A method that accounts for differential detectability in mixed samples of long‐term infections with applications to the case of chronic wasting disease in cervids

Assessing freedom from chronic wasting disease in semi-domesticated reindeer in Norway and Sweden

Establishing freedom from disease is a key component of surveillance and may have direct consequences for trade and economy. Transboundary populations pose challenges in terms of variable legislation, efforts, and data availability between countries, often limiting surveillance efficiency. Chronic wasting disease (CWD) is a contagious prion disease of cervids. The long incubation period and slow initial epidemic growth make it notoriously difficult to detect CWD in the early phase of an epidemic. The recent emergence of CWD in wild reindeer in Norway poses a threat to approximately 250,000 semi-domesticated reindeer in Norway and 250,000 in Sweden, including transboundary populations. Here, we provide a first analysis of surveillance data (2016-2022) from all reindeer districts in Norway and Sweden to determine the probability of freedom from CWD infection. During the six years, 6017 semi-domesticated reindeer were tested in Sweden and 51,974 in Norway. Most samples came from healthy slaughtered animals (low risk). Reindeer use large and remote areas and (high risk) samples from fallen stock and animals with clinical signs were difficult to obtain. A scenario tree model was run for seven different set of values for the input parameters (design prevalence within and between districts, probability of introduction, and relative risks) to determine the effect on surveillance sensitivity. At the national level, the mean probability of disease freedom was 59.0 % in Sweden and 87.0 % in Norway by 2021. The most marked effect on sensitivity was varying the design prevalence both within and between districts. Uncertainty about relative risk ratios affected sensitivity for Sweden more than for Norway, due to the higher proportion of animals in the high-risk group in the former (13.8 % vs. 2.1 %, respectively). A probability of disease freedom of 90 % or higher was reached in 8.2 % of the 49 districts in Sweden and 43.5 % of the 46 districts in Norway for a design prevalence of 0.5 %. The probability of freedom remained below 60 % in 29 districts (59.2 %) in Sweden and 10 districts (21.7 %) in Norway. At the national level, only Norway had a sufficiently large number of samples to reach a probability of more than 95 % of disease freedom within a period of 10 years. Our cross-border assessment forms an important knowledge base for designing future surveillance efforts depending on the spatial pattern of prevalence of CWD and risk of spread.

Based on knowledge capital value for disease cost accounting of diagnosis related groups

Background

The National Health Commission and the other relevant departments in China have initiated testing of the Diagnosis Related Groups (DRGs) system in 30 pilot locations since 2019. In the process of DRG payment reform, accounting for the costs of diseases has become a highly challenging issue. The traditional method of disease accounting method overlooks the compensation for the knowledge capital value of medical personnel.

Objective

The primary objective of this study is to analyze the cost accounting scheme of China's Diagnosis Related Groups (C-DRG), focusing on the value of knowledge capital.

Methods

The study initially proposes a measurement index system for the value of knowledge-based capital, including the difficulty of disease treatment, labor intensity of disease treatment, risk of disease treatment, and operation/treatment time for diseases. The Analytic Hierarchy Process (AHP) is then utilized to weigh the features of medical workers' knowledge capital value. First, pairwise comparisons are conducted in this stage to develop a two-pair judgment matrix of the primary indicators. Second, the eigenvectors corresponding to the maximum eigenvalues of the matrix are calculated to generate the weight coefficient of each feature. The consistency test is carried out after this stage. An empirical analysis is conducted by collecting data, including the full costs of treating three types of diseases-hip replacement, acute simple appendicitis, and heart bypass surgery-from one public medical institution.

Results

The empirical analysis examines whether this DRG costing accounting can address the issue of neglecting the value of medical workers' knowledge capital. The methods reconfigure the positive incentive mechanism, stimulate the endogenous motivation of the medical service system, foster independent changes in medical behavior, and achieve the goals of reasonable cost control.

Conclusion

In the cost accounting system of C-DRG, the value of medical workers' knowledge capital is acknowledged. This acknowledgment not only boosts the enthusiasm and creativity of medical workers in optimizing and standardizing the diagnosis and treatment process but also improves the transparency and authenticity of DRG pricing. This is particularly evident in the optimization and standardization of the diagnosis and treatment processes within medical institutions and in monitoring inadequate medical practices within these institutions.

Monitoring of chronic wasting disease (CWD) (IV)

The European Commission requested an analysis of the Chronic Wasting Disease (CWD) monitoring programme in Norway, Sweden, Finland, Iceland, Estonia, Latvia, Lithuania and Poland (9 January 2017-28 February 2022). Thirteen cases were detected in reindeer, 15 in moose and 3 in red deer. They showed two phenotypes, distinguished by the presence or absence of detectable disease-associated normal cellular prion protein (PrP) in lymphoreticular tissues. CWD was detected for the first time in Finland, Sweden and in other areas of Norway. In countries where the disease was not detected, the evidence was insufficient to rule out its presence altogether. Where cases were detected, the prevalence was below 1%. The data also suggest that the high-risk target groups for surveillance should be revised, and 'road kill' removed. Data show that, in addition to differences in age and sex, there are differences in the prion protein gene (PRNP) genotypes between positive and negative wild reindeer. A stepwise framework has been proposed with expanded minimum background surveillance to be implemented in European countries with relevant cervid species. Additional surveillance may include ad hoc surveys for four different objectives, specific to countries with/without cases, focusing on parallel testing of obex and lymph nodes from adult cervids in high-risk target groups, sustained over time, using sampling units and a data-driven design prevalence. Criteria for assessing the probability of CWD presence have been outlined, based on the definition of the geographical area, an annual assessment of risk of introduction, sustained minimum background surveillance, training and engagement of stakeholders and a surveillance programme based on data-driven parameters. All positive cases should be genotyped. Sample sizes for negative samples have been proposed to detect and estimate the frequency of PRNP polymorphisms. Double-strand sequencing of the entire PRNP open reading frame should be undertaken for all selected samples, with data collated in a centralised collection system at EU level.

Evaluation of Real-Time Quaking-Induced Conversion, ELISA, and Immunohistochemistry for Chronic Wasting Disease Diagnosis

Chronic wasting disease (CWD) is a transmissible prion disorder, primarily affecting free-ranging and captive cervids in North America (United States and Canada), South Korea, and Europe (Finland, Norway, and Sweden). Current diagnostic methods used in the United States for detection of CWD in hunter harvested deer involve demonstration of the causal misfolded prion protein (PrP^CWD) in the obex or retropharyngeal lymph nodes (RLNs) using an antigen detection ELISA as a screening tool, followed by a confirmation by the gold standard method, immunohistochemistry (IHC). Real-time quaking-induced conversion (RT-QuIC) assay is a newer approach that amplifies misfolded CWD prions in vitro and has facilitated CWD prion detection in a variety of tissues, body fluids, and excreta. The current study was undertaken to compare ELISA, IHC, and RT-QuIC on RLNs (n = 1,300 animals) from white-tailed deer (WTD) in Michigan. In addition, prescapular, prefemoral and popliteal lymph nodes collected from a small subset (n = 7) of animals were tested. Lastly, the location of the positive samples within Michigan was documented and the percentage of CWD positive RLNs was calculated by sex and age. ELISA and RT-QuIC detected PrP^CWD in 184 and 178 out of 1,300 RLNs, respectively. Of the 184 ELISA positive samples, 176 were also IHC positive for CWD. There were seven discordant results when comparing IHC and ELISA. RT-QuIC revealed that six of the seven samples matched the IHC outcomes. One RLN was negative by IHC, but positive by ELISA and RT-QuIC. RT-QuIC, IHC, and ELISA also detected PrP^CWD in prescapular, prefemoral and popliteal lymph nodes. CWD infection heterogeneities were observed in different age and sex groups, with young males having higher CWD prevalence. All, except one, CWD positive RLNs analyzed were from ten Counties geographically located in the West Michigan region of the Lower Peninsula. Taken together, we show evidence that the RT-QuIC assay is comparable to ELISA and IHC and could be helpful for routine CWD detection in surveillance programs. RT-QuIC also demonstrated that CWD prions are distributed across lymph nodes in a variety of anatomic locations. A multi-laboratory validation on blinded sample panels is underway and is likely to help to provide insight into the variability (lab-to-lab), analytical sensitivity, and specificity of gold standard diagnostics vs. RT-QuIC assay.

Chronic wasting disease in Europe: new strains on the horizon

Prion diseases are fatal neurodegenerative disorders with known natural occurrence in humans and a few other mammalian species. The diseases are experimentally transmissible, and the agent is derived from the host-encoded cellular prion protein (PrP^C), which is misfolded into a pathogenic conformer, designated PrP^Sc (scrapie). Aggregates of PrP^Sc molecules, constitute proteinaceous infectious particles, known as prions. Classical scrapie in sheep and goats and chronic wasting disease (CWD) in cervids are known to be infectious under natural conditions. In CWD, infected animals can shed prions via bodily excretions, allowing direct host-to-host transmission or indirectly via prion-contaminated environments. The robustness of prions means that transmission via the latter route can be highly successful and has meant that limiting the spread of CWD has proven difficult. In 2016, CWD was diagnosed for the first time in Europe, in reindeer (Rangifer tarandus) and European moose (Alces alces). Both were diagnosed in Norway, and, subsequently, more cases were detected in a semi-isolated wild reindeer population in the Nordfjella area, in which the first case was identified. This population was culled, and all reindeer (approximately 2400) were tested for CWD; 18 positive animals, in addition to the first diagnosed case, were found. After two years and around 25,900 negative tests from reindeer (about 6500 from wild and 19,400 from semi-domesticated) in Norway, a new case was diagnosed in a wild reindeer buck on Hardangervidda, south of the Nordfjella area, in 2020. Further cases of CWD were also identified in moose, with a total of eight in Norway, four in Sweden, and two cases in Finland. The mean age of these cases is 14.7 years, and the pathological features are different from North American CWD and from the Norwegian reindeer cases, resembling atypical prion diseases such as Nor98/atypical scrapie and H- and L-forms of BSE. In this review, these moose cases are referred to as atypical CWD. In addition, two cases were diagnosed in red deer (Cervus elaphus) in Norway. The emergence of CWD in Europe is a threat to European cervid populations, and, potentially, a food-safety challenge, calling for a swift, evidence-based response. Here, we review data on surveillance, epidemiology, and disease characteristics, including prion strain features of the newly identified European CWD agents.

Review on PRNP genetics and susceptibility to chronic wasting disease of Cervidae

To date, chronic wasting disease (CWD) is the most infectious form of prion disease affecting several captive, free ranging and wild cervid species. Responsible for marked population declines in North America, its geographical spread is now becoming a major concern in Europe. Polymorphisms in the prion protein gene (PRNP) are an important factor influencing the susceptibility to prions and their rate of propagation. All reported cervid PRNP genotypes are affected by CWD. However, in each species, some polymorphisms are associated with lower attack rates and slower progression of the disease. This has potential consequences in terms of genetic selection, CWD diffusion and strain evolution. CWD also presents a zoonotic risk due to prions capacity to cross species barriers. This review summarizes our current understanding of CWD control, focusing on PRNP genetic, strain diversity and capacity to infect other animal species, including humans.

Risk-based surveillance of chronic wasting disease in semi-domestic reindeer

Reindeer pastoralism is a widespread practise across Fennoscandia and Russia. An outbreak of chronic wasting disease (CWD) among wild reindeer (Rangifer tarandus) poses a severe threat to the semi-domestic reindeer herding culture. Establishing surveillance is therefore key, but current models for surveillance of CWD are designed for wild cervids and rely on samples obtained from recreational hunters. Targeting animal groups with a higher infection probability is often used for more efficient disease surveillance. CWD has a long incubation period of 2-3 years, and the animals show clinical signs in the later stages of the infection i.e. 1-4 months prior to death. The semi-domestic reindeer are free-ranging most of the year, but during slaughtering in late fall, herders stress the animals in penned areas. This allows removal of animals with deviant behaviour or physical appearance, and such removals are likely to include animals in the clinical stages of CWD if the population is infected. In Norway, the semi-domestic reindeer in Filefjell is adjacent to a previously CWD infected wild population. We developed a risk-based surveillance method for this semi-domestic setting to establish the probability of freedom from infection over time, or enable early disease detection and mitigation. The surveillance scheme with a scenario tree using three risk categories (sample category, demographic group, and deviations in behaviour or physical appearance) was more effective and less invasive as compared to the surveillance method developed for wild reindeer. We also simulated how variation in susceptibility, incubation period and time for onset of clinical signs (linked to variation in the prion protein gene, PRNP) would potentially affect surveillance. Surveillance for CWD was mandatory within EU-member states with reindeer (2018-2020). The diversity of management systems and epidemiological settings will require the development of a set of surveillance systems suitable for each different context. Our surveillance model is designed for a population with a high risk of CWD introduction requiring massive sampling, while at the same time aiming to limit adverse effects to the populations in areas of surveillance.

A Landscape Epidemiological Approach for Predicting Chronic Wasting Disease: A Case Study in Virginia, US

Many infectious diseases in wildlife occur under quantifiable landscape ecological patterns useful in facilitating epidemiological surveillance and management, though little is known about prion diseases. Chronic wasting disease (CWD), a fatal prion disease of the deer family Cervidae, currently affects white-tailed deer (Odocoileus virginianus) populations in the Mid-Atlantic United States (US) and challenges wildlife veterinarians and disease ecologists from its unclear mechanisms and associations within landscapes, particularly in early phases of an outbreak when CWD detections are sparse. We aimed to provide guidance for wildlife disease management by identifying the extent to which CWD-positive cases can be reliably predicted from landscape conditions. Using the CWD outbreak in Virginia, US from 2009 to early 2020 as a case study system, we used diverse algorithms (e.g., principal components analysis, support vector machines, kernel density estimation) and data partitioning methods to quantify remotely sensed landscape conditions associated with CWD cases. We used various model evaluation tools (e.g., AUC ratios, cumulative binomial testing, Jaccard similarity) to assess predictions of disease transmission risk using independent CWD data. We further examined model variation in the context of uncertainty. We provided significant support that vegetation phenology data representing landscape conditions can predict and map CWD transmission risk. Model predictions improved when incorporating inferred home ranges instead of raw hunter-reported coordinates. Different data availability scenarios identified variation among models. By showing that CWD could be predicted and mapped, our project adds to the available tools for understanding the landscape ecology of CWD transmission risk in free-ranging populations and natural conditions. Our modeling framework and use of widely available landscape data foster replicability for other wildlife diseases and study areas.

Harvest strategies for the elimination of low prevalence wildlife diseases

The intensive harvesting of hosts is often the only practicable strategy for controlling emerging wildlife diseases. Several harvesting approaches have been explored theoretically with the objective of lowering transmission rates, decreasing the transmission period or specifically targeting spatial disease clusters or high-risk demographic groups. Here, we present a novel model-based approach to evaluate alternative harvest regimes, in terms of demographic composition and rates, intended to increase the probability to remove all infected individuals in the population during the early phase of an outbreak. We tested the utility of the method for the elimination of chronic wasting disease based on empirical data for reindeer (Rangifer tarandus) in Norway, in populations with (Nordfjella) and without (Hardangervidda) knowledge about exact disease prevalence and population abundance. Low and medium harvest intensities were unsuccessful in eliminating the disease, even at low prevalence. High-intensity harvesting had a high likelihood of eliminating the disease, but probability was strongly influenced by the disease prevalence. We suggest that the uncertainty about disease prevalence can be mitigated by using an adaptive management approach: forecast from models after each harvest season with updated data, derive prevalence estimates and forecast further harvesting. We identified the problems arising from disease surveillance with large fluctuations in harvesting pressure and hence sample sizes. The elimination method may be suitable for pathogens that cause long-lasting infections and with slow epidemic growth, but the method should only be attempted if there is a low risk of reinfection, either by a new disease introduction event (e.g. dispersing hosts) or due to environmental reservoirs. Our simulations highlighted the short time window when such a strategy is likely to be successful before approaching near complete eradication of the population.

Getting in Front of Chronic Wasting Disease: Model-Informed Proactive Approach for Managing an Emerging Wildlife Disease

Continuing geographic spread of chronic wasting disease (CWD) poses a serious threat to the sustainable future of cervids and hunting in North America. Moreover, CWD has been detected in captive cervids in South Korea and, in recent years, in free-ranging reindeer in Europe (Norway). Management of this disease is limited by logistical, financial, and sociopolitical considerations, and current strategies primarily focus on reducing host densities through hunter harvest and targeted culling. The success of such strategies in mitigating the spread and prevalence of CWD only upon detection is questionable. Here, we propose a proactive approach that emphasizes pre-emptive management through purposeful integration of virtual experiments (simulating alternate interventions as model scenarios) with the aim of evaluating their effectiveness. Here, we have used a published agent-based model that links white-tailed deer demography and behavior with CWD transmission dynamics to first derive a CWD outbreak trajectory and then use the trajectory to highlight issues associated with different phases of the CWD outbreak (pre-establishment/transition/endemic). Specifically, we highlight the practical constraints on surveillance in the pre-establishment phase and recommend that agencies use a realistic detection threshold for their CWD surveillance programs. We further demonstrate that many disease introductions are "dead ends" not leading to a full epidemic due to high stochasticity and harvesting in the pre-establishment phase of CWD. Model evaluated pre-emptive (pre-detection) harvest strategies could increase the resilience of the deer population to CWD spread and establishment. We conclude it is important to adaptively position CWD management ahead of, rather than behind, the CWD front.

Studies in bank voles reveal strain differences between chronic wasting disease prions from Norway and North America

Chronic wasting disease (CWD) is a relentless epidemic disorder caused by infectious prions that threatens the survival of cervid populations and raises increasing public health concerns in North America. In Europe, CWD was detected for the first time in wild Norwegian reindeer (Rangifer tarandus) and moose (Alces alces) in 2016. In this study, we aimed at comparing the strain properties of CWD prions derived from different cervid species in Norway and North America. Using a classical strain typing approach involving transmission and adaptation to bank voles (Myodes glareolus), we found that prions causing CWD in Norway induced incubation times, neuropathology, regional deposition of misfolded prion protein aggregates in the brain, and size of their protease-resistant core, different from those that characterize North American CWD. These findings show that CWD prion strains affecting Norwegian cervids are distinct from those found in North America, implying that the highly contagious North American CWD prions are not the proximate cause of the newly discovered Norwegian CWD cases. In addition, Norwegian CWD isolates showed an unexpected strain variability, with reindeer and moose being caused by different CWD strains. Our findings shed light on the origin of emergent European CWD, have significant implications for understanding the nature and the ecology of CWD in Europe, and highlight the need to assess the zoonotic potential of the new CWD strains detected in Europe.

Hunting strategies to increase detection of chronic wasting disease in cervids

The successful mitigation of emerging wildlife diseases may involve controversial host culling. For livestock, ‘preemptive host culling’ is an accepted practice involving the removal of herds with known contact to infected populations. When applied to wildlife, this proactive approach comes in conflict with biodiversity conservation goals. Here, we present an alternative approach of ‘proactive hunting surveillance’ with the aim of early disease detection that simultaneously avoids undesirable population decline by targeting demographic groups with (1) a higher likelihood of being infected and (2) a lower reproductive value. We applied this harvesting principle to populations of reindeer to substantiate freedom of chronic wasting disease (CWD) infection. Proactive hunting surveillance reached 99% probability of freedom from infection (<4 reindeer infected) within 3–5 years, in comparison to ~10 years using ordinary harvest surveillance. However, implementation uncertainties linked to social issues appear challenging also with this kind of host culling.

Rarely are the outcomes of mathematical (probability) models of wildlife disease detection used to inform policy or management changes. Here the authors develop a proactive hunting surveillance program that shortened the time required to establish freedom from chronic wasting disease at the population level in reindeer.

Control and Surveillance Operations to Prevent Chronic Wasting Disease Establishment in Free-Ranging White-Tailed Deer in Québec, Canada

Chronic wasting disease (CWD), a degenerative and fatal prion disease affecting cervids, was detected for the first time in the province of Québec, Canada, in a red deer (Cervus elaphus) farm in the Laurentides region on 10 September 2018. To assess CWD prevalence and control the disease in the free-ranging white-tailed deer (Odocoileus virginianus) population, a response plan including enhanced surveillance, population control, regulatory measures, and public outreach was deployed by the Ministry of Forests, Wildlife, and Parks (MFFP). In the 401 km² white-tailed deer control area, a total of 750 free-ranging white-tailed deer were culled over 70 days, from 22 September to 15 December 2018. Of the culled deer, 534 were tested for CWD. We also tested for CWD a total of 447 white-tailed deer hunted from the enhanced surveillance zone and 2584 free-ranging white-tailed deer harvested outside this zone. Regulations were applied to prevent the spread of the disease through movements of infected animals harvested by hunters. Although no case of CWD was detected in free-ranging cervids in Québec in 2018, this does not confirm the absence of the disease in these populations. However, the results suggest that if CWD is present, few free-ranging cervids are infected, making it possible to prevent its establishment in the province of Québec.

Chronic wasting disease associated with prion protein gene (PRNP) variation in Norwegian wild reindeer (Rangifer tarandus)

The emergence of CWD in Europe in 2016 and the first natural infection in wild reindeer warranted disease management. This led to the testing of 2424 hunted or culled reindeer during 2016–2018, from the infected subpopulation in the Nordfjella mountain range in Southern Norway. To identify any association between PRNP variation and CWD susceptibility, we characterized the open reading frame of the PRNP gene in 19 CWD positive reindeer and in 101 age category- and sex-matched CWD negative controls. Seven variant positions were identified: 6 single nucleotide variants (SNVs) and a 24 base pair (bp) deletion located between nucleotide position 238 and 272, encoding four instead of five octapeptide repeats. With a single exception, all variant positions but one were predicted to be non-synonymous. The synonymous SNV and the deletion are novel in reindeer. Various combinations of the non-synonymous variant positions resulted in the identification of five PRNP alleles (A-E) that structured into 14 genotypes. We identified an increased CWD risk in reindeer carrying two copies of the most common allele, A, coding for serine in position 225 (Ser225) and in those carrying allele A together with the 24 bp deletion.

Update on chronic wasting disease (CWD) III

The European Commission asked EFSA for a Scientific Opinion: to revise the state of knowledge about the differences between the chronic wasting disease (CWD) strains found in North America (NA) and Europe and within Europe; to review new scientific evidence on the zoonotic potential of CWD and to provide recommendations to address the potential risks and to identify risk factors for the spread of CWD in the European Union. Full characterisation of European isolates is being pursued, whereas most NA CWD isolates have not been characterised in this way. The differing surveillance programmes in these continents result in biases in the types of cases that can be detected. Preliminary data support the contention that the CWD strains identified in Europe and NA are different and suggest the presence of strain diversity in European cervids. Current data do not allow any conclusion on the implications of strain diversity on transmissibility, pathogenesis or prevalence. Available data do not allow any conclusion on the zoonotic potential of NA or European CWD isolates. The risk of CWD to humans through consumption of meat cannot be directly assessed. At individual level, consumers of meat, meat products and offal derived from CWD-infected cervids will be exposed to the CWD agent(s). Measures to reduce human dietary exposure could be applied, but exclusion from the food chain of whole carcasses of infected animals would be required to eliminate exposure. Based on NA experiences, all the risk factors identified for the spread of CWD may be associated with animals accumulating infectivity in both the peripheral tissues and the central nervous system. A subset of risk factors is relevant for infected animals without involvement of peripheral tissues. All the risk factors should be taken into account due to the potential co-localisation of animals presenting with different disease phenotypes.