Analytical framework to evaluate and optimize the use of imperfect diagnostics to inform outbreak response: Application to the 2017 plague epidemic in Madagascar

Multiple Introductions of Yersinia pestis during Urban Pneumonic Plague Epidemic, Madagascar, 2017

Pneumonic plague (PP) is characterized by high infection rate, person-to-person transmission, and rapid progression to severe disease. In 2017, a PP epidemic occurred in 2 Madagascar urban areas, Antananarivo and Toamasina. We used epidemiologic data and Yersinia pestis genomic characterization to determine the sources of this epidemic. Human plague emerged independently from environmental reservoirs in rural endemic foci >20 times during August-November 2017. Confirmed cases from 5 emergences, including 4 PP cases, were documented in urban areas. Epidemiologic and genetic analyses of cases associated with the first emergence event to reach urban areas confirmed that transmission started in August; spread to Antananarivo, Toamasina, and other locations; and persisted in Antananarivo until at least mid-November. Two other Y. pestis lineages may have caused persistent PP transmission chains in Antananarivo. Multiple Y. pestis lineages were independently introduced to urban areas from several rural foci via travel of infected persons during the epidemic.

The potential of resilience indicators to anticipate infectious disease outbreaks, a systematic review and guide

To reduce the consequences of infectious disease outbreaks, the timely implementation of public health measures is crucial. Currently used early-warning systems are highly context-dependent and require a long phase of model building. A proposed solution to anticipate the onset or termination of an outbreak is the use of so-called resilience indicators. These indicators are based on the generic theory of critical slowing down and require only incidence time series. Here we assess the potential for this approach to contribute to outbreak anticipation. We systematically reviewed studies that used resilience indicators to predict outbreaks or terminations of epidemics. We identified 37 studies meeting the inclusion criteria: 21 using simulated data and 16 real-world data. 36 out of 37 studies detected significant signs of critical slowing down before a critical transition (i.e., the onset or end of an outbreak), with a highly variable sensitivity (i.e., the proportion of true positive outbreak warnings) ranging from 0.03 to 1 and a lead time ranging from 10 days to 68 months. Challenges include low resolution and limited length of time series, a too rapid increase in cases, and strong seasonal patterns which may hamper the sensitivity of resilience indicators. Alternative types of data, such as Google searches or social media data, have the potential to improve predictions in some cases. Resilience indicators may be useful when the risk of disease outbreaks is changing gradually. This may happen, for instance, when pathogens become increasingly adapted to an environment or evolve gradually to escape immunity. High-resolution monitoring is needed to reach sufficient sensitivity. If those conditions are met, resilience indicators could help improve the current practice of prediction, facilitating timely outbreak response. We provide a step-by-step guide on the use of resilience indicators in infectious disease epidemiology, and guidance on the relevant situations to use this approach.

Emerging bacterial infectious diseases/pathogens vectored by human lice

Human lice have always been a major public health concern due to their vector capacity for louse-borne infectious diseases, like trench fever, louse-borne relapsing fever, and epidemic fever, which are caused by Bartonella quintana, Borrelia recurrentis, and Rickettsia prowazekii, respectively. Those diseases are currently re-emerging in the regions of poor hygiene, social poverty, or wars with life-threatening consequences. These louse-borne diseases have also caused outbreaks among populations in jails and refugee camps. In addition, antibodies and DNAs to those pathogens have been steadily detected in homeless populations. Importantly, more bacterial pathogens have been detected in human lice, and some have been transmitted by human lice in laboratories. Here, we provide a comprehensive review and update on louse-borne infectious diseases/bacterial pathogens.