Countries with delayed COVID-19 introduction - characteristics, drivers, gaps, and opportunities

Background

Three months after the first reported cases, COVID-19 had spread to nearly 90% of World Health Organization (WHO) member states and only 24 countries had not reported cases as of 30 March 2020. This analysis aimed to 1) assess characteristics, capability to detect and monitor COVID-19, and disease control measures in these 24 countries, 2) understand potential factors for the reported delayed COVID-19 introduction, and 3) identify gaps and opportunities for outbreak preparedness, particularly in low and middle-income countries (LMICs). We collected and analyzed publicly available information on country characteristics, COVID-19 testing, influenza surveillance, border measures, and preparedness activities in these countries. We also assessed the association between the temporal spread of COVID-19 in all countries with reported cases with globalization indicator and geographic location.

Results

Temporal spreading of COVID-19 was strongly associated with countries’ globalization indicator and geographic location. Most of the 24 countries with delayed COVID-19 introduction were LMICs; 88% were small island or landlocked developing countries. As of 30 March 2020, only 38% of these countries reported in-country COVID-19 testing capability, and 71% reported conducting influenza surveillance during the past year. All had implemented two or more border measures, (e.g., travel restrictions and border closures) and multiple preparedness activities (e.g., national preparedness plans and school closing).

Conclusions

Limited testing capacity suggests that most of the 24 delayed countries may have lacked the capability to detect and identify cases early through sentinel and case-based surveillance. Low global connectedness, geographic isolation, and border measures were common among these countries and may have contributed to the delayed introduction of COVID-19 into these countries. This paper contributes to identifying opportunities for pandemic preparedness, such as increasing disease detection, surveillance, and international collaborations. As the global situation continues to evolve, it is essential for countries to improve and prioritize their capacities to rapidly prevent, detect, and respond, not only for COVID-19, but also for future outbreaks.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00678-4.

Observations of the global epidemiology of COVID-19 from the prepandemic period using web-based surveillance: a cross-sectional analysis

Background

Scant data are available about global patterns of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread and global epidemiology of early confirmed cases of COVID-19 outside mainland China. We describe the global spread of SARS-CoV-2 and characteristics of COVID-19 cases and clusters before the characterisation of COVID-19 as a pandemic.

Methods

Cases of COVID-19 reported between Dec 31, 2019, and March 10, 2020 (ie, the prepandemic period), were identified daily from official websites, press releases, press conference transcripts, and social media feeds of national ministries of health or other government agencies. Case characteristics, travel history, and exposures to other cases were abstracted. Countries with at least one case were classified as affected. Early cases were defined as those among the first 100 cases reported from each country. Later cases were defined as those after the first 100 cases. We analysed reported travel to affected countries among the first case reported from each country outside mainland China, demographic and exposure characteristics among cases with age or sex information, and cluster frequencies and sizes by transmission settings.

Findings

Among the first case reported from each of 99 affected countries outside of mainland China, 75 (76%) had recent travel to affected countries; 60 (61%) had travelled to China, Italy, or Iran. Among 1200 cases with age or sex information, 874 (73%) were early cases. Among 762 early cases with age information, the median age was 51 years (IQR 35–63); 25 (3%) of 762 early cases occurred in children younger than 18 years. Overall, 21 (2%) of 1200 cases were in health-care workers and none were in pregnant women. 101 clusters were identified, of which the most commonly identified transmission setting was households (76 [75%]; mean 2·6 cases per cluster [range 2–7]), followed by non-health-care occupational settings (14 [14%]; mean 4·3 cases per cluster [2–14]), and community gatherings (11 [11%]; mean 14·2 cases per cluster [4–36]).

Interpretation

Cases with travel links to China, Italy, or Iran accounted for almost two-thirds of the first reported COVID-19 cases from affected countries. Among cases with age information available, most were among adults aged 18 years and older. Although there were many clusters of household transmission among early cases, clusters in occupational or community settings tended to be larger, supporting a possible role for physical distancing to slow the progression of SARS-CoV-2 spread.

Funding

None.

Impact of indoor residual spraying on malaria parasitaemia in the Bunkpurugu-Yunyoo District in northern Ghana

BACKGROUND

Since 2008 indoor residual spraying (IRS) has become one of the interventions for malaria control in Ghana. Key partners in the scale-up of IRS have been the US President's Malaria Initiative (PMI) and AngloGold Ashanti (AGA). This study was designed to assess the impact of IRS on malaria parasitaemia among children less than 5 years-old in Bunkpurugu-Yunyoo, one of PMI-sponsored districts in northern Ghana, where rates of parasitaemia significantly exceeded the national average.

METHODS

Two pre-IRS cross-sectional surveys using microscopy were conducted in November 2010 and April 2011 to provide baseline estimates of malaria parasitaemia for the high and low transmission seasons, respectively. IRS for the entire district was conducted in May/June to coincide with the beginning of the rains. Alpha-cypermethrin was used in 2011 and 2012, and changed to pirimiphos-methyl in 2013 and 2014 following declining susceptibility of local vectors to pyrethroids. Post-IRS cross-sectional surveys were conducted between 2011 and 2014 to provide estimates for the end of high (2011-2014) and the end of low (2012-2013) transmission seasons.

RESULTS

The end of high transmission season prevalence of asexual parasitaemia declined marginally from 52.4% (95% CI: 50.0-54.7%) to 47.7% (95% CI: 45.5-49.9%) following 2 years of IRS with alpha-cypermethrin. Prevalence declined substantially to 20.6% (95% CI: 18.4-22.9%) following one year of IRS with pirimiphos-methyl.

CONCLUSIONS

The use of a more efficacious insecticide for IRS can reduce malaria parasitaemia among children less than 5 years-old in northern Ghana.

Introduction to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infections

Surgical site infection (SSI) is a common type of health-care-associated infection (HAI) and adds considerably to the individual, social, and economic costs of surgical treatment. This document serves to introduce the updated Guideline for the Prevention of SSI from the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC). The Core section of the guideline addresses issues relevant to multiple surgical specialties and procedures. The second procedure-specific section focuses on a high-volume, high-burden procedure: Prosthetic joint arthroplasty. While many elements of the 1999 guideline remain current, others warrant updating to incorporate new knowledge and changes in the patient population, operative techniques, emerging pathogens, and guideline development methodology.

A reduction in malaria transmission intensity in Northern Ghana after 7 years of indoor residual spraying

Background

Indoor residual spraying (IRS) is being implemented as one of the malaria prevention methods in the Northern Region of Ghana. Changes in longevity, sporozoite and entomological inoculation rates (EIRs) of major malaria vectors were monitored to assess the impact of IRS in selected districts.

Methods

Monthly human landing catches (HLCs) were used to collect mosquitoes from sentinel sites in three adjacent districts between July 2009 and December 2014: Savelugu Nanton (SND) where IRS had been implemented from 2008 to 2014; Tolon Kumbungu (TKD) where IRS had been implemented between 2008 and 2012 and Tamale Metropolis (TML) with no history of IRS. Mosquitoes were morphologically identified to species level and into sibling species, using PCR. Samples of Anopheles gambiae sensu lato (s.l.) were examined for parity and infectivity. EIR was calculated from biting and infectivity rates of malaria vectors.

Results

Parity rates of An. gambiae s.l. decreased significantly (p < 0.0001) in SND from 44.8% in 2011 to 28.1% by 2014, and in TKD from 53.3% in 2011 to 46.6% in 2012 (p = 0.001). However 2 years after IRS was discontinued in TKD, the proportion of parous An. gambiae s.l. increased significantly to 68.5% in 2014 (p < 0.0001). Parity rates in the unsprayed district remained high throughout the study period, ranging between 68.6% in 2011 and 72.3% in 2014. The sum of monthly EIRs post-IRS season (July–December) in SND ranged between 2.1 and 6.3 infective bites/person/season (ib/p/s) during the 3 years that the district was sprayed with alphacypermethrin. EIR in SND was reduced to undetectable levels when the insecticide was switched to pirimiphos methyl CS in 2013 and 2014. Two years after IRS was withdrawn from TKD the sum of monthly EIRs (July–December) increased by about fourfold from 41.8 ib/p/s in 2012 to 154.4 ib/p/s in 2014. The EIR in the control area, TML, ranged between 35 ib/p/s in 2009 to 104.71 ib/p/s by 2014.

Conclusions

This study demonstrates that IRS application did have a significant impact on entomological indicators of malaria transmission in the IRS project districts of Northern Ghana. Transmission indicators increased following the withdrawal of IRS from Tolon Kumbungu District.

Introduction to the Centers for Disease Control and Prevention and Healthcare Infection Control Practices Advisory Committee Guideline for Prevention of Surgical Site Infection: Prosthetic Joint Arthroplasty Section

Peri-prosthetic joint infection (PJI) is a severe complication of total joint arthroplasty that appears to be increasing as more of these procedures are performed. Numerous risk factors for incisional (superficial and deep) and organ/space (e.g., PJI) surgical site infections (SSIs) have been identified. A better understanding and reversal of modifiable risk factors may lead to a reduction in the incidence of incisional SSI and PJI. The Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recently updated the national Guideline for Prevention of Surgical Site Infection. The updated guideline applies evidence-based methodology, presents recommendations for potential strategies to reduce the risk of SSI, and includes an arthroplasty-specific section. This article serves to introduce the guideline development process and to complement the Prosthetic Joint Arthroplasty section with background information on PJI-specific economic burden, epidemiology, pathogenesis and microbiology, and risk factor information.

Comparative intervention study among Danish daycare children: the effect on illness of time spent outdoors

Aims: The purpose of the study was to examine the correlation between illnesses, and in particular contagious illnesses, among daycare children and the amount of time spent outdoors, and whether through the intervention of increasing the amount of time spent outdoors it is possible to lower the incidence of illness. Methods: The study was conducted among eight daycare centres within the same county. A total of 326 children, 17 homeroom groups, were divided into two study groups. Each of the two study groups had a two-month period in which the percentage of time spent outdoors per day was almost double that of the other study group. Results: The overall frequency of sick days was 4%. There was no significant effect of spending more time outdoors on the number of illness episodes, length of the episode, or cause of illness. Conclusion: Our negative findings are in accordance with the theory that illness among daycare children is largely a result of contact among children and the hygiene standards of the institution, and thus these are the factors that may need to be addressed to reduce the level of illness among daycare children.

A tuberculosis outbreak fueled by cross-border travel and illicit substances: Nevada and Arizona

OBJECTIVES

From May 2006 to August 2008, the Southern Nevada Health District identified eight tuberculosis (TB) cases in six adults and two children in a Hispanic community. We conducted an outbreak investigation to determine the extent of TB transmission and prevent additional cases.

METHODS

We investigated TB cases in Nevada and Arizona with the outbreak genotype or cases with suspected epidemiologic links to this cluster but without genotyping data. We reviewed medical records and interviewed patients and contacts. Subsequently, genotype surveillance was conducted for approximately four years to monitor additional outbreak-related cases.

RESULTS

Eight outbreak cases were identified among six adults and two children. All patients were Hispanic and five were U.S.-born. The index patient was diagnosed while detained in Immigration and Customs Enforcement custody but deported before treatment completion. He was lost to follow-up for two years, during which time he served as the source for six secondary TB cases, including his own child. Along with the index patient, five patients reportedly engaged in the sale or use of methamphetamine. Follow-up surveillance in the two states identified eight additional cases with the outbreak genotype; three had epidemiologic links to the index case.

CONCLUSIONS

We found that incomplete TB treatment led to extensive TB transmission. We recommend thorough discharge planning and active measures to ensure continuity of care and TB treatment completion for people in custody at higher risk for loss to follow-up, which likely includes those engaged in the sale or use of illicit substances.

Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010

OBJECTIVE

To describe antimicrobial resistance patterns for healthcare-associated infections (HAIs) reported to the National Healthcare Safety Network (NHSN) during 2009-2010.

METHODS

Central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, and surgical site infections were included. Pooled mean proportions of isolates interpreted as resistant (or, in some cases, nonsusceptible) to selected antimicrobial agents were calculated by type of HAI and compared to historical data.

RESULTS

Overall, 2,039 hospitals reported 1 or more HAIs; 1,749 (86%) were general acute care hospitals, and 1,143 (56%) had fewer than 200 beds. There were 69,475 HAIs and 81,139 pathogens reported. Eight pathogen groups accounted for about 80% of reported pathogens: Staphylococcus aureus (16%), Enterococcus spp. (14%), Escherichia coli (12%), coagulase-negative staphylococci (11%), Candida spp. (9%), Klebsiella pneumoniae (and Klebsiella oxytoca; 8%), Pseudomonas aeruginosa (8%), and Enterobacter spp. (5%). The percentage of resistance was similar to that reported in the previous 2-year period, with a slight decrease in the percentage of S. aureus resistant to oxacillins (MRSA). Nearly 20% of pathogens reported from all HAIs were the following multidrug-resistant phenotypes: MRSA (8.5%); vancomycin-resistant Enterococcus (3%); extended-spectrum cephalosporin-resistant K. pneumoniae and K. oxytoca (2%), E. coli (2%), and Enterobacter spp. (2%); and carbapenem-resistant P. aeruginosa (2%), K. pneumoniae/oxytoca (<1%), E. coli (<1%), and Enterobacter spp. (<1%). Among facilities reporting HAIs with 1 of the above gram-negative bacteria, 20%-40% reported at least 1 with the resistant phenotype.

CONCLUSION

While the proportion of resistant isolates did not substantially change from that in the previous 2 years, multidrug-resistant gram-negative phenotypes were reported from a moderate proportion of facilities.

Immune response to diphtheria booster vaccine in the Baltic states

A study was done to measure baseline levels of immunity to diphtheria and antibody responses to different doses of diphtheria vaccine in study participants in the three Baltic states. Diphtheria booster vaccines containing either 3 (Estonia and Lithuania), 6 (Latvia), or 12 (Latvia) limit of flocculation units of diphtheria toxoid were administered to 2315 adults. Diphtheria antibody levels were tested before and 1-2 months after vaccination. Before vaccination, 40% of the participants in Estonia, 32% in Lithuania, and 38% in Latvia had antibody levels <0.01 IU/mL, the level for minimum protection. After vaccination, 79% of the participants in Estonia, 83% in Lithuania, and 81% in Latvia had antibody levels >0. 1 IU/mL, the minimum level for full protection. However, in each of the countries, about one-third of the 40- to 49-year-old participants would have benefited from additional doses of vaccine. There was not a significantly different antibody response among persons receiving the three different doses. Age and the level of prevaccination immunity had a modifying effect on the response to vaccination; however, sex did not.

Lower esophageal sphincter pressure in histologic esophagitis

The fasting lower esophageal sphincter pressure of 18 normal volunteers was compared to 22 patients with symptoms and objective evidence of gastroesophageal reflux. Lower esophageal sphincter pressure was measured by rapid pull-through using an 8-lumen radially perfused catheter that sampled pressure every45 degrees around the circumference of the sphincter. The 22 reflux patients were subdivided for analysis into two groups, those with an acute inflammatory infiltrate on biopsy and those without inflammation. Those patients without inflammatory esophagitis had normal sphincter pressures. Those with a definite inflammatory infiltrate had pressures significantly less than normal. The least reliable separation between normals and those with inflammatory esophagitis occurred in the anterior orientations. We conclude that while basal lower esophageal sphincter pressure measurement may identify patients with reflux and inflammatory esophagitis, it is of no help in identifying those patients with reflux unassociated with inflammation. Decreased basal fasting LESP does not appear to be the most important primary determinant of gastroesophageal reflux.