Strengthening COVID-19 pandemic response coordination through public health emergency operations centres (PHEOC) in Africa: Review of a multi-faceted knowledge management and sharing approach, 2020-2021

The coronavirus disease 2019 (COVID-19) pandemic disrupted health security program implementation and incremental gains achieved after the West African Ebola outbreak in 2016 across Africa. Following cancellation of in-person events, a multi-faceted intervention program was established in May 2020 by Africa Centres for Disease Control and Prevention (Africa CDC), the World Health Organisation, and partners to strengthen national COVID-19 response coordination through public health emergency operations centres (PHEOC) utilizing continuous learning, mentorship, and networking. We present the lessons learned and reflection points. A multi-partner program coordination group was established to facilitate interventions' delivery including webinars and virtual community of practice (COP). We retrieved data from Africa CDC's program repository, synthesised major findings and describe these per thematic area. The virtual COP recorded 1,968 members and approximately 300 engagements in its initial three months. Fifty-six webinar sessions were held, providing 97 cumulative learning hours to 12,715 unique participants. Zoom data showed a return rate of 85%; 67% of webinar attendees were from Africa, and about 26 interactions occurred between participants and facilitators per session. Of 4,084 (44%) participants responding to post-session surveys, over 95% rated the topics as being relevant to their work and contributing to improving their understanding of PHEOC operationalisation. In addition, 95% agreed that the simplicity of the training delivery encouraged a greater number of public health staff to participate and spread lessons from it to their own networks. This just-in-time, progressively adaptive multi-faceted learning and knowledge management approach in Africa, with a consequential global audience at the peak of the COVID-19 pandemic, served its intended audience, had a high number of participants from Africa and received greatly satisfactory feedback.

Public health emergency operations centres in Africa: a cross-sectional study assessing the implementation status of core components and areas for improvement, December 2021

OBJECTIVE

To assess implementation status of public health emergency operations centres (PHEOCs) in all countries in Africa.

DESIGN

Cross-sectional.

SETTING

Fifty-four national PHEOC focal points in Africa responded to an online survey between May and November 2021. Included variables aimed to assess capacities for each of the four PHEOC core components. To assess the PHEOCs' functionality, criteria were defined from among the collected variables by expert consensus based on PHEOC operations' prioritisation. We report results of the descriptive analysis, including frequencies of proportions.

RESULTS

A total of 51 (93%) African countries responded to the survey. Among these, 41 (80%) have established a PHEOC. Twelve (29%) of these met 80% or more of the minimum requirements and were classified as fully functional. Twelve (29%) and 17 (41%) PHEOCs that met 60%-79% and below 60% the minimum requirements were classified as functional and partially functional, respectively.

CONCLUSIONS

Countries in Africa made considerable progress in setting up and improving functioning of PHEOCs. One-third of the responding countries with a PHEOC have one fulfilling at least 80% of the minimum requirements to operate the critical emergency functions. There are still several African countries that either do not have a PHEOC or whose PHEOCs only partially meet these minimal requirements. This calls for significant collaboration across all stakeholders to establish functional PHEOCs in Africa.

Mapping and monitoring tick (Acari, Ixodida) distribution, seasonality, and host associations in the United Kingdom between 2017 and 2020

Tick-borne disease risk is intrinsically linked to the distribution of tick vector species. To assess risk and anticipate disease emergence, an understanding of tick distribution, host associations, and seasonality is needed. This can be achieved, to some extent, using passive surveillance supported by engagement with the public, animal health, and public health experts. The Tick Surveillance Scheme (TSS) collects data and maps tick distribution across the United Kingdom (UK). Between 2017 and 2020, 3720 tick records were received and 39 tick species were detected. Most records were acquired in the UK, with a subset associated with recent overseas travel. The dominant UK acquired species was Ixodes ricinus (Ixodida: Ixodidae, Linnaeus), the main vector of Lyme borreliosis. Records peaked during May and June, highlighting a key risk period for tick bites. Other key UK species were detected, including Dermacentor reticulatus (Ixodida: Ixodidae, Fabricius) and Haemaphysalis punctata (Ixodida: Ixodidae, Canestrini & Fanzago) as well as several rarer species that may present novel tick-borne disease risk to humans and other animals. Updated tick distribution maps highlight areas in the UK where tick exposure has occurred. There is evidence of increasing human tick exposure over time, including during the COVID-19 pandemic, but seasonal patterns remain unchanged.

Impact of green space connectivity on urban tick presence, density and Borrelia infected ticks in different habitats and seasons in three cities in southern England

Understanding the effects of local habitat and wider landscape connectivity factors on tick presence, nymph density and Borrelia species (spp.) prevalence in the tick population is important for identifying the public health risk from Lyme borreliosis. This multi-city study collected data in three southern England cities (Bath, Bristol, and Southampton) during spring, summer, and autumn in 2017. Focusing specifically on urban green space used for recreation which were clearly in urbanised areas, 72 locations were sampled. Additionally, geospatial datasets on urban green space coverage within 250 m and 1 km of sampling points, as well as distance to woodland were incorporated into statistical models. Distance to woodland was negatively associated with tick presence and nymph density, particularly during spring and summer. Furthermore, we observed an interaction effect between habitat and season for tick presence and nymph density, with woodland habitat having greater tick presence and nymph density during spring. Borrelia spp. infected Ixodes ricinus were found in woodland, woodland edge and under canopy habitats in Bath and Southampton. Overall Borrelia spp. prevalence in nymphs was 2.8%, similar to wider UK studies assessing prevalence in Ixodes ricinus in rural areas. Bird-related Borrelia genospecies dominated across sites, suggesting bird reservoir hosts may be important in urban green space settings for feeding and infecting ticks. Whilst overall density of infected nymphs across the three cities was low (0.03 per 100 m²), risk should be further investigated by incorporating data on tick bites acquired in urban settings, and subsequent Lyme borreliosis transmission.

Ixodes ricinus density, Borrelia prevalence and the density of infected nymphs along an urban-rural gradient in southern England

Ticks are found across a range of habitats, with woodland being particularly important for high densities and prevalence of Borrelia infection. Assessments of risk in urban woodland can be difficult if there are low densities and small sample sizes for Borrelia prevalence estimates. This study targeted six urban woodlands with established tick populations, as well as six woodlands in peri-urban zones and six woodlands in rural zones in and around the cities of Bath and Southampton, in the South of England. Nymph densities were estimated, and 100 nymphs were tested from each of the 18 woodlands studied. Ixodes ricinus ticks were found in all woodlands surveyed, and overall density of nymphs (DON) per 100 m² was 18.17 in urban woodlands, 26.0 in peri-urban woodlands and 17.67 in rural woodlands. Out of 600 nymphs tested across urban woodlands, 10.3% were infected with Borrelia. The same proportion of nymphs collected in rural woodlands were positive for Borrelia. In peri-urban woodlands, 10.8% of nymphs tested positive. Across both cities combined, density of infected nymphs (DIN) was 2.73 per 100 m² in peri-urban woodland, 1.87 per 100 m² in urban woodland and 1.82 per 100 m² in rural woodland. Overall, DON, Borrelia prevalence and DIN did not differ significantly along an urban-rural gradient. This suggests the risk of Lyme borreliosis transmission could be similar, or perhaps even elevated in urban woodland if there is higher public footfall, subsequent contact with ticks and less awareness of the risks. This is particularly important from a public health perspective, as Borrelia garinii dominated across the gradient and this genospecies is linked to neuroborreliosis.

Spatial and temporal heterogeneity of the density of Borrelia burgdorferi-infected Ixodes ricinus ticks across a landscape: A 5-year study in southern England

The density of Borrelia burgdorferi-infected Ixodes ricinus nymphs (DIN) was investigated during 2013-2017 across a Lyme disease-endemic landscape in southern England. The density of nymphs (DON), nymph infection prevalence (NIP), and DIN varied across five different natural habitats, with the highest DIN in woodland edge and high biodiversity woodlands. DIN was significantly lower in scrub grassland compared to the woodland edge, with low DON and no evidence of infection in ticks in non-scrub grassland. Over the 5 years, DON, NIP and DIN were comparable within habitats, except in 2014, with NIP varying three-fold and DIN significantly lower compared to 2015-2017. Borrelia garinii was most common, with bird-associated Borrelia (B. garinii/valaisiana) accounting for ~70% of all typed sequences. Borrelia burgdorferi sensu stricto was more common than B. afzelii. Borrelia afzelii was more common in scrub grassland than woodland and absent in some years. The possible impact of scrub on grazed grassland, management of ecotonal woodland margins with public access, and the possible role of birds/gamebirds impacting NIP are discussed. Mean NIP was 7.6%, highlighting the potential risk posed by B. burgdorferi in this endemic area. There is a need for continued research to understand its complex ecology and identify strategies for minimizing risk to public health, through habitat/game management and public awareness.

A nationwide study on Borrelia burgdorferi s.l. infection rates in questing Ixodes ricinus: a six-year snapshot study in protected recreational areas in England and Wales

Understanding the variation in Borrelia burgdorferi s.l. infection rates in Ixodes ricinus ticks is important for assessing the potential for Lyme borreliosis transmission. This study aimed to investigate infection rates of B. burgdorferi s.l. bacteria in I. ricinus across 24 field sites in England and Wales, focussing on protected recreational areas in National Parks (NPs) and Areas of Outstanding Natural Beauty (AONBs), to provide comparable data across multiple years to assess spatio-temporal changes in B. burgdorferi s.l. infection. Working with park rangers, questing ticks were collected each spring from 2014 to 2019. A subset of ticks, 4104 nymphs, were analysed using a pan-Borrelia qPCR assay, as well as a Borrelia miyamotoi-specific qPCR, and sequenced to determine Borrelia burgdorferi s.l. genospecies. Site-specific B. burgdorferi s.l. infection rates in I. ricinus nymphs varied from 0% to 24%, with overall infection rates ranging from 2.5% to 5.1% across the years. Genospecies composition of sequenced samples was 62.5% B. garinii, 20.3% B. valaisiana and 17.2% B. afzelii. Borrelia miyamotoi was detected in 0.2% of ticks. This study increases our knowledge on B. burgdorferi s.l.. infection in areas used by the public for outdoor activity across England and Wales, highlighting the spatial and temporal variability which can impact the changing risk to humans from infected tick bites.

Ixodes ricinus and Borrelia burgdorferi sensu lato in the Royal Parks of London, UK

Assessing the risk of tick-borne disease in areas with high visitor numbers is important from a public health perspective. Evidence suggests that tick presence, density, infection prevalence and the density of infected ticks can vary between habitats within urban green space, suggesting that the risk of Lyme borreliosis transmission can also vary. This study assessed nymph density, Borrelia prevalence and the density of infected nymphs across a range of habitat types in nine parks in London which receive millions of visitors each year. Ixodes ricinus were found in only two of the nine locations sampled, and here they were found in all types of habitat surveyed. Established I. ricinus populations were identified in the two largest parks, both of which had resident free-roaming deer populations. Highest densities of nymphs (15.68 per 100 m²) and infected nymphs (1.22 per 100 m²) were associated with woodland and under canopy habitats in Richmond Park, but ticks infected with Borrelia were found across all habitat types surveyed. Nymphs infected with Borrelia (7.9%) were only reported from Richmond Park, where Borrelia burgdorferi sensu stricto and Borrelia afzelii were identified as the dominant genospecies. Areas with short grass appeared to be less suitable for ticks and maintaining short grass in high footfall areas could be a good strategy for reducing the risk of Lyme borreliosis transmission to humans in such settings. In areas where this would create conflict with existing practices which aim to improve and/or meet historic landscape, biodiversity and public access goals, promoting public health awareness of tick-borne disease risks could also be utilised.

Detection of new endemic focus of tick-borne encephalitis virus (TBEV), Hampshire/Dorset border, England, September 2019

The presence of tick-borne encephalitis virus (TBEV) was detected in a questing tick pool in southern England in September 2019. Hitherto, TBEV had only been detected in a limited area in eastern England. This southern English viral genome sequence is distinct from TBEV-UK, being most similar to TBEV-NL. The new location of TBEV presence highlights that the diagnosis of tick-borne encephalitis should be considered in encephalitic patients in areas of the United Kingdom outside eastern England.

Working towards a Co-Ordinated Approach to Invasive Mosquito Detection, Response and Control in the UK

The United Kingdom (UK) has reported a single detection of the eggs of the invasive mosquito vector Aedes albopictus in each of the three years from 2016 to 2018, all in southeast England. Here, we report the detection of mosquito eggs on three occasions at two sites in London and southeast England in September 2019. Mosquito traps were deployed at 56 sites, in England, Scotland, Wales, and Northern Ireland, as part of a coordinated surveillance programme with local authorities, Edge Hill University, and government departments. Response to each detection was coordinated by Public Health England’s (PHE) local health protection teams, with technical support from PHE’s Medical Entomology group, and control conducted by the respective local authority. Control, including source reduction and larviciding, was conducted within a 300 metre radius of the positive site. The response followed a National Contingency Plan for Invasive Mosquitoes: Detection of Incursions. Although the response to these incidents was rapid and well co-ordinated, recommendations are made to further develop mosquito surveillance and control capability for the UK.

Seasonality and anatomical location of human tick bites in the United Kingdom

Tick bites on humans can occur in a variety of habitats and may result in the transmission of tick-borne pathogens, such as the causative agent of Lyme borreliosis (LB), Borrelia burgdorferi sensu lato. As the risk of transmission of this pathogen to the host increases with the duration of tick feeding, the recognition and removal of ticks as soon as possible following attachment is important for reducing the risk of infection. Performing a thorough body examination for ticks following potential exposure is recommended by tick awareness campaigns. Knowledge of where on the body feeding ticks are frequently found, and at which times of year peak tick exposure occurs, provides important information for public health messaging and may aid those bitten by ticks to engage more effectively with tick-checking behaviour. This paper summarizes human tick bites in the United Kingdom (UK) during 2013-2018 reported to Public Health England's passive Tick Surveillance Scheme and further examines the anatomical location and seasonality of bites from the most commonly encountered tick and LB vector Ixodes ricinus. A total of 1,328 tick records from humans were received of which 93% were I. ricinus. Humans were most commonly bitten by I. ricinus nymphs (70% bites). Tick bites were recorded on all parts of the body, but there were significant differences in their anatomical location on adults and children. Most tick bites on adults occurred on the legs (50%), whereas on children tick bites were mostly on the head and neck (43%). Bites from I. ricinus were recorded throughout the year but were most numerous during May to August. This study adds to the body of research on the seasonality and anatomical location of human tick bites in temperate Europe and highlights the importance of data collected through passive surveillance in addition to research and epidemiological studies.

Hyalomma rufipes on an untraveled horse: Is this the first evidence of Hyalomma nymphs successfully moulting in the United Kingdom?

During September 2018, a tick was submitted to Public Health England's Tick Surveillance Scheme for identification. The tick was sent from a veterinarian who removed it from a horse in Dorset, England, with no history of overseas travel. The tick was identified as a male Hyalomma rufipes using morphological and molecular methods and then tested for a range of tick-borne pathogens including; Alkhurma virus, Anaplasma, Babesia, Bhanja virus, Crimean-Congo Haemorrhagic fever virus, Rickettsia and Theileria. The tick tested positive for Rickettsia aeschlimannii, a spotted fever group rickettsia linked to a number of human cases in Africa and Europe. This is the first time H. rufipes has been reported in the United Kingdom (UK), and the lack of travel by the horse (or any in-contact horses) suggests that this could also be the first evidence of successful moulting of a Hyalomma nymph in the UK. It is postulated that the tick was imported into the UK on a migratory bird as an engorged nymph which was able to complete its moult to the adult stage and find a host. This highlights that passive tick surveillance remains an important method for the detection of unusual species that may present a threat to public health in the UK. Horses are important hosts of Hyalomma sp. adults in their native range, therefore, further surveillance studies should be conducted to check horses for ticks in the months following spring bird migration; when imported nymphs may have had time to drop off their avian host and moult to adults. The potential human and animal health risks of such events occurring more regularly are discussed.

Canine babesiosis and tick activity monitored using companion animal electronic health records in the UK

Recent publications highlighting autochthonous Babesia canis infection in dogs from Essex that have not travelled outside the UK are a powerful reminder of the potential for pathogen emergence in new populations. Here the authors use electronic health data collected from two diagnostic laboratories and a network of 392 veterinary premises to describe canine Babesia cases and levels of Babesia concern from January 2015 to March 2016, and the activity of ticks during December 2015–March 2016. In most areas of the UK, Babesia diagnosis in this population was rare and sporadic. In addition, there was a clear focus of Babesia cases in the affected area in Essex. Until February 2016, analysis of health records indicated only sporadic interest in Babesia largely in animals coming from overseas. Following media coverage in March 2016, there was a spike in owner concern that was geographically dispersed beyond the at-risk area. Tick activity (identified as ticks being removed from animals in veterinary consultations) was consistent but low during the period preceding the infections (<5 ticks/10,000 consultations), but increased in March. This highlights the use of electronic health data to describe rapidly evolving risk and concern that follows the emergence of a pathogen.

A role for MRP8 in in stent restenosis in diabetes

OBJECTIVE

The most common cause of death in diabetes mellitus is cardiovascular disease. Patients frequently undergo vascular intervention such as stenting. The occurrence of in stent restenosis (ISR) has been reduced by the use of drug eluting stents in non-diabetic patients but the incidence of restenosis and stent thrombosis remains higher in diabetic patients. We investigated the pathogenesis of in stent restenosis in an animal model of type 2 diabetes mellitus.

METHODS AND RESULTS

Stents were placed in Zucker Fatty rat (ZFR) and wild type rat carotid arteries, and tissues were harvested 14 days post surgery for morphometric analysis. Unstented carotid arteries from both groups were harvested for microarray analysis. In vitro apoptosis, proliferation and migration assays were performed on rat and human aortic endothelial cells (EC). ZFRs developed an exaggerated intimal response to stent placement compared to wild type controls 14 days post stent placement. MRP8 and MRP14 were up-regulated in unstented ZFR carotid arteries in comparison to controls. Expression of MRP8/14 was also elevated in EC exposed to high glucose conditions. EC function was impaired by high glucose concentrations, and this effect could be mimicked by MRP8 over-expression. MRP8 knockdown by shRNA significantly restored EC function after exposure to high glucose concentrations. MRP8 expression in glucose exposed cells was also inhibited using pharmacological blockade of glucose-induced pathways.

CONCLUSIONS

EC dysfunction caused by elevated glucose levels could be mimicked by MRP8/14 over-expression and reversed/prevented by MRP8 knockdown. Thus, MRP8/14 likely plays a role in exaggerated ISR in diabetes mellitus, and MRP8 inhibition may be useful in improving outcome after stent placement in diabetes mellitus.