Experience and lessons from surveillance and studies of the 2009 pandemic in Europe

Anxiety levels and solution-focused thinking skills of nurses and midwives working in primary care during the COVID-19 pandemic: A descriptive correlational study

AIMS

To determine the state-trait anxiety levels and solution-focused thinking skills of primary care nurses/midwives during the COVID-19 pandemic, and to evaluate the factors affecting these variables and the determinants of state-trait anxiety levels.

BACKGROUND

The COVID-19 outbreak has created intense anxiety in nurses/midwives that may affect the care they provide. Nurses and midwives may manage anxiety using solution-focused thinking skills.

METHODS

This descriptive correlational study included 170 nurses/midwives at 61 family health centres evaluated from 1 August to 14 September 2020.

RESULTS

The participants' state and trait anxiety scores were above average, indicating a moderate level of anxiety and the mean total solution-focused inventory scores were at a moderate level. It was determined that 47.9% of the variance in state anxiety scores could be explained by trait anxiety, age, years of professional experience, chronic illness, type of work shift during the pandemic, follow-up of patients diagnosed with COVID-19 using computed tomography or a COVID-19 test, and whether the institution was taking necessary measures against COVID-19. There was a negative relationship between state anxiety and solution-focused inventory total score.

CONCLUSION

Nurses/midwives displayed a moderate level of anxiety and solution-focused thinking skills during the COVID-19 pandemic.

IMPLICATIONS FOR NURSING MANAGEMENT

Steps should be taken to improve nurses' solution-focused thinking skills to enable them to organise quickly and manage care processes successfully in extraordinary circumstances such as pandemics. Moreover, personal empowerment programmes should be recommended for nurses and midwives to help them cope with anxiety.

Modelling the Economic Impact and Ripple Effects of Disease Outbreaks

The Coronavirus Disease 2019 (COVID-19) outbreak has had alarming effects on human lives and the economies of affected countries. With the world’s manufacturing hubs experiencing a period of extended factory closures, the economic impact transcends territorial borders via global supply chains. This paper provides a roadmap on how to evaluate the vulnerability that cascades through the supply chain due to a disease outbreak at the firm level, national level, and global scale. The final extent of losses is not yet known, but the development of economic models combined with epidemiological models and network analysis techniques can yield more realistic estimates to select appropriate strategies in a timely manner.

Assessing the severity of influenza: a role for longitudinal telephone surveys?

During the 2009 influenza pandemic, a rapid assessment of disease severity was a challenge as a significant proportion of cases did not seek medical care; care-seeking behaviour changed and the proportion asymptomatic was unknown. A random-digit-dialling telephone survey was undertaken during the 2011/12 winter season in England and Wales to address the feasibility of answering these questions. A proportional quota sampling strategy was employed based on gender, age group, geographical location, employment status and level of education. Households were recruited pre-season and re-contacted immediately following peak seasonal influenza activity. The pre-peak survey was undertaken in October 2011 with 1061 individuals recruited and the post-peak telephone survey in March 2012. Eight hundred and thirty-four of the 1061 (78.6%) participants were successfully re-contacted. Their demographic characteristics compared well to national census data. In total, 8.4% of participants self-reported an influenza-like illness (ILI) in the previous 2 weeks, with 3.2% conforming to the World Health Organization (WHO) ILI case definition. In total, 29.6% of the cases reported consulting their general practitioner. 54.1% of the 1061 participants agreed to be re-contacted about providing biological samples. A population-based cohort was successfully recruited and followed up. Longitudinal survey methodology provides a practical tool to assess disease severity during future pandemics.

Detecting a Surprisingly Low Transmission Distance in the Early Phase of the 2009 Influenza Pandemic

The spread of the 2009 H1N1 influenza pandemic in England was characterized by two major waves of infections: the first one was highly spatially localized (mainly in the London area), while the second one spread homogeneously through the entire country. The reasons behind this complex spatiotemporal dynamics have yet to be clarified. In this study, we perform a Bayesian analysis of five models entailing different hypotheses on the possible determinants of the observed pattern. We find a consensus among all models in showing a surprisingly low transmission distance (defined as the geographic distance between the place of residence of the infectors and her/his infectees) during the first wave: about 1.5 km (2.2 km if infections linked to household and school transmission are excluded). The best-fitting model entails a change in human activity regarding contacts not related to household and school. By using this model we estimate that the transmission distance sharply increased to 5.3 km (10 km when excluding infections linked to household and school transmission) during the second wave. Our study reveals a possible explanation for the observed pattern and highlights the need of better understanding human mobility and activity patterns under the pressure posed by a pandemic threat.

Public preferences for vaccination programmes during pandemics caused by pathogens transmitted through respiratory droplets - a discrete choice experiment in four European countries, 2013

This study aims to quantify and compare preferences of citizens from different European countries for vaccination programme characteristics during pandemics, caused by pathogens which are transmitted through respiratory droplets. Internet panel members, nationally representative based on age, sex, educational level and region, of four European Union Member States (Netherlands, Poland, Spain, and Sweden, n = 2,068) completed an online discrete choice experiment. These countries, from different geographical areas of Europe, were chosen because of the availability of high-quality Internet panels and because of the cooperation between members of the project entitled Effective Communication in Outbreak Management: development of an evidence-based tool for Europe (ECOM). Data were analysed using panel latent class regression models. In the case of a severe pandemic scenario, vaccine effectiveness was the most important characteristic determining vaccination preference in all countries, followed by the body that advises on vaccination. In Sweden, the advice of family and/or friends and the advice of physicians strongly affected vaccine preferences, in contrast to Poland and Spain, where the advice of (international) health authorities was more decisive. Irrespective of pandemic scenario or vaccination programme characteristics, the predicted vaccination uptakes were lowest in Sweden, and highest in Poland. To increase vaccination uptake during future pandemics, the responsible authorities should align with other important stakeholders in the country and communicate in a coordinated manner.

Framing post-pandemic preparedness: Comparing eight European plans

Framing has previously been studied in the field of pandemic preparedness and global health governance and influenza pandemics have usually been framed in terms of security and evidence-based medicine on a global scale. This paper is based on the pandemic preparedness plans, published after 2009, from eight European countries. We study how pandemic preparedness is framed and how pandemic influenza in general is narrated in the plans. All plans contain references to 'uncertainty', 'pandemic phases', 'risk management', 'vulnerability' and 'surveillance'. These themes were all framed differently in the studied plans. The preparedness plans in the member states diverge in ways that will challenge the ambition of the European Union to make the pandemic preparedness plans interoperable and to co-ordinate the member states during future pandemics.

Effectiveness of travel restrictions in the rapid containment of human influenza: a systematic review

OBJECTIVE

To assess the effectiveness of internal and international travel restrictions in the rapid containment of influenza.

METHODS

We conducted a systematic review according to the requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Health-care databases and grey literature were searched and screened for records published before May 2014. Data extraction and assessments of risk of bias were undertaken by two researchers independently. Results were synthesized in a narrative form.

FINDINGS

The overall risk of bias in the 23 included studies was low to moderate. Internal travel restrictions and international border restrictions delayed the spread of influenza epidemics by one week and two months, respectively. International travel restrictions delayed the spread and peak of epidemics by periods varying between a few days and four months. Travel restrictions reduced the incidence of new cases by less than 3%. Impact was reduced when restrictions were implemented more than six weeks after the notification of epidemics or when the level of transmissibility was high. Travel restrictions would have minimal impact in urban centres with dense populations and travel networks. We found no evidence that travel restrictions would contain influenza within a defined geographical area.

CONCLUSION

Extensive travel restrictions may delay the dissemination of influenza but cannot prevent it. The evidence does not support travel restrictions as an isolated intervention for the rapid containment of influenza. Travel restrictions would make an extremely limited contribution to any policy for rapid containment of influenza at source during the first emergence of a pandemic virus.

The consortium for the standardization of influenza seroepidemiology (CONSISE): a global partnership to standardize influenza seroepidemiology and develop influenza investigation protocols to inform public health policy

CONSISE - The consortium for the Standardization of Influenza Seroepidemiology - is a global partnership to develop influenza investigation protocols and standardize seroepidemiology to inform health policy. This international partnership was formed in 2011 and was created out of a need, identified during the 2009 H1N1 pandemic, for timely seroepidemiological data to better estimate pandemic virus infection severity and attack rates to inform policy decisions. CONSISE has developed into a consortium of two interactive working groups: epidemiology and laboratory, with a steering committee composed of individuals from several organizations. CONSISE has had two international meetings with more planned for 2013. We seek additional members from public health agencies, academic institutions and other interested parties.

The epidemiology and surveillance response to pandemic influenza A (H1N1) among local health departments in the San Francisco Bay Area

BACKGROUND

Public health surveillance and epidemiologic investigations are critical public health functions for identifying threats to the health of a community. Very little is known about how these functions are conducted at the local level. The purpose of the Epidemiology Networks in Action (EpiNet) Study was to describe the epidemiology and surveillance response to the 2009 pandemic influenza A (H1N1) by city and county health departments in the San Francisco Bay Area in California. The study also documented lessons learned from the response in order to strengthen future public health preparedness and response planning efforts in the region.

METHODS

In order to characterize the epidemiology and surveillance response, we conducted key informant interviews with public health professionals from twelve local health departments in the San Francisco Bay Area. In order to contextualize aspects of organizational response and performance, we recruited two types of key informants: public health professionals who were involved with the epidemiology and surveillance response for each jurisdiction, as well as the health officer or his/her designee responsible for H1N1 response activities. Information about the organization, data sources for situation awareness, decision-making, and issues related to surge capacity, continuity of operations, and sustainability were collected during the key informant interviews. Content and interpretive analyses were conducted using ATLAS.ti software.

RESULTS

The study found that disease investigations were important in the first months of the pandemic, often requiring additional staff support and sometimes forcing other public health activities to be put on hold. We also found that while the Incident Command System (ICS) was used by all participating agencies to manage the response, the manner in which it was implemented and utilized varied. Each local health department (LHD) in the study collected epidemiologic data from a variety of sources, but only case reports (including hospitalized and fatal cases) and laboratory testing data were used by all organizations. While almost every LHD attempted to collect school absenteeism data, many respondents reported problems in collecting and analyzing these data. Laboratory capacity to test influenza specimens often aided an LHD's ability to conduct disease investigations and implement control measures, but the ability to test specimens varied across the region and even well-equipped laboratories exceeded their capacity. As a whole, the health jurisdictions in the region communicated regularly about key decision-making (continued on next page) (continued from previous page) related to the response, and prior regional collaboration on pandemic influenza planning helped to prepare the region for the novel H1N1 influenza pandemic. The study did find, however, that many respondents (including the majority of epidemiologists interviewed) desired an increase in regional communication about epidemiology and surveillance issues.

CONCLUSION

The study collected information about the epidemiology and surveillance response among LHDs in the San Francisco Bay Area that has implications for public health preparedness and emergency response training, public health best practices, regional public health collaboration, and a perceived need for information sharing.

Influenza serological studies to inform public health action: best practices to optimise timing, quality and reporting

BACKGROUND

Serological studies can detect infection with a novel influenza virus in the absence of symptoms or positive virology, providing useful information on infection that goes beyond the estimates from epidemiological, clinical and virological data. During the 2009 A(H1N1) pandemic, an impressive number of detailed serological studies were performed, yet the majority of serological data were available only after the first wave of infection. This limited the ability to estimate the transmissibility and severity of this novel infection, and the variability in methodology and reporting limited the ability to compare and combine the serological data.

OBJECTIVES

  To identify best practices for conduct and standardisation of serological studies on outbreak and pandemic influenza to inform public policy.

METHODS/SETTING

An international meeting was held in February 2011 in Ottawa, Canada, to foster the consensus for greater standardisation of influenza serological studies.

RESULTS

Best practices for serological investigations of influenza epidemiology include the following: classification of studies as pre-pandemic, outbreak, pandemic or inter-pandemic with a clearly identified objective; use of international serum standards for laboratory assays; cohort and cross-sectional study designs with common standards for data collection; use of serum banks to improve sampling capacity; and potential for linkage of serological, clinical and epidemiological data. Advance planning for outbreak studies would enable a rapid and coordinated response; inclusion of serological studies in pandemic plans should be considered.

CONCLUSIONS

Optimising the quality, comparability and combinability of influenza serological studies will provide important data upon emergence of a novel or variant influenza virus to inform public health action.

Public health communication with frontline clinicians during the first wave of the 2009 influenza pandemic

CONTEXT

During public health emergencies, office-based frontline clinicians are critical partners in the detection, treatment, and control of disease. Communication between public health authorities and frontline clinicians is critical, yet public health agencies, medical societies, and healthcare delivery organizations have all called for improvements.

OBJECTIVES

Describe communication processes between public health and frontline clinicians during the first wave of the 2009 novel influenza A(H1N1) pandemic; assess clinicians' use of and knowledge about public health guidance; and assess clinicians' perceptions and preferences about communication during a public health emergency.

DESIGN AND METHODS

During the first wave of the pandemic, we performed a process analysis and surveyed 509 office-based primary care providers in Utah.

SETTING AND PARTICIPANTS

Public health and healthcare leaders from major agencies involved in emergency response in Utah and office-based primary care providers located throughout Utah.

MAIN OUTCOME MEASURE(S)

Communication process and information flow, distribution of e-mails, proportion of clinicians who accessed key Web sites at least weekly, clinicians' knowledge about recent guidance and perception about e-mail load, primary information sources, and qualitative findings from clinician feedback.

RESULTS

The process analysis revealed redundant activities and messaging. The 141 survey respondents (28%) received information from a variety of sources: 68% received information from state public health; almost 100% received information from health care organizations. Only one-third visited a state public health or institutional Web site frequently enough (at least weekly) to obtain updated guidance. Clinicians were knowledgeable about guidance that did not change during the first wave; however, correct knowledge was lower after guidance changed. Clinicians felt overwhelmed by e-mail volume, preferred a single institutional e-mail for clinical guidance, and suggested that new information be concise and clearly identified.

CONCLUSION

: Communication between public health, health care organizations and clinicians was redundant and overwhelming and can be enhanced considering clinician preferences and institutional communication channels.

Transmission dynamics, border entry screening, and school holidays during the 2009 influenza A (H1N1) pandemic, China

Screening delayed spread by <4 days; autumn school holidays reduced the effective reproduction number by ≈40%.

Pandemic influenza A (H1N1) 2009 virus spread rapidly around the world in 2009. We used multiple data sources from surveillance systems and specific investigations to characterize the transmission patterns of this virus in China during May–November 2009 and analyze the effectiveness of border entry screening and holiday-related school closures on transmission. In China, age distribution and transmission dynamic characteristics were similar to those in Northern Hemisphere temperate countries. The epidemic was focused in children, with an effective reproduction number of ≈1.2–1.3. The 8 days of national holidays in October reduced the effective reproduction number by 37% (95% credible interval 28%–45%) and increased underreporting by ≈20%–30%. Border entry screening detected at most 37% of international travel–related cases, with most (89%) persons identified as having fever at time of entry. These findings suggest that border entry screening was unlikely to have delayed spread in China by >4 days.

Nowcasting influenza epidemics using non-homogeneous hidden Markov models

Timeliness of a public health surveillance system is one of its most important characteristics. The process of predicting the present situation using available incomplete information from surveillance systems has received the term nowcasting and has high public health interest. Generally in Europe, general practitioners' sentinel networks support the epidemiological surveillance of influenza activity, and each week's epidemiological bulletins are usually issued between Wednesday and Friday of the following week. In this work, we have developed a non-homogeneous hidden Markov model (HMM) that, on a weekly basis, uses as covariates an early observation of influenza-like illness (ILI) incidence rate and the number of ILI cases tested positive to nowcast the current week ILI rate and the probability that the influenza activity is in an epidemic state. We use Bayesian inference to find estimates of the model parameters and nowcasted quantities. The results obtained with data provided by the Portuguese influenza surveillance system show the additional value of using a non-homogeneous HMM instead of a homogeneous one. The use of a non-homogeneous HMM improves the surveillance system timeliness in 2 weeks.

Immunogenicity of low-dose MF59-adjuvanted 2009 influenza A/H1N1 vaccine in dialysis patients

BACKGROUND

In response to the pandemic 2009 A/H1N1 virus, monovalent MF59-adjuvanted vaccines were prepared. Recently, single 3.75-μg doses of MF59-adjuvanted vaccines have shown good immunogenicity in young adults. However, the immunogenicity of these vaccines has not been evaluated in dialysis patients.

METHODS

Dialysis patients received a single 3.75-μg dose of MF59-adjuvanted vaccine by intramuscular injection. For immunogenicity assays, serum samples were obtained before vaccination and 28 days after vaccination. All sera were tested by hemagglutination inhibition assays.

RESULTS

Overall, 48 hemodialysis (HD) patients and 34 peritoneal dialysis (PD) patients were included in immunogenicity analysis. In HD patients, geometric mean titers (GMTs) were significantly increased compared with baseline GMTs in both young (aged 18-60 years) and elderly (aged ≥ 60 years) patients (51.2 ± 51.4 vs. 14.1 ± 20.7 in young patients, P = 0.012; 37.9 ± 73.9 vs. 6.8 ± 8.0 in elderly patients, P = 0.018, respectively). The rates of seroprotection and seroconversion were 27.6 and 17.2 % in young patients and 31.6 and 26.3 % in elderly patients, respectively. Among PD patients, GMTs were increased only in young patients (39.8 ± 51.4 vs. 6.8 ± 5.0, P = 0.001). The rates of seroprotection and seroconversion were 36.0 and 36.0 % in young patients and 11.1 and 0.0 % in elderly patients, respectively.

CONCLUSION

A single 3.75-μg dose of MF59-adjuvanted vaccine was suboptimal to elicit protective antibody response in dialysis patients. Antibody responses against vaccine were compromised especially in elderly PD patients. Trials of different vaccination protocols such as a two-dose schedule or a higher hemagglutinin antigen dose of MF59-adjuvanted vaccine are necessary for improving antibody response in dialysis patients.

Developing pandemic preparedness in Europe in the 21st century: experience, evolution and next steps

PROBLEM

Improving pandemic planning and preparedness is a challenge in Europe, a diverse region whose regional bodies (the Regional Office for Europe of the World Health Organization [WHO], the European Commission and the European Centre for Disease Prevention and Control) have overlapping roles and responsibilities.

APPROACH

European pandemic preparedness indicators were used to develop an assessment tool and procedure based on the 2005 global WHO checklist for pandemic preparedness. These were then applied to Member States of WHO's European Region, initially as part of structured national assessments conducted during short visits by external teams.

LOCAL SETTING

Countries in WHO's European Region.

RELEVANT CHANGES

From 2005 to 2008, 43 countries underwent a pandemic preparedness assessment that included a short external assessment visit by an expert team. These short visits developed into a longer self-assessment procedure involving an external team but "owned" by the countries, which identified gaps and developed plans for improving preparedness. The assessment tool and procedure became more sophisticated as national and local pandemic preparedness became more complex. The 2009 pandemic revealed new gaps in planning, surveillance communications and immunization.

LESSONS LEARNT

Structured national self-assessments with support from external teams allow individual countries to identify gaps in their pandemic preparedness plans and enable regional bodies to assess the regional and global resources that such plans require. The 2009 pandemic revealed additional problems with surveillance, pandemic severity estimates, the flexibility of the response, vaccination, involvement of health-care workers and communication. European national plans are being upgraded and global leadership is required to ensure that these plans are uniformly applied across the region.

Rapid estimation of excess mortality: nowcasting during the heatwave alert in England and Wales in June 2011

Background

A Heat-Health Watch system has been established in England and Wales since 2004 as part of the national heatwave plan following the 2003 European-wide heatwave. One important element of this plan has been the development of a timely mortality surveillance system. This article reports the findings and timeliness of a daily mortality model used to ‘nowcast’ excess mortality (utilising incomplete surveillance data to estimate the number of deaths in near-real time) during a heatwave alert issued by the Met Office for regions in South and East England on 24 June 2011.

Methods

Daily death registrations were corrected for reporting delays with historical data supplied by the General Registry Office. These corrected counts were compared with expected counts from an age-specific linear regression model to ascertain if any excess had occurred during the heatwave.

Results

Excess mortality of 367 deaths was detected across England and Wales in ≥85-year-olds on 26 and 27 June 2011, coinciding with the period of elevated temperature. This excess was localised to the east of England and London. It was detected 3 days after the heatwave.

Conclusion

A daily mortality model was sensitive and timely enough to rapidly detect a small excess, both, at national and regional levels. This tool will be useful when future events of public health significance occur.

Understanding theoretically the impact of reporting of disease cases in epidemiology

In conducting preliminary analysis during an epidemic, data on reported disease cases offer key information in guiding the direction to the in-depth analysis. Models for growth and transmission dynamics are heavily dependent on preliminary analysis results. When a particular disease case is reported more than once or alternatively is never reported or detected in the population, then in such a situation, there is a possibility of existence of multiple reporting or under reporting in the population. In this work, a theoretical approach for studying reporting error in epidemiology is explored. The upper bound for the error that arises due to multiple reporting is higher than that which arises due to under reporting. Numerical examples are provided to support the arguments. This paper mainly treats reporting error as deterministic and one can explore a stochastic model for the same.

Epidemiological and clinical characteristics of the outbreak of 2009 pandemic influenza A (H1N1) at a middle school in Luoyang, China

OBJECTIVES

To describe the epidemiological and clinical characteristics of 2009 H1N1 influenza, particularly the incubation period and the duration of symptoms, and to assess the public health response to this outbreak.

STUDY DESIGN

A retrospective cohort study was conducted among all students and employees in a middle school by telephone survey and laboratory inspection.

METHODS

Nasopharyngeal specimens were collected and tested, and real-time reverse transcriptase polymerase chain reaction testing was performed to confirm the viral infection. The epidemiological and clinical characteristics were obtained through a telephone survey, and the incubation period and the duration of symptoms associated with 2009 H1N1 influenza were estimated by parametric distribution.

RESULTS

In total, 253 cases of influenza-like illness were found among students and employees, and 79 of these cases were confirmed as H1N1 infection through laboratory inspection. The response rate for the telephone survey was 93.48% for the students (2586/2768) and 85.87% for the employees (158/184). The average attack rate was 9.22% (253/2744). The main reported symptoms were fever (100%), cough (74.68%), sore throat (59.49%), headache (56.96%) and myalgia/arthralgia (51.90%). No complications were reported and no deaths occurred. The confirmed and suspected cases had no associated travel history or contact with a confirmed or probable case. The estimated median incubation period was 1.6 days [95% confidence interval (CI) 1.2-2.3]. The duration of symptoms was 3-11 days, and the median duration of symptoms was 7.5 days (95% CI 4.5-10.5).

CONCLUSIONS

The results suggest that the outbreak of 2009 H1N1 influenza in this middle school was widespread but not severe. The natural history of 2009 H1N1 influenza virus appears to be similar to that of previously circulating pandemic and interpandemic influenza viruses. The public health response indicates that school closure could have a substantial impact on the spread of 2009 H1N1 influenza.

The community impact of the 2009 influenza pandemic in the WHO European region: a comparison with historical seasonal data from 28 countries

BACKGROUND

The world has recently experienced the first influenza pandemic of the 21st century that lasted 14 months from June 2009 to August 2010. This study aimed to compare the timing, geographic spread and community impact during the winter wave of influenza pandemic A (H1N1) 2009 to historical influenza seasons in countries of the WHO European region.

METHODS

We assessed the timing of pandemic by comparing the median peak of influenza activity in countries of the region during the last seven influenza seasons. The peaks of influenza activity were selected by two independent researchers using predefined rules. The geographic spread was assessed by correlating the peak week of influenza activity in included countries against the longitude and latitude of the central point in each country. To assess the community impact of pandemic influenza, we constructed linear regression models to compare the total and age-specific influenza-like-illness (ILI) or acute respiratory infection (ARI) rates reported by the countries in the pandemic season to those observed in the previous six influenza seasons.

RESULTS

We found that the influenza activity reached its peak during the pandemic, on average, 10.5 weeks (95% CI 6.4-14.2) earlier than during the previous 6 seasons in the Region, and there was a west to east spread of pandemic A(H1N1) influenza virus in the western part of the Region. A regression analysis showed that the total ILI or ARI rates were not higher than historical rates in 19 of the 28 countries. However, in countries with age-specific data, there were significantly higher consultation rates in the 0-4 and/or 5-14 age groups in 11 of the 20 countries.

CONCLUSIONS

Using routine influenza surveillance data, we found that pandemic influenza had several differential features compared to historical seasons in the region. It arrived earlier, caused significantly higher number of outpatient consultations in children in most countries and followed west to east spread that was previously observed during some influenza seasons with dominant A (H3N2) ifluenza viruses. The results of this study help to understand the epidemiology of 2009 influenza pandemic and can be used for pandemic preparedness planning.

Emerging and neglected tropical diseases: translational application of proteomics

The challenges of identifying and controlling emerging diseases impact individual health, as well as political, social and economic situations. In this review we discuss the role of proteomics for investigation of pathogen discovery, outbreak investigation, bio-defense, disease control, host-pathogen dynamics and vaccine development of emerging and neglected tropical diseases (NTDs). In the future the discipline of proteomics may help define multiple aspects of emerging and NTDs with respect to personalized medicine and public health.

Seroprevalence to influenza A(H1N1) 2009 virus--where are we?

Age-specific seroprevalences for influenza virus make important contributions to estimating the burden of infection and determining the vulnerable populations. It is especially difficult to know the true clinical attack rates of the 2009 influenza A(H1N1) pandemic; however, we can estimate infection rates through analyses of seroprevalences based on national studies from different continents and countries with different demographics. After the 2009 influenza A(H1N1) pandemic, seroprevalence studies found 5 to 60% of populations across different continents and age groups having antibodies against the A(H1N1) 2009 virus. The seropositivity was highest in children and teenagers (20 to 60%) as well as in the elderly older than 80 years (20 to 40%). Preexisting cross-reactive antibodies against the virus were present mostly in sera of older people (born before 1950) who could have encountered viruses descended from the 1918 pandemic viruses. Experience with the 2009 pandemic indicates how essential early and timely serology data against the emerging virus can be for informing decisions on use of antivirals and vaccination campaigns, especially in regard to risk groups. The objectives of this review were to summarize the current data available on seroprevalence before and after the 2009 influenza A(H1N1) pandemic and the lessons learned for future pandemic preparedness.

Determination of the relative economic impact of different molecular-based laboratory algorithms for respiratory viral pathogen detection, including Pandemic (H1N1), using a secure web based platform

Background

During period of crisis, laboratory planners may be faced with a need to make operational and clinical decisions in the face of limited information. To avoid this dilemma, our laboratory utilizes a secure web based platform, Data Integration for Alberta Laboratories (DIAL) to make near real-time decisions.

This manuscript utilizes the data collected by DIAL as well as laboratory test cost modeling to identify the relative economic impact of four proposed scenarios of testing for Pandemic H1N1 (2009) and other respiratory viral pathogens.

Methods

Historical data was collected from the two waves of the pandemic using DIAL. Four proposed molecular testing scenarios were generated: A) Luminex respiratory virus panel (RVP) first with/without US centers for Disease Control Influenza A Matrix gene assay (CDC-M), B) CDC-M first with/without RVP, C) RVP only, and D) CDC-M only. Relative cost estimates of different testing algorithm were generated from a review of historical costs in the lab and were based on 2009 Canadian dollars.

Results

Scenarios A and B had similar costs when the rate of influenza A was low (< 10%) with higher relative cost in Scenario A with increasing incidence. Scenario A provided more information about mixed respiratory virus infection as compared with Scenario B.

Conclusions

No one approach is applicable to all conditions. Testing costs will vary depending on the test volume, prevalence of influenza A strains, as well as other circulating viruses and a more costly algorithm involving a combination of different tests may be chosen to ensure that tests results are returned to the clinician in a quicker manner. Costing should not be the only consideration for determination of laboratory algorithms.

Nowcasting pandemic influenza A/H1N1 2009 hospitalizations in the Netherlands

During emerging epidemics of infectious diseases, it is vital to have up-to-date information on epidemic trends, such as incidence or health care demand, because hospitals and intensive care units have limited excess capacity. However, real-time tracking of epidemics is difficult, because of the inherent delay between onset of symptoms or hospitalizations, and reporting. We propose a robust algorithm to correct for reporting delays, using the observed distribution of reporting delays. We apply the algorithm to pandemic influenza A/H1N1 2009 hospitalizations as reported in the Netherlands. We show that the proposed algorithm is able to provide unbiased predictions of the actual number of hospitalizations in real-time during the ascent and descent of the epidemic. The real-time predictions of admissions are useful to adjust planning in hospitals to avoid exceeding their capacity.

Influenza A (H1N1) in Victoria, Australia: a community case series and analysis of household transmission

BACKGROUND

We characterise the clinical features and household transmission of pandemic influenza A (pH1N1) in community cases from Victoria, Australia in 2009.

METHODS

Questionnaires were used to collect information on epidemiological characteristics, illness features and co-morbidities of cases identified in the 2009 Victorian Influenza Sentinel Surveillance program.

RESULTS

The median age of 132 index cases was 21 years, of whom 54 (41%) were under 18 years old and 28 (21%) had medical co-morbidities. The median symptom duration was significantly shorter for children who received antivirals than in those who did not (p = 0.03). Assumed influenza transmission was observed in 63 (51%) households. Influenza-like illness (ILI) developed in 115 of 351 household contacts, a crude secondary attack rate of 33%. Increased ILI rates were seen in households with larger numbers of children but not larger numbers of adults. Multivariate analysis indicated contacts of cases with cough and diarrhoea, and contacts in quarantined households were significantly more likely to develop influenza-like symptoms.

CONCLUSION

Most cases of pH1N1 in our study were mild with similar clinical characteristics to seasonal influenza. Illness and case features relating to virus excretion, age and household quarantine may have influenced secondary ILI rates within households.

Reflections on pandemic (H1N1) 2009 and the international response

Gabriel Leung and Angus Nicoll provide their reflections on the international response to the 2009 H1N1 influenza pandemic, including what went well and what changes need to be made in anticipation of future flu pandemics.

Report of the 6th meeting on the evaluation of pandemic influenza vaccines in clinical trials World Health Organization, Geneva, Switzerland, 17-18 February 2010

On February 17-18, 2010, the World Health Organization (WHO) convened the 6th meeting on the "Evaluation of pandemic influenza vaccines in clinical trials" to review the progress made on new A (H1N1) 2009 vaccines and prototype H5N1 vaccines and their evaluation in clinical trials. A number of vaccine types were reviewed, including classical egg-derived and cell culture-derived inactivated vaccines, such as split virus or whole-virion vaccines, and live-attenuated vaccines (LAIV), as well as vaccines developed using new technologies. The amount of antigen needed, the effect of adjuvants and the number of doses required to induce adequate antibody responses in various populations, together with the issue of safety of the vaccines, were major topics of the meeting. The effectiveness of H1N1 vaccines and the need for standardization of vaccine potency tests were also discussed. Independent of the vaccine type and the presence or absence of an adjuvant, all A (H1N1) 2009 vaccines were well tolerated, eliciting only mild to moderate local or systemic reactions. For most vaccines tested, a single dose was sufficient to elicit a potentially protective antibody response in the majority of vaccinees >10 years of age. However, a second dose of vaccine was needed to boost immune responses in infants and toddlers 6 months to 3 years of age and, with some vaccines, in children aged 3-9 years.

A surveillance sector review applied to infectious diseases at a country level

Background

The new International Health Regulations (IHR) require World Health Organization (WHO) member states to assess their core capacity for surveillance. Such reviews also have the potential to identify important surveillance gaps, improve the organisation of disparate surveillance systems and to focus attention on upstream hazards, determinants and interventions.

Methods

We developed a surveillance sector review method for evaluating all of the surveillance systems and related activities across a sector, in this case those concerned with infectious diseases in New Zealand. The first stage was a systematic description of these surveillance systems using a newly developed framework and classification system. Key informant interviews were conducted to validate the available information on the systems identified.

Results

We identified 91 surveillance systems and related activities in the 12 coherent categories of infectious diseases examined. The majority (n = 40 or 44%) of these were disease surveillance systems. They covered all categories, particularly for more severe outcomes including those resulting in death or hospitalisations. Except for some notifiable diseases and influenza, surveillance of less severe, but important infectious diseases occurring in the community was largely absent. There were 31 systems (34%) for surveillance of upstream infectious disease hazards, including risk and protective factors. This area tended to have many potential gaps and lack integration, partly because such systems were operated by a range of different agencies, often outside the health sector. There were fewer surveillance systems for determinants, including population size and characteristics (n = 9), and interventions (n = 11).

Conclusions

It was possible to create and populate a workable framework for describing all the infectious diseases surveillance systems and related activities in a single developed country and to identify potential surveillance sector gaps. This is the first stage in a review process that will lead to identification of priorities for surveillance sector development.