Investigations of selected historically important syndromic outbreaks: impact and lessons learned for public health preparedness and response

Task Force for a rapid response to an outbreak of severe acute hepatitis of unknown aetiology in children in Portugal in 2022

On 5 April 2022, the United Kingdom reported an increase of cases of severe acute hepatitis of unknown aetiology in children, several needing hospitalisation and some required liver transplant or died. Thereafter, 35 countries reported probable cases, almost half of them in Europe. Facing the alert, on 28 April, Portugal created a multidisciplinary Task Force (TF) for rapid detection of probable cases and response. The experts of the TF came from various disciplines: clinicians, laboratory experts, epidemiologists, public health experts and national and international communication. Moreover, Portugal adopted the European Centre for Disease Prevention and Control (ECDC) and the World Health Organization (WHO) case definition and recommendations. By 31 December 2022, 28 probable cases of severe acute hepatitis of unknown aetiology were reported: 16 male and 17 aged under 2 years. Of these cases, 23 were hospitalised but none required liver transplant or died. Adenovirus was detected from nine of 26 tested cases. No association was observed between adenovirus infection and hospital admission after adjusting for age, sex and region in a binomial regression model. The TF in Portugal may have contributed to increase awareness among clinicians, enabling early detection and prompt management of the outbreak.

Investigating outbreaks of initially unknown aetiology in complex settings: findings and recommendations from 10 case studies

BACKGROUND

Outbreaks of unknown aetiology in complex settings pose challenges and there is little information about investigation methods. We reviewed investigations into such outbreaks to identify methods favouring or impeding identification of the cause.

METHODS

We used two approaches: reviewing scientific literature and soliciting key informants. Case studies were developed through interviews with people involved and triangulated with documents available from the time of the investigation.

RESULTS

Ten outbreaks in African or Asian countries within the period 2007-2017 were selected. The cause was identified in seven, of which two had an unclear mode of transmission, and in three, neither origin nor transmission mode was identified. Four events were caused by infectious agents and three by chemical poisoning. Despite differences in the outbreaks, similar obstacles were noted: incomplete or delayed description of patients, comorbidities confounding clinical pictures and case definitions wrongly attributed. Repeated rounds of data collection and laboratory investigations were common and there was limited capacity to ship samples.

DISCUSSION

It was not possible to define activities that led to prompt identification of the cause in the case studies selected. Based on the observations, we conclude that basing case definitions on precise medical observations, implementing initial comprehensive data collection, including environmental, social and behavioural information; and involving local informants could save precious time and hasten implementation of control measures.

Shiga Toxin-Producing Escherichia coli (STEC) O157:H7 and Romaine Lettuce: Source Labeling, Prevention, and Business

From May to November most romaine lettuce shipments in the United States come from California's Central Coast region, whereas from December to April most come from the Yuma, Arizona, region. During 2017-2018, the 3 outbreaks of Shiga toxin-producing Escherichia coli (STEC) O157:H7 in US romaine lettuce all occurred at the tail end of a region's production season. During the fall 2018 outbreak, the US Food and Drug Administration (FDA) recommended that suppliers begin labeling romaine packaging so that consumers can identify the product's harvest region.We used publicly available data to show that labels may not avert many illnesses in future outbreaks but may reduce suppliers' financial losses and reduce food loss.Market data available during both 2018 outbreak investigations showed that there was no romaine production from one of the 2 regions when the first illness onset occurred. That is, at the beginning of an outbreak investigation, market data may allow the FDA to quickly rule out an entire production region as a source of contamination.

Missouri K-12 school collection and reporting of school-based syndromic surveillance data: a cross sectional study

BACKGROUND

School participation in collecting and reporting syndromic surveillance (SS) data to public health officials and school nurses' attitudes regarding SS have not been assessed.

METHODS

An online survey was sent to Missouri Association of School Nurses members during the 2013/2014 school year to assess whether K-12 schools were collecting and reporting SS data. Z-scores were used to assess collection versus reporting of SS indicators. Logistic regressions were used to describe factors predicting nurses' collection and reporting of SS indicators: all-cause absenteeism, influenza-like illness and gastrointestinal illness. Univariate predictors were assessed with Chi-Squares.

RESULTS

In total, 133 school nurses participated (33.6 % response rate). Almost all (90.2 %, n = 120) collect at least one SS indicator; half (49.6 %, n = 66) report at least one. Schools are collecting more SS data than they are reporting to the health department (p < .05 for all comparisons). Determinants of school nurses' collection of SS data included perceived administrative support, and knowledge of collecting and analyzing SS data. The strongest predictive factors for reporting SS data were the perception that the health department was interested in SS data and being approached by the health department to collect SS data.

CONCLUSION

Schools are collecting SS indicators at a relatively high rate, yet less than half of the data is reported to public health officials. Findings from this study indicate that public health officials can increase access to school-based SS data by approaching schools about collecting and reporting this important data.

Health Information in the Background: Justifying Public Health Surveillance Without Patient Consent

Often we think of collecting, storing, and using health data without patient consent as unethical and illegal. However, there are situations where the collection of health information without consent is not only ethical and legal, it is essential for community and public health. Public health surveillance – the ongoing, systematic collection, analysis, and interpretation of health-related data with the a priori purpose of preventing or controlling disease or injury, or identifying unusual events of public health importance, followed by the dissemination and use of information for public health action – allows the government to meet its ethical obligation to protect the health of the population. By adhering to public health ethics principles, public health surveillance systems, including pervasive information and computing technology (PICT), can be designed and implemented in ways that both honor individuals and protect communities.