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Tannis A, Miele K, Carlson JM, O'Callaghan KP, Woodworth KR, Anderson B, Praag A, Pulliam K, Coppola N, Willabus T, Mbotha D, Abetew D, Currenti S, Longcore ND, Akosa A, Meaney-Delman D, Tong VT, Gilboa SM, Olsen EO. Syphilis Treatment Among People Who Are Pregnant in Six U.S. States, 2018-2021. Obstet Gynecol 2024:00006250-990000000-01059. [PMID: 38626449 DOI: 10.1097/aog.0000000000005586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/07/2024] [Indexed: 04/18/2024]
Abstract
OBJECTIVE To describe syphilis treatment status and prenatal care among people with syphilis during pregnancy to identify missed opportunities for preventing congenital syphilis. METHODS Six jurisdictions that participated in SET-NET (Surveillance for Emerging Threats to Pregnant People and Infants Network) conducted enhanced surveillance among people with syphilis during pregnancy based on case investigations, medical records, and linkage of laboratory data with vital records. Unadjusted risk ratios (RRs) were used to compare demographic and clinical characteristics by syphilis stage (primary, secondary, or early latent vs late latent or unknown) and treatment status during pregnancy (adequate per the Centers for Disease Control and Prevention's "Sexually Transmitted Infections Treatment Guidelines, 2021" vs inadequate or not treated) and by prenatal care (timely: at least 30 days before pregnancy outcome; nontimely: less than 30 days before pregnancy outcome; and no prenatal care). RESULTS As of September 15, 2023, of 1,476 people with syphilis during pregnancy, 855 (57.9%) were adequately treated and 621 (42.1%) were inadequately treated or not treated. Eighty-two percent of the cohort received timely prenatal care. Although those with nontimely or no prenatal care were more likely to receive inadequate or no treatment (RR 2.50, 95% CI, 2.17-2.88 and RR 2.73, 95% CI, 2.47-3.02, respectively), 32.1% of those with timely prenatal care were inadequately or not treated. Those with reported substance use or a history of homelessness were nearly twice as likely to receive inadequate or no treatment (RR 2.04, 95% CI, 1.82-2.28 and RR 1.83, 95% CI, 1.58-2.13, respectively). CONCLUSION In this surveillance cohort, people without timely prenatal care had the highest risk for syphilis treatment inadequacy; however, almost a third of people who received timely prenatal care were not adequately treated. These findings underscore gaps in syphilis screening and treatment for pregnant people, especially those experiencing substance use and homelessness, and the need for systems-based interventions, such as treatment outside of traditional prenatal care settings.
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Affiliation(s)
- Ayzsa Tannis
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, and the Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, and the Georgia Department of Public Health, Atlanta, Georgia; Eagle Global Scientific, LLC, San Antonio, Texas; Lukos LLC, Tampa, Florida; the Arizona Department of Health Services and Maricopa County Public Health, Phoenix, Arizona; the New Jersey Department of Health, Trenton, New Jersey; the Washington State Department of Health, Bellevue, Washington; and the New York State Department of Health, Albany, New York
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Gosdin L, Wallace B, Lanzieri TM, O’Malley Olsen E, Lewis EL, Chang DJ, Khuwaja S, Chicchelly S, Ojo KD, Lush M, Heitner D, Longcore ND, Delgado-López C, Humphries BK, Sizemore L, Mbotha D, Hall AJ, Ellington S, Gilboa SM, Tong VT, Woodworth K. Six-Month Outcomes of Infants Born to People With SARS-CoV-2 in Pregnancy. Pediatrics 2022; 150:e2022059009. [PMID: 36317478 PMCID: PMC9761394 DOI: 10.1542/peds.2022-059009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES To assess the 6-month incidence of laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, postnatal care, hospitalization, and mortality among infants born to people with laboratory-confirmed SARS-CoV-2 infection during pregnancy by timing of maternal infection. METHODS Using a cohort of liveborn infants from pregnancies with SARS-CoV-2 infections in the year 2020 from 10 United States jurisdictions in the Surveillance for Emerging Threats to Mother and Babies Network, we describe weighted estimates of infant outcomes from birth through 6 months of age from electronic health and laboratory records. RESULTS Of 6601 exposed infants with laboratory information through 6 months of age, 1.0% (95% confidence interval: 0.8-1.1) tested positive, 19.1% (17.5-20.6) tested negative, and 80.0% (78.4-81.6) were not known to be tested for SARS-CoV-2. Among those ≤14 days of age, SARS-CoV-2 infection occurred only with maternal infection ≤14 days before delivery. Of 3967 infants with medical record abstraction, breastmilk feeding initiation was lower when maternal infection occurred ≤14 days before delivery compared with >14 days (77.6% [72.5-82.6] versus 88.3% [84.7-92.0]). Six-month all-cause hospitalization was 4.1% (2.0-6.2). All-cause mortality was higher among infants born to people with infection ≤14 days (1.0% [0.4-1.6]) than >14 days (0.3% [0.1-0.5]) before delivery. CONCLUSIONS Results are reassuring, with low incidences of most health outcomes examined. Incidence of infant SARS-CoV-2, breastmilk feeding initiation, and all-cause mortality differed by timing of maternal infection. Strategies to prevent infections and support pregnant people with coronavirus disease 2019 may improve infant outcomes.
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Affiliation(s)
- Lucas Gosdin
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Bailey Wallace
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tatiana M. Lanzieri
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Emily O’Malley Olsen
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Elizabeth L. Lewis
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Daniel J. Chang
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
- Oak Ridge Institute for Science and Education, U.S. Department of Energy, Oak Ridge, Tennessee
| | | | | | | | - Mamie Lush
- Nebraska Department of Health and Human Services, Lincoln, Nebraska
| | | | | | | | - Brian K. Humphries
- South Carolina Department of Health and Environmental Control Columbia, South Carolina
| | | | - Deborah Mbotha
- Washington State Department of Health, Olympia, Washington
| | - Aron J. Hall
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sascha Ellington
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Suzanne M. Gilboa
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Van T. Tong
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kate Woodworth
- COVID-19 Emergency Response, Centers for Disease Control and Prevention, Atlanta, Georgia
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3
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Neelam V, Reeves EL, Woodworth KR, O'Malley Olsen E, Reynolds MR, Rende J, Wingate H, Manning SE, Romitti P, Ojo KD, Silcox K, Barton J, Mobley E, Longcore ND, Sokale A, Lush M, Delgado‐Lopez C, Diedhiou A, Mbotha D, Simon W, Reynolds B, Hamdan TS, Beauregard S, Ellis EM, Seo JY, Bennett A, Ellington S, Hall AJ, Azziz‐Baumgartner E, Tong VT, Gilboa SM. Pregnancy and infant outcomes by trimester of SARS-CoV-2 infection in pregnancy-SET-NET, 22 jurisdictions, January 25, 2020-December 31, 2020. Birth Defects Res 2022; 115:145-159. [PMID: 36065896 PMCID: PMC9537929 DOI: 10.1002/bdr2.2081] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/04/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVES We describe clinical characteristics, pregnancy, and infant outcomes in pregnant people with laboratory-confirmed SARS-CoV-2 infection by trimester of infection. STUDY DESIGN We analyzed data from the Surveillance for Emerging Threats to Mothers and Babies Network and included people with infection in 2020, with known timing of infection and pregnancy outcome. Outcomes are described by trimester of infection. Pregnancy outcomes included live birth and pregnancy loss (<20 weeks and ≥20 weeks gestation). Infant outcomes included preterm birth (<37 weeks gestation), small for gestational age, birth defects, and neonatal intensive care unit admission. Adjusted prevalence ratios (aPR) were calculated for pregnancy and selected infant outcomes by trimester of infection, controlling for demographics. RESULTS Of 35,200 people included in this analysis, 50.8% of pregnant people had infection in the third trimester, 30.8% in the second, and 18.3% in the first. Third trimester infection was associated with a higher frequency of preterm birth compared to first or second trimester infection combined (17.8% vs. 11.8%; aPR 1.44 95% CI: 1.35-1.54). Prevalence of birth defects was 553.4/10,000 live births, with no difference by trimester of infection. CONCLUSIONS There were no signals for increased birth defects among infants in this population relative to national baseline estimates, regardless of timing of infection. However, the prevalence of preterm birth in people with SARS-CoV-2 infection in pregnancy in our analysis was higher relative to national baseline data (10.0-10.2%), particularly among people with third trimester infection. Consequences of COVID-19 during pregnancy support recommended COVID-19 prevention strategies, including vaccination.
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Affiliation(s)
- Varsha Neelam
- Centers for Disease Control and Prevention COVID‐19 Response, Epidemiology Task ForceAtlantaGeorgiaUSA
| | - Emily L. Reeves
- Centers for Disease Control and Prevention COVID‐19 Response, Epidemiology Task ForceAtlantaGeorgiaUSA,Eagle Global Scientific, LLCAtlantaGeorgiaUSA
| | - Kate R. Woodworth
- Centers for Disease Control and Prevention COVID‐19 Response, Epidemiology Task ForceAtlantaGeorgiaUSA
| | - Emily O'Malley Olsen
- Centers for Disease Control and Prevention COVID‐19 Response, Epidemiology Task ForceAtlantaGeorgiaUSA
| | - Megan R. Reynolds
- Centers for Disease Control and Prevention COVID‐19 Response, Epidemiology Task ForceAtlantaGeorgiaUSA
| | - Joy Rende
- New Jersey Department of HealthTrentonNew JerseyUSA
| | | | - Susan E. Manning
- Centers for Disease Control and Prevention COVID‐19 Response, Epidemiology Task ForceAtlantaGeorgiaUSA,Massachusetts Department of Public HealthBostonMassachusettsUSA
| | - Paul Romitti
- University of Iowa College of Public HealthIowa CityIowaUSA
| | | | | | | | - Evan Mobley
- Missouri Department of Health and Senior ServicesJefferson CityMissouriUSA
| | | | - Ayomide Sokale
- Philadelphia Department of Public HealthPhiladelphiaPennsylvaniaUSA
| | - Mamie Lush
- Nebraska Department of Health and Human ServicesLincolnNebraskaUSA
| | | | - Abdoulaye Diedhiou
- South Carolina Department of Health and Environmental ControlColumbiaSouth CarolinaUSA
| | - Deborah Mbotha
- Washington State Department of HealthShorelineWashingtonUSA
| | - Wanda Simon
- Arkansas Department of HealthLittle RockArkansasUSA
| | | | | | - Suzann Beauregard
- New Hampshire Department of Health and Human ServicesConcordNew HampshireUSA
| | - Esther M. Ellis
- U.S. Virgin Islands Department of HealthChristianstedVirgin IslandsUSA
| | | | - Amanda Bennett
- Centers for Disease Control and Prevention COVID‐19 Response, Epidemiology Task ForceAtlantaGeorgiaUSA,Illinois Department of Public HealthChicagoIllinoisUSA
| | - Sascha Ellington
- Centers for Disease Control and Prevention COVID‐19 Response, Epidemiology Task ForceAtlantaGeorgiaUSA
| | - Aron J. Hall
- Centers for Disease Control and Prevention COVID‐19 Response, Epidemiology Task ForceAtlantaGeorgiaUSA
| | - Eduardo Azziz‐Baumgartner
- Centers for Disease Control and Prevention COVID‐19 Response, Epidemiology Task ForceAtlantaGeorgiaUSA
| | - Van T. Tong
- Centers for Disease Control and Prevention COVID‐19 Response, Epidemiology Task ForceAtlantaGeorgiaUSA
| | - Suzanne M. Gilboa
- Centers for Disease Control and Prevention COVID‐19 Response, Epidemiology Task ForceAtlantaGeorgiaUSA
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Wainaina M, Lindahl JF, Dohoo I, Mayer-Scholl A, Roesel K, Mbotha D, Roesler U, Grace D, Bett B, Al Dahouk S. Longitudinal Study of Selected Bacterial Zoonoses in Small Ruminants in Tana River County, Kenya. Microorganisms 2022; 10:microorganisms10081546. [PMID: 36013964 PMCID: PMC9414833 DOI: 10.3390/microorganisms10081546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 11/19/2022] Open
Abstract
Brucellosis, Q fever, and leptospirosis are priority zoonoses worldwide, yet their epidemiology is understudied, and studies investigating multiple pathogens are scarce. Therefore, we selected 316 small ruminants in irrigated, pastoral, and riverine settings in Tana River County and conducted repeated sampling for animals that were initially seronegative between September 2014 and June 2015. We carried out serological and polymerase chain reaction tests and determined risk factors for exposure. The survey-weighted serological incidence rates were 1.8 (95% confidence intervals [CI]: 1.3–2.5) and 1.3 (95% CI: 0.7–2.3) cases per 100 animal-months at risk for Leptospira spp. and C. burnetii, respectively. We observed no seroconversions for Brucella spp. Animals from the irrigated setting had 6.83 (95% CI: 2.58–18.06, p-value = 0.01) higher odds of seropositivity to C. burnetii than those from riverine settings. Considerable co-exposure of animals to more than one zoonosis was also observed, with animals exposed to one zoonosis generally having 2.5 times higher odds of exposure to a second zoonosis. The higher incidence of C. burnetii and Leptospira spp. infections, which are understudied zoonoses in Kenya compared to Brucella spp., demonstrate the need for systematic prioritization of animal diseases to enable the appropriate allocation of resources.
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Affiliation(s)
- Martin Wainaina
- Department of Biological Safety, German Federal Institute for Risk Assessment, 12277 Berlin, Germany; (A.M.-S.); (S.A.D.)
- Department of Veterinary Medicine, Freie Universität Berlin, 14163 Berlin, Germany; (K.R.); (D.M.)
- Animal & Human Health Program, International Livestock Research Institute, Nairobi 00100, Kenya; (J.F.L.); (D.G.); (B.B.)
- Correspondence:
| | - Johanna F. Lindahl
- Animal & Human Health Program, International Livestock Research Institute, Nairobi 00100, Kenya; (J.F.L.); (D.G.); (B.B.)
- Zoonosis Science Center, Department of Medical Biochemistry and Microbiology, Uppsala University, 75237 Uppsala, Sweden
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, 75007 Uppsala, Sweden
| | - Ian Dohoo
- Centre for Veterinary Epidemiologic Research, University of Prince Edward Island, Charlottetown, PE C1A 4P3, Canada;
| | - Anne Mayer-Scholl
- Department of Biological Safety, German Federal Institute for Risk Assessment, 12277 Berlin, Germany; (A.M.-S.); (S.A.D.)
| | - Kristina Roesel
- Department of Veterinary Medicine, Freie Universität Berlin, 14163 Berlin, Germany; (K.R.); (D.M.)
- Animal & Human Health Program, International Livestock Research Institute, Nairobi 00100, Kenya; (J.F.L.); (D.G.); (B.B.)
| | - Deborah Mbotha
- Department of Veterinary Medicine, Freie Universität Berlin, 14163 Berlin, Germany; (K.R.); (D.M.)
- Animal & Human Health Program, International Livestock Research Institute, Nairobi 00100, Kenya; (J.F.L.); (D.G.); (B.B.)
| | - Uwe Roesler
- Institute for Animal Hygiene and Environmental Health, Freie Universität Berlin, 14163 Berlin, Germany;
| | - Delia Grace
- Animal & Human Health Program, International Livestock Research Institute, Nairobi 00100, Kenya; (J.F.L.); (D.G.); (B.B.)
- Natural Resources Institute, University of Greenwich, Kent ME4 4TB, UK
| | - Bernard Bett
- Animal & Human Health Program, International Livestock Research Institute, Nairobi 00100, Kenya; (J.F.L.); (D.G.); (B.B.)
| | - Sascha Al Dahouk
- Department of Biological Safety, German Federal Institute for Risk Assessment, 12277 Berlin, Germany; (A.M.-S.); (S.A.D.)
- Department of Internal Medicine, RWTH Aachen University Hospital, 52074 Aachen, Germany
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5
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Olsen EO, Roth NM, Aveni K, Santos P, Sizemore L, Halai U, Nestoridi E, Barton JE, Mobley E, Siebman S, Fussman C, Mbotha D, Dzimira P, Silcox KM, Khuwaja S, Roscom D, Lush M, Chicchelly S, Delgado‐López C, Schlosser L, Read J, Ellington SR, Hall AJ, Gilboa SM, Tong VT, Woodworth KR. SARS-CoV-2 infections among neonates born to pregnant people with SARS-CoV-2 infection: Maternal, pregnancy and birth characteristics. Paediatr Perinat Epidemiol 2022; 36:476-484. [PMID: 35437799 PMCID: PMC9115399 DOI: 10.1111/ppe.12883] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 03/19/2022] [Accepted: 03/26/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Multiple reports have described neonatal SARS-CoV-2 infection, including likely in utero transmission and early postnatal infection, but published estimates of neonatal infection range by geography and design type. OBJECTIVES To describe maternal, pregnancy and neonatal characteristics among neonates born to people with SARS-CoV-2 infection during pregnancy by neonatal SARS-CoV-2 testing results. METHODS Using aggregated data from the Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET) describing infections from 20 January 2020 to 31 December 2020, we identified neonates who were (1) born to people who were SARS-CoV-2 positive by RT-PCR at any time during their pregnancy, and (2) tested for SARS-CoV-2 by RT-PCR during the birth hospitalisation. RESULTS Among 28,771 neonates born to people with SARS-CoV-2 infection during pregnancy, 3816 (13%) underwent PCR testing and 138 neonates (3.6%) were PCR positive. Ninety-four per cent of neonates testing positive were born to people with infection identified ≤14 days of delivery. Neonatal SARS-CoV-2 infection was more frequent among neonates born preterm (5.7%) compared to term (3.4%). Neonates testing positive were born to both symptomatic and asymptomatic pregnant people. CONCLUSIONS Jurisdictions reported SARS-CoV-2 RT-PCR results for only 13% of neonates known to be born to people with SARS-CoV-2 infection during pregnancy. These results provide evidence of neonatal infection identified through multi-state systematic surveillance data collection and describe characteristics of neonates with SARS-CoV-2 infection. While perinatal SARS-CoV-2 infection was uncommon among tested neonates born to people with SARS-CoV-2 infection during pregnancy, nearly all cases of tested neonatal infection occurred in pregnant people infected around the time of delivery and was more frequent among neonates born preterm. These findings support the recommendation for neonatal SARS-CoV-2 RT-PCR testing, especially for people with acute infection around the time of delivery.
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Affiliation(s)
- Emily O'Malley Olsen
- Centers for Disease Control and Prevention COVID‐19 ResponseEpidemiology Task ForceAtlantaGeorgiaUSA
| | - Nicole M. Roth
- Centers for Disease Control and Prevention COVID‐19 ResponseEpidemiology Task ForceAtlantaGeorgiaUSA
| | | | | | | | - Umme‐Aiman Halai
- Los Angeles County Department of Public HealthLos AngelesCaliforniaUSA
| | | | | | - Evan Mobley
- Missouri Department of Health and Senior ServicesJefferson CityMissouriUSA
| | - Samantha Siebman
- Tennessee Department of HealthNashvilleTennesseeUSA,Minnesota Department of HealthSaint PaulMinnesotaUSA
| | - Chris Fussman
- Michigan Department of Health and Human ServicesLansingMichiganUSA
| | - Deborah Mbotha
- Washington State Department of HealthOlympiaWashingtonUSA
| | - Paula Dzimira
- Pennsylvania Department of HealthHarrisburgPennsylvaniaUSA
| | | | | | | | - Mamie Lush
- Nebraska Department of Health and Human ServicesLincolnNebraskaUSA
| | | | | | - Levi Schlosser
- North Dakota Department of HealthBismarckNorth DakotaUSA
| | - Jennifer Read
- Vermont Department of HealthUniversity of Vermont School of MedicineBurlingtonVermontUSA
| | - Sascha R. Ellington
- Centers for Disease Control and Prevention COVID‐19 ResponseEpidemiology Task ForceAtlantaGeorgiaUSA
| | - Aron J. Hall
- Centers for Disease Control and Prevention COVID‐19 ResponseEpidemiology Task ForceAtlantaGeorgiaUSA
| | - Suzanne M. Gilboa
- Centers for Disease Control and Prevention COVID‐19 ResponseEpidemiology Task ForceAtlantaGeorgiaUSA
| | - Van T. Tong
- Centers for Disease Control and Prevention COVID‐19 ResponseEpidemiology Task ForceAtlantaGeorgiaUSA
| | - Kate R. Woodworth
- Centers for Disease Control and Prevention COVID‐19 ResponseEpidemiology Task ForceAtlantaGeorgiaUSA
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6
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Griffin I, Woodworth KR, Galang RR, Burkel VK, Neelam V, Siebman S, Barton J, Manning SE, Aveni K, Longcore ND, Harvey EM, Ngo V, Mbotha D, Chicchelly S, Lush M, Eckert V, Dzimira P, Sokale A, Valencia-Prado M, Azziz-Baumgartner E, MacNeil A, Gilboa SM, Tong VT. Recurrent SARS-CoV-2 RNA Detection after COVID-19 Illness Onset during Pregnancy. Emerg Infect Dis 2022; 28:873-876. [PMID: 35213801 PMCID: PMC8962892 DOI: 10.3201/eid2804.212354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The Surveillance for Emerging Threats to Mothers and Babies Network conducts longitudinal surveillance of pregnant persons in the United States with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection during pregnancy. Of 6,551 infected pregnant persons in this analysis, 142 (2.2%) had positive RNA tests >90 days and up to 416 days after infection.
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7
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Galang RR, Newton SM, Woodworth KR, Griffin I, Oduyebo T, Sancken CL, Olsen EO, Aveni K, Wingate H, Shephard H, Fussman C, Alaali ZS, Silcox K, Siebman S, Halai UA, Lopez CD, Lush M, Sokale A, Barton J, Chaudhary I, Patrick PH, Schlosser L, Reynolds B, Gaarenstroom N, Chicchelly S, Read JS, de Wilde L, Mbotha D, Azziz-Baumgartner E, Hall AJ, Tong VT, Ellington S, Gilboa SM. Risk Factors for Illness Severity Among Pregnant Women With Confirmed Severe Acute Respiratory Syndrome Coronavirus 2 Infection-Surveillance for Emerging Threats to Mothers and Babies Network, 22 State, Local, and Territorial Health Departments, 29 March 2020-5 March 2021. Clin Infect Dis 2021; 73:S17-S23. [PMID: 34021332 PMCID: PMC8194562 DOI: 10.1093/cid/ciab432] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Pregnant women with coronavirus disease 2019 (COVID-19) are at increased risk for severe illness compared with nonpregnant women. Data to assess risk factors for illness severity among pregnant women with COVID-19 are limited. This study aimed to determine risk factors associated with COVID-19 illness severity among pregnant women with SARS-CoV-2 infection. Methods Pregnant women with SARS-CoV-2 infection confirmed by molecular testing were reported during March 29, 2020–March 5, 2021 through the Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET). Criteria for illness severity (asymptomatic, mild, moderate-to-severe, or critical) were adapted from National Institutes of Health and World Health Organization criteria. Crude and adjusted risk ratios for moderate-to-severe or critical COVID-19 illness were calculated for selected demographic and clinical characteristics. Results Among 7,950 pregnant women with SARS-CoV-2 infection, moderate-to-severe or critical COVID-19 illness was associated with age 25 years and older, healthcare occupation, pre-pregnancy obesity, chronic lung disease, chronic hypertension, and pregestational diabetes mellitus. Risk of moderate-to-severe or critical illness increased with the number of underlying medical or pregnancy-related conditions. Conclusions Older age and having underlying medical conditions were associated with increased risk of moderate-to-severe or critical COVID-19 illness among pregnant women. This information might help pregnant women understand their risk for moderate-to-severe or critical COVID-19 illness and inform targeted public health messaging.
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Affiliation(s)
- Romeo R Galang
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Suzanne M Newton
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kate R Woodworth
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Isabel Griffin
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Titilope Oduyebo
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Christina L Sancken
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Emily O'Malley Olsen
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kathryn Aveni
- Division of Family Health Services, New Jersey Department of Health, Trenton, New Jersey, USA
| | - Heather Wingate
- Communicable and Environmental Disease and Emergency Preparedness, Tennessee Department of Health, Nashville, Tennessee, USA
| | - Hanna Shephard
- Bureau of Family Health and Nutrition, Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Chris Fussman
- Maternal and Child Health Epidemiology Section, Michigan Department of Health and Human Services, Lansing, Michigan, USA
| | - Zahra S Alaali
- Division of Epidemiology, New York State Department of Health, Albany, New York, USA
| | - Kristin Silcox
- Maternal and Child Health Bureau, Maryland Department of Health, Baltimore, Maryland, USA
| | - Samantha Siebman
- Emerging Infections Program, Minnesota Department of Health, St Paul, Minnesota, USA
| | - Umme-Aiman Halai
- Acute Communicable Disease Control Program, Los Angeles County Department of Public Health, Los Angeles, California, USA
| | - Camille Delgado Lopez
- Division of Children With Special Medical Needs, Puerto Rico Department of Health, San Juan, Puerto Rico, USA
| | - Mamie Lush
- Division of Public Health, Nebraska Department of Health and Human Services, Lincoln, Nebraska, USA
| | - Ayomide Sokale
- Division of Maternal, Child and Family Health, Philadelphia Department of Public Health, Philadelphia, Pennsylvania, USA
| | - Jerusha Barton
- Epidemiology Division, Georgia Department of Public Health, Atlanta, Georgia, USA
| | - Ifrah Chaudhary
- Division of Disease Prevention and Control, Houston Health Department, Houston, Texas, USA
| | - Paul H Patrick
- Perinatal and Reproductive Health Division, Oklahoma State Department of Health, Oklahoma City, Oklahoma, USA
| | - Levi Schlosser
- Division of Disease Control, North Dakota Department of Health, Bismarck, North Dakota, USA
| | - Bethany Reynolds
- Bureau of Epidemiology, Pennsylvania Department of Health, Pittsburgh, Pennsylvania, USA
| | | | - Sarah Chicchelly
- Infectious Disease Epidemiology and Response, Kansas Department of Health and Environment, Topeka, Kansas, USA
| | - Jennifer S Read
- Infectious Disease Epidemiology, Vermont Department of Health, Burlington, Vermont, USA.,Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Leah de Wilde
- Epidemiology Division, US Virgin Islands Department of Health, Christiansted, St Croix, US Virgin Islands
| | - Deborah Mbotha
- Office of Communicable Disease Epidemiology, Washington State Department of Health, Shoreline, Washington, USA
| | | | - Aron J Hall
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Van T Tong
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sascha Ellington
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Suzanne M Gilboa
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Mbotha D, Hoppenheit A, Lindahl J, Bett B, Grace D, Lutomiah J, Pieper L, Kairu-Wanyoike S, Clausen PH. Relative Distribution, Diversity, and Bloodmeal Sources of Mosquitoes and Known Vectors of Rift Valley Fever Phlebovirus in Three Differing Ecosystems in Bura, Tana River County, Kenya. Vector Borne Zoonotic Dis 2020; 20:365-373. [PMID: 31990632 DOI: 10.1089/vbz.2019.2503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Environmental modifications disturb the equilibrium of mosquito populations, altering the risk of mosquito-borne diseases. Mosquito distribution, diversity, and bloodmeal sources were examined to compare Rift Valley fever (RVF) risk among irrigated, riverine, and pastoral ecosystems in Bura, Tana River County, Kenya, between September 2014 and June 2015. Thirty-eight households and 21 irrigation fields were selected for the study. Mosquitoes were trapped with carbon dioxide-impregnated CDC traps, one trap per household and three traps per irrigated field, and morphologically identified using taxonomic keys. Host DNA was extracted from engorged females and cytochrome b genes amplified by PCR to identify sources of bloodmeals. A total of 21,015 mosquitoes were collected; 5742 within households in the 3 ecosystems and 15,273 within irrigated fields. Mosquitoes collected within irrigated fields belonged to 8 genera and 37 species, while those from households within the irrigation scheme belonged to 6 genera and 29 species. Collections from riverine and pastoral households belonged to five and four genera, respectively. The most abundant genera in the irrigated fields were Aedes (21%) and Mansonia (22%), while Anopheles (43%) was the most abundant within households. Most mosquitoes in riverine and pastoral households belonged to Anopheles (76%) and Aedes (65%) genera, respectively. Seasonal variation driven by rainfall was evidenced by spikes in mosquito numbers within irrigated and riverine ecosystems. Host species identification revealed that goats and humans were the main sources of bloodmeal. There was an overall increase in mosquito abundance and diversity as a result of the presence of the irrigated ecosystem in this county, and an increased availability of highly RVF-susceptible hosts as a result of the establishment and concentration of residential areas, promoting potential vector-host contacts. These results highlight the impact of anthropogenic changes on mosquito ecology, potentially heightening the risk of transmission and maintenance of RVF in this region.
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Affiliation(s)
- Deborah Mbotha
- Institute for Parasitology and Tropical Veterinary Medicine, Freie Universitaet Berlin, Berlin, Germany.,International Livestock Research Institute, Nairobi, Kenya
| | - Antje Hoppenheit
- Institute for Parasitology and Tropical Veterinary Medicine, Freie Universitaet Berlin, Berlin, Germany
| | - Johanna Lindahl
- International Livestock Research Institute, Nairobi, Kenya.,Food Safety and Zoonoses, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Bernard Bett
- International Livestock Research Institute, Nairobi, Kenya
| | - Delia Grace
- International Livestock Research Institute, Nairobi, Kenya
| | - Joel Lutomiah
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Laura Pieper
- Institute for Veterinary Epidemiology and Biostatistics, Freie Universitaet Berlin, Berlin, Germany
| | | | - Peter-Henning Clausen
- Institute for Parasitology and Tropical Veterinary Medicine, Freie Universitaet Berlin, Berlin, Germany
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Lindahl JF, Ragan IK, Rowland RR, Wainaina M, Mbotha D, Wilson W. A multiplex fluorescence microsphere immunoassay for increased understanding of Rift Valley fever immune responses in ruminants in Kenya. J Virol Methods 2019; 269:70-76. [PMID: 30974177 DOI: 10.1016/j.jviromet.2019.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/07/2019] [Accepted: 04/07/2019] [Indexed: 10/27/2022]
Abstract
Rift Valley fever virus (RVFV) is an important mosquito-borne pathogen with devastating impacts on agriculture and public health. With outbreaks being reported beyond the continent of Africa to the Middle East, there is great concern that RVFV will continue to spread to non-endemic areas such as the Americas and Europe. There is a need for safe and high throughput serological assays for rapid detection of RVFV during outbreaks and for surveillance. We evaluated a multiplexing fluorescence microsphere immunoassay (FMIA) for the detection of IgG and IgM antibodies in ruminant sera against the RVFV nucleocapsid Np, glycoprotein Gn, and non-structural protein NSs. Sheep and cattle sera from a region in Kenya with previous outbreaks were tested by FMIA and two commercially available competitive ELISAs (BDSL and IDvet). Our results revealed strong detection of RVFV antibodies against the Np, Gn and NSs antigen targets. Additionally, testing of samples with FMIA Np and Gn had 100% agreement with the IDvet ELISA. The targets developed in the FMIA assay provided a basis for a larger ruminant disease panel that can simultaneously screen several abortive and zoonotic pathogens.
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Affiliation(s)
- Johanna F Lindahl
- International Livestock Research Institute, Nairobi, Kenya; Zoonosis Science Center, Uppsala University, Uppsala, Sweden; Swedish University of Agricultural Research, Uppsala, Sweden.
| | - Izabela K Ragan
- Department of Biomedical Sciences, Colorado State University, Fort Collins, CO, USA; Department of Diagnostic Medicine and Pathobiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA
| | - R R Rowland
- Department of Diagnostic Medicine and Pathobiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS, USA
| | | | - Deborah Mbotha
- International Livestock Research Institute, Nairobi, Kenya; Institute for Parasitology and Tropical Veterinary Medicine, Freie Universitaet Berlin, Berlin, Germany
| | - William Wilson
- Arthropod-Borne Animal Diseases Research Unit, USDA, ARS, Manhattan, KS, USA
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Mbotha D, Bett B, Kairu-Wanyoike S, Grace D, Kihara A, Wainaina M, Hoppenheit A, Clausen PH, Lindahl J. Inter-epidemic Rift Valley fever virus seroconversions in an irrigation scheme in Bura, south-east Kenya. Transbound Emerg Dis 2017; 65:e55-e62. [PMID: 28710814 DOI: 10.1111/tbed.12674] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Indexed: 11/30/2022]
Abstract
Rift Valley fever (RVF) is an acute mosquito-borne viral zoonosis whose outbreaks are often associated with prolonged rainfall and flooding, during which large numbers of vectors emerge. Recent studies into the inter-epidemic maintenance of RVF virus (RVFV) suggest that both vertical transmission in vectors and direct transmission between hosts act in combination with predisposing factors for persistence of the virus. A comparative longitudinal survey was carried out in Tana River County, Kenya, in irrigated, riverine and pastoral ecosystems from September 2014-June 2015. The objectives were to investigate the possibility of low-level RVFV transmission in these ecosystems during an inter-epidemic period (IEP), examine variations in RVFV seroprevalence in sheep and goats and determine the risk factors for transmission. Three hundred and sixteen small ruminants were selected and tested for immunoglobulin G antibodies against RVFV nucleoprotein using a competitive ELISA during six visits. Data on potential risk factors were also captured. Inter-epidemic RVFV transmission was evidenced by 15 seroconversions within the irrigated and riverine villages. The number of seroconversions was not significantly different (OR = 0.66, CI = 0.19-2.17, p = .59) between irrigated and riverine areas. No seroconversions were detected in the pastoral ecosystem. This study highlights the increased risk of inter-epidemic RVFV transmission posed by irrigation, through provision of necessary environmental conditions that enable vectors access to more breeding grounds, resting places and shade, which favour their breeding and survival.
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Affiliation(s)
- D Mbotha
- International Livestock Research Institute, Nairobi, Kenya.,Institute for Parasitology and Tropical Veterinary Medicine, Freie Universitaet Berlin, Berlin, Germany
| | - B Bett
- International Livestock Research Institute, Nairobi, Kenya
| | | | - D Grace
- International Livestock Research Institute, Nairobi, Kenya
| | - A Kihara
- International Livestock Research Institute, Nairobi, Kenya
| | - M Wainaina
- International Livestock Research Institute, Nairobi, Kenya
| | - A Hoppenheit
- Institute for Parasitology and Tropical Veterinary Medicine, Freie Universitaet Berlin, Berlin, Germany
| | - P-H Clausen
- Institute for Parasitology and Tropical Veterinary Medicine, Freie Universitaet Berlin, Berlin, Germany
| | - J Lindahl
- International Livestock Research Institute, Nairobi, Kenya.,Swedish University of Agricultural Sciences, Uppsala, Sweden.,Uppsala University, Uppsala, Sweden
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Bett B, Kiunga P, Gachohi J, Sindato C, Mbotha D, Robinson T, Lindahl J, Grace D. Effects of climate change on the occurrence and distribution of livestock diseases. Prev Vet Med 2016; 137:119-129. [PMID: 28040271 DOI: 10.1016/j.prevetmed.2016.11.019] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 11/30/2016] [Indexed: 12/25/2022]
Abstract
The planet's mean air and ocean temperatures have been rising over the last century because of increasing greenhouse gas (GHG) emissions. These changes have substantial effects on the epidemiology of infectious diseases. We describe direct and indirect processes linking climate change and infectious diseases in livestock with reference to specific case studies. Some of the studies are used to show a positive association between temperature and expansion of the geographical ranges of arthropod vectors (e.g. Culicoides imicola, which transmits bluetongue virus) while others are used to illustrate an opposite trend (e.g. tsetse flies that transmit a range of trypanosome parasites in sub-Saharan Africa). We further describe a positive association between extreme events: droughts and El Niño/southern oscillation (ENSO) weather patterns and Rift Valley fever outbreaks in East Africa and some adaptation practices used to mitigate the impacts of climate change that may increase risk of exposure to infectious pathogens. We conclude by outlining mitigation and adaptation measures that can be used specifically in the livestock sector to minimize the impacts of climate change-associated livestock diseases.
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Affiliation(s)
- B Bett
- International Livestock Research Institute, P.O. Box 30709-00100, Nairobi, Kenya.
| | - P Kiunga
- International Livestock Research Institute, P.O. Box 30709-00100, Nairobi, Kenya; Department of Veterinary Services, Ministry of Agriculture, Livestock and Fisheries, Private Bag, Kabete, 00625 Kangemi, Kenya
| | - J Gachohi
- International Livestock Research Institute, P.O. Box 30709-00100, Nairobi, Kenya; College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, P. O. Box 62000, Nairobi, Kenya
| | - C Sindato
- National Institute for Medical Research, P.O. Box - 482, Tabora, Tanzania
| | - D Mbotha
- International Livestock Research Institute, P.O. Box 30709-00100, Nairobi, Kenya
| | - T Robinson
- International Livestock Research Institute, P.O. Box 30709-00100, Nairobi, Kenya
| | - J Lindahl
- International Livestock Research Institute, P.O. Box 30709-00100, Nairobi, Kenya; Swedish University of Agricultural Sciences, P.O. Box 7054, SE-750 07, Uppsala, Sweden
| | - D Grace
- International Livestock Research Institute, P.O. Box 30709-00100, Nairobi, Kenya
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Norton E, Benaben S, Mbotha D, Schley D. Seasonal variations in physical contact amongst domestic sheep and the implications for disease transmission. Livest Sci 2012. [DOI: 10.1016/j.livsci.2011.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Marcotty T, Matthys F, Godfroid J, Rigouts L, Ameni G, Gey van Pittius N, Kazwala R, Muma J, van Helden P, Walravens K, de Klerk LM, Geoghegan C, Mbotha D, Otte M, Amenu K, Abu Samra N, Botha C, Ekron M, Jenkins A, Jori F, Kriek N, McCrindle C, Michel A, Morar D, Roger F, Thys E, van den Bossche P. Zoonotic tuberculosis and brucellosis in Africa: neglected zoonoses or minor public-health issues? The outcomes of a multi-disciplinary workshop. Ann Trop Med Parasitol 2010; 103:401-11. [PMID: 19583911 DOI: 10.1179/136485909x451771] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Late in 2007, veterinary, medical and anthropological professionals from Europe and Africa met in a 2-day workshop in Pretoria, South Africa, to evaluate the burden, surveillance and control of zoonotic tuberculosis and brucellosis in sub-Saharan Africa. Keynote presentations reviewed the burden of these diseases on human and livestock health, the existing diagnostic tools, and the available control methods. These presentations were followed by group discussions and the formulation of recommendations. The presence of Mycobacterium bovis and Brucella spp. in livestock was considered to be a serious threat to public health, since livestock and animal products are the only source of such infections in human beings. The impact of these pathogens on human health appears to be relatively marginal, however, when compared with Mycobacterium tuberculosis infections and drug resistance, HIV and malaria. Appropriate diagnostic tools are needed to improve the detection of M. bovis and Brucella spp. in humans. In livestock, the 'test-and-slaughter' approach and the pasteurization of milk, which have been used successfully in industrialized countries, might not be the optimal control tools in Africa. Control strategies should fit the needs and perceptions of local communities. Improved intersectoral and international collaboration in surveillance, diagnosis and control, and in the education of medical and veterinary personnel, are advocated.
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Affiliation(s)
- T Marcotty
- Department of Animal Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium.
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Brooker S, Kabatereine NB, Smith JL, Mupfasoni D, Mwanje MT, Ndayishimiye O, Lwambo NJ, Mbotha D, Karanja P, Mwandawiro C, Muchiri E, Clements AC, Bundy DA, Snow RW. An updated atlas of human helminth infections: the example of East Africa. Int J Health Geogr 2009; 8:42. [PMID: 19589144 PMCID: PMC2714505 DOI: 10.1186/1476-072x-8-42] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Accepted: 07/09/2009] [Indexed: 11/18/2022] Open
Abstract
Background Reliable and updated maps of helminth (worm) infection distributions are essential to target control strategies to those populations in greatest need. Although many surveys have been conducted in endemic countries, the data are rarely available in a form that is accessible to policy makers and the managers of public health programmes. This is especially true in sub-Saharan Africa, where empirical data are seldom in the public domain. In an attempt to address the paucity of geographical information on helminth risk, this article describes the development of an updated global atlas of human helminth infection, showing the example of East Africa. Methods Empirical, cross-sectional estimates of infection prevalence conducted since 1980 were identified using electronic and manual search strategies of published and unpublished sources. A number of inclusion criteria were imposed for identified information, which was extracted into a standardized database. Details of survey population, diagnostic methods, sample size and numbers infected with schistosomes and soil-transmitted helminths were recorded. A unique identifier linked each record to an electronic copy of the source document, in portable document format. An attempt was made to identify the geographical location of each record using standardized geolocation procedures and the assembled data were incorporated into a geographical information system. Results At the time of writing, over 2,748 prevalence surveys were identified through multiple search strategies. Of these, 2,612 were able to be geolocated and mapped. More than half (58%) of included surveys were from grey literature or unpublished sources, underlining the importance of reviewing in-country sources. 66% of all surveys were conducted since 2000. Comprehensive, countrywide data are available for Burundi, Rwanda and Uganda. In contrast, information for Kenya and Tanzania is typically clustered in specific regions of the country, with few records from areas with very low population density and/or environmental conditions which are unfavourable for helminth transmission. Information is presented on the prevalence and geographical distribution for the major helminth species. Conclusion For all five countries, the information assembled in the current atlas provides the most reliable, up-to-date and comprehensive source of data on the distribution of common helminth infections to guide the rational implementation of control efforts.
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Affiliation(s)
- Simon Brooker
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK.
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