole blood supplies in Riga between February and October 2008 ranged from 1.4 to 10.6per 10,000 donated units. In people under 40 years of age, the risk of receiving an infectious blood transfusion was more than 3.0 per 10,000 recipients between August and October 2008 during the peak of the outbreak. We conclude that there is a previously under-recognised impact of HAV on blood safety during widespread outbreaks of this disease. Estimating the risk of contamination of blood supplies during an infectious disease outbreak scenario is important for fine tuning risk assessments and potentially improving public health practices.

Assessing the impact of the 2009 H1N1 influenza pandemic on reporting of other threats through the Early Warning and Response System

Since the start of 2009 H1N1 influenza pandemic, a notable surge in messages communicated through the Early Warning and Response System (EWRS) for the prevention and control of communicable diseases in the European Union has been recorded. In order to measure the impact of this increase on the reporting of other events, we compared the messages posted in the EWRS since April 2009 with those posted in the previous years (2004-2008). The analysis revealed that a ten-fold increase in messages was recorded during the pandemic period, from April to September 2009, and that the reporting of other threats dropped to a significantly low rate. These results suggest an important impact on the notification process of events in case of a situation requiring extensive mobilisation of public health resources. It emphasises the importance keeping an appropriate balancing of resources during sustained emergencies, in particular in view of a possible second wave of pandemic influenza cases, to ensure prompt detection and reporting of potential concomitant emerging threats.

New perspectives after the transition of EPIET to ECDC – the future of the programme

Strengthening capacity in intervention epidemiology is key to the overall goal of responding to the challenge to detect and counter threats posed by outbreaks of infectious diseases in the European Union (EU). Since its founding in 1995, the European Programme for Intervention Epidemiology Training (EPIET) has become a core resource in training in intervention epidemiology in the EU. EPIET was integrated into the European Centre for Disease Prevention and Control (ECDC) on 1 November 2007 and this has resulted in an increased sustainability of the programme, allowing for long-term planning. Also, a new training programme, the European public health microbiology training (EUPHEM), was set up in 2008 to increase the response capacity for microbiology. Collaboration with EU Member States and other training programmes has been further intensified. Merging EPIET and other training activities in the ECDC training section has created the opportunity to develop an integrated multilevel approach to training in applied field epidemiology. An integrated approach to training activities on EU level, and increasing the number of EPIET and EPIET-associated fellows are essential to respond to the training needs of EU Member States, particularly new Member States. An external evaluation of EPIET in 2009 will provide guidance for a future strategy for the programme. This article examines the achievements of the EPIET programme after its transition to ECDC and provides an outlook on its future.

New perspectives after the transition of EPIET to ECDC - the future of the programme

Strengthening capacity in intervention epidemiology is key to the overall goal of responding to the challenge to detect and counter threats posed by outbreaks of infectious diseases in the European Union (EU). Since its founding in 1995, the European Programme for Intervention Epidemiology Training (EPIET) has become a core resource in training in intervention epidemiology in the EU. EPIET was integrated into the European Centre for Disease Prevention and Control (ECDC) on 1 November 2007 and this has resulted in an increased sustainability of the programme, allowing for long-term planning. Also, a new training programme, the European public health microbiology training (EUPHEM), was set up in 2008 to increase the response capacity for microbiology. Collaboration with EU Member States and other training programmes has been further intensified. Merging EPIET and other training activities in the ECDC training section has created the opportunity to develop an integrated multilevel approach to training in applied field epidemiology. An integrated approach to training activities on EU level, and increasing the number of EPIET and EPIET-associated fellows are essential to respond to the training needs of EU Member States, particularly new Member States. An external evaluation of EPIET in 2009 will provide guidance for a future strategy for the programme. This article examines the achievements of the EPIET programme after its transition to ECDC and provides an outlook on its future.

Contribution of EPIET to public health workforce in the EU, 1995-2008

We analyse activities and outputs of fellows of the European Programme for Intervention Epidemiology Training (EPIET) between 1995 and 2008 and describe the employment history of graduates after the training to demonstrate the contribution of this programme and of national EPIET-associated programmes to the public health workforce in the European Union and Norway. Up to 2008, some 161 fellows entered the training: 121 in EPIET and 40 in EPIET-associated programmes. Of these 149 were awarded a diploma. Fellows engaged in projects in all areas of surveillance, in outbreaks and field investigations and produced 340 publications in peer-reviewed journals. Seventy fellows were sent to 98 individual assignments on 65 international missions. The vast majority of graduates (90%) take up a position and remain employed in applied public health, either on regional, national or international level. Several (27) are working outside the EU, all in public health, including 13 working in Switzerland for international organisations. Only three of the 12 EU Member States that joined the EU since 2004, employ EPIET graduates. A major challenge for training the public health workforce is the retention of professionals in countries with limited job opportunities or wages significantly below the EU average.

Contribution of EPIET to public health workforce in the EU, 1995-2008

We analyse activities and outputs of fellows of the European Programme for Intervention Epidemiology Training (EPIET) between 1995 and 2008 and describe the employment history of graduates after the training to demonstrate the contribution of this programme and of national EPIET-associated programmes to the public health workforce in the European Union and Norway. Up to 2008, some 161 fellows entered the training: 121 in EPIET and 40 in EPIET-associated programmes. Of these 149 were awarded a diploma. Fellows engaged in projects in all areas of surveillance, in outbreaks and field investigations and produced 340 publications in peer-reviewed journals. Seventy fellows were sent to 98 individual assignments on 65 international missions. The vast majority of graduates (90%) take up a position and remain employed in applied public health, either on regional, national or international level. Several (27) are working outside the EU, all in public health, including 13 working in Switzerland for international organisations. Only three of the 12 EU Member States that joined the EU since 2004, employ EPIET graduates. A major challenge for training the public health workforce is the retention of professionals in countries with limited job opportunities or wages significantly below the EU average.

Public health preparedness for two mass gathering events in the context of pandemic influenza (H1N1) 2009--Serbia, July 2009

Preparedness planning for two large mass gatherings events were considered in Serbia in the context of pandemic influenza (H1N1) 2009. Planning included approaches to prevention, detection and response in order to mitigate the situation at this early stage of the epidemic in Serbia. Cases of influenza A(H1N1)v were identified nationally immediately prior to the mass gatherings but also identified in association with both events, as expected in the context of the pandemic situation. This article describes the experiences of planning and the epidemiological situation during the period of the mass gathering events.

Europe's initial experience with pandemic (H1N1) 2009 - mitigation and delaying policies and practices

Europe has experienced more than two months of the first transmissions and outbreak of the 2009 pandemic of A(H1N1)v. This article summarises some of the experience to date and looks towards the expected autumn increases of influenza activity that will affect every country. To date the distribution of transmission has been highly heterogenous between and within countries, with one country the United Kingdom (UK) experiencing the most cases and the highest transmission rates. Most infections are mild but there are steadily increasing numbers of people needing hospital care and more deaths are being reported. An initial difference in practice between Europe and North America was over case-finding and treatment with some authorities in Europe using active case-finding, contact tracing and treatment/prophylaxis with antivirals to try and delay transmission. This article details the history of this practice in the past two months and explains how and why countries are moving to mitigation, especially treating with antivirals those at higher risk of experiencing severe disease.

Epidemic intelligence and travel-related diseases: ECDC experience and further developments

The European Centre for Disease Prevention and Control (ECDC) started to work on information gathering for early detection of public health threats in June 2005. Since then, based on a framework including events and data-based surveillance, EDCD has been learning by doing. The internal tools and procedures for epidemic intelligence (EI) were developed while screening signals. Information including relevant epidemiological data, media news detected and actions taken are recorded in a specific event information system (Threat Tracking Tool). We describe the main elements, process and outputs of EI activities at ECDC. We also describe the main results regarding travel-related diseases. Efforts are needed to better identify and gather information about travellers coming to the EU with imported diseases with a potential for further spread inside our territory.

Why are Mexican data important?

This issue of Eurosurveillance contains an article by a French team on the transmission of the new influenza A(H1N1) in Mexico, which uses published figures from the outbreak to estimate important parameters for transmission, among them the reproduction rate, R [1]. Such studies may have important implications for public health action in Europe.

Hepatitis A in the European Union: responding to challenges related to new epidemiological patterns

In the European Union (EU), the overall incidence of hepatitis A has decreased over the last 10 years from 15.1 per 100,000 population in 1996 to 3.9 per 100,000 in 2006. However, reduction in circulation of HAV leads to decreased acquisition of immunity and, in the absence of universal vaccination, an accumulation of susceptible individuals. The impact of increasing susceptibility of the general population on the risk for outbreaks is clearly illustrated in independent outbreaks in Czech Republic, Latvia and Slovakia in 2008, described in three of the articles published in this week’s issue of Eurosurveillance.

Electronic surveillance of outbreaks in Lebanon

BACKGROUND

This paper describes and assesses the electronic surveillance of outbreaks based on the early warning for four endemic diseases - typhoid fever, amebic dysentery, viral hepatitis A and brucellosis - in Lebanon, for the first 28 weeks of 2005 and first 26 weeks of 2007.

METHODS

The electronic early warning system is based on the mandatory notification of 37 targeted diseases. The four target diseases assessed in this paper are based on monthly notification. Standards were set for case definitions and forms. Physicians and hospitals report to the Ministry of Public Health (MOPH), where data is checked and transmitted to a central location for entry into the national database, which stores historical and current data, as well as population estimates based on national surveys. The event date was selected for case dating. Indicators triggering abnormalities include number of cases, rates, and relative ratios. Four relative ratios were selected using the period of 1 week, 4 weeks or 52 weeks for the current and previous years. Screening was conducted on a weekly basis in 2005, and on a daily basis in 2007. Abnormal signals were verified, documented and grouped by alert-episodes for each disease, district, and period. MOPH teams verified and investigated case clustering.

RESULTS

During the first 28 weeks of 2005 and the first 26 weeks of 2007, screening operations were 68% and 89%, respectively, for completeness. Detected abnormal signals were 26 and 166 and identified alert-episodes were 11 and 22, respectively. Verified clusters were 7 and 11; positive predictive value for clusters identification was 64% and 50%, respectively. The time interval between first cases and first abnormal signals was on average 4 weeks and 5 weeks, respectively.

CONCLUSION

Timely reporting, transmission, data entry, analysis and communication are the elements of timely outbreak detection. The electronic surveillance of outbreaks for epidemic-prone diseases, which are mandatory notified on a monthly basis using indicator-based thresholds, is capable of detecting spatio-temporal clusters and outbreaks; however, with some delay. The national surveillance system needs to be reviewed in order to provide timely data for early warning surveillance and response.

Unknown disease in South Africa identified as arenavirus infection

On 12 September 2008, a tourist guide organising safari trips, residing in Lusaka, Zambia, was evacuated in a critical condition to Johannesburg, South Africa. She was admitted to a clinic where she died on 14 September about 10 days after the onset of symptoms. The symptoms included a prodromal phase with fever, myalgia, vomiting, diarrhoea, followed by rash, liver dysfunction and convulsions [1]. Cerebral oedema was detected on scan examination. No laboratory specimen was available for investigation. The paramedic who had cared for the index case during her evacuation to Johannesburg developed prodromal symptoms similar to the index case. He was hospitalised on 27 September. His condition deteriorated and he died on 2 October. An intensive care unit nurse who cared for the index case in Johannesburg developed similar flu-like symptoms and was hospitalised on 1 October. Her condition deteriorated on 4 October and she died on 5 October of acute respiratory distress syndrome. In both cases, the incubation period is estimated to have been about one week. On 13 October, the World Health Organization (WHO) posted a website update informing about a fourth case affecting a nurse who had been in contact with the paramedic [2]. On 12 October 2008, the National Institute for Communicable Diseases (NICD) in South Africa provided preliminary evidence that the causative agent of the disease was a virus from the Arenaviridae family [3]. Specimens were shipped to the United States Centers for Disease Control and Prevention (CDC) in Atlanta for additional investigations.

Unknown disease in South Africa identified as arenavirus infection

On 12 September 2008, a tourist guide organising safari trips, residing in Lusaka, Zambia, was evacuated in a critical condition to Johannesburg, South Africa. She was admitted to a clinic where she died on 14 September about 10 days after the onset of symptoms. The symptoms included a prodromal phase with fever, myalgia, vomiting, diarrhoea, followed by rash, liver dysfunction and convulsions [1]. Cerebral oedema was detected on scan examination. No laboratory specimen was available for investigation.

Melamine contamination of dairy products in China – public health impact on citizens of the European Union

On 10 September 2008, ProMED issued a request for information concerning 14 cases of kidney stones in infants hospitalised in Gansu province, China, in the previous two months [1]. On 21 September, Chinese authorities reported 39,965 cases of kidney stones in infants, including three deaths related to the consumption of melamine-contaminated powdered infant formula. On that day, 12,892 of them were hospitalised, 104 with severe illness. Most of these cases (82%) affected children under two years of age.

Preparedness activities ahead of the Beijing 2008 Olympic Games - enhancing EU epidemic intelligence

This Friday, 8 August 2008 will see the official opening of the Beijing 2008 Olympic Games. In the following weeks (8-24 August) an estimated 10,500 athletes from 205 participating countries will compete in the Olympics, followed by the Paralympics (6-17 September). Sporting events will be held in Olympic venues hosted mainly in Beijing city, Tianjin, Hong Kong, Shanghai, Shenyang, Qinhuangdao and Qingdao (See Figure). An estimated 2.4 million spectators are anticipated to join in the celebration of the Olympics alone, with over 20,000 accredited media present [1] and 450,000 foreigners expected [2].