Analysis of environmental factors influencing endemic cholera risks in sub-Saharan Africa

The recurring cholera outbreaks in sub-Saharan Africa are of growing concern, especially considering the potential acceleration in the global trend of larger and more lethal cholera outbreaks due to the impacts of climate change. However, there is a scarcity of evidence-based research addressing the environmental and infrastructure factors that sustain cholera recurrence in Africa. This study adopts a statistical approach to investigate over two decades of endemic cholera outbreaks and their relationship with five environmental factors: water provision, sanitation provision, raising temperatures, increased rainfall and GDP. The analysis covers thirteen of the forty-two countries in the mainland sub-Saharan region, collectively representing one-third of the region's territory and half of its population. This breadth enables the findings to be generalised at a regional level. Results from all analyses consistently associate water provision with cholera reduction. The stratified model links increased water provision with a reduction in cholera risk that ranged from 4.2 % to 84.1 % among eight countries (out of 13 countries) as well as a reduction of such risk that ranged from 9.8 % to 68.9 % when there is increased sanitation provision, which was observed in nine countries (out of 13). These results indicate that the population's limited access to water and sanitation, as well as the rise in temperatures, are critical infrastructure and environmental factors contributing to endemic cholera and the heightened risk of outbreaks across the sub-Saharan region. Therefore, these are key areas for targeted interventions and cross-border collaboration to enhance resilience to outbreaks and lead to the end of endemic cholera in the region. However, it is important to interpret the results of this study with caution; hence, further investigation is recommended to conduct a more detailed analysis of the impact of infrastructure and environmental factors on reducing cholera risk.

A mathematical, classical stratification modeling approach to disentangling the impact of weather on infectious diseases: A case study using spatio-temporally disaggregated Campylobacter surveillance data for England and Wales

Disentangling the impact of the weather on transmission of infectious diseases is crucial for health protection, preparedness and prevention. Because weather factors are co-incidental and partly correlated, we have used geography to separate out the impact of individual weather parameters on other seasonal variables using campylobacteriosis as a case study. Campylobacter infections are found worldwide and are the most common bacterial food-borne disease in developed countries, where they exhibit consistent but country specific seasonality. We developed a novel conditional incidence method, based on classical stratification, exploiting the long term, high-resolution, linkage of approximately one-million campylobacteriosis cases over 20 years in England and Wales with local meteorological datasets from diagnostic laboratory locations. The predicted incidence of campylobacteriosis increased by 1 case per million people for every 5° (Celsius) increase in temperature within the range of 8°-15°. Limited association was observed outside that range. There were strong associations with day-length. Cases tended to increase with relative humidity in the region of 75-80%, while the associations with rainfall and wind-speed were weaker. The approach is able to examine multiple factors and model how complex trends arise, e.g. the consistent steep increase in campylobacteriosis in England and Wales in May-June and its spatial variability. This transparent and straightforward approach leads to accurate predictions without relying on regression models and/or postulating specific parameterisations. A key output of the analysis is a thoroughly phenomenological description of the incidence of the disease conditional on specific local weather factors. The study can be crucially important to infer the elusive mechanism of transmission of campylobacteriosis; for instance, by simulating the conditional incidence for a postulated mechanism and compare it with the phenomenological patterns as benchmark. The findings challenge the assumption, commonly made in statistical models, that the transformed mean rate of infection for diseases like campylobacteriosis is a mere additive and combination of the environmental variables.

Mechanisms of cholera transmission via environment in India and Bangladesh: state of the science review

OBJECTIVES

Cholera has a long history in India and Bangladesh, the region where six out of the past seven global pandemics have been seeded. The changing climate and growing population have led to global cholera cases remaining high despite a consistent improvement in the access to clean water and sanitation. We aim to provide a holistic overview of variables influencing environmental cholera transmission within the context of India and Bangladesh, with a focus on the mechanisms by which they act.

CONTENT

We identified 56 relevant texts (Bangladesh n = 40, India n = 7, Other n = 5). The results of the review found that cholera transmission is associated with several socio-economic and environmental factors, each associated variable is suggested to have at least one mediating mechanism. Increases in ambient temperature and coastal sea surface temperature support cholera transmission via increases in plankton and a preference of Vibrio cholerae for warmer waters. Increased rainfall can potentially support or reduce transmission via several mechanisms.

SUMMARY AND OUTLOOK

Common issues in the literature are co-variance of seasonal factors, limited access to high quality cholera data, high research bias towards research in Dhaka and Matlab (Bangladesh). A specific and detailed understanding of the relationship between SST and cholera incidence remains unclear.

Mapping the evidence of the effects of environmental factors on the prevalence of antibiotic resistance in the non-built environment: Protocol for a systematic evidence map

BACKGROUND

Human, animal, and environmental health are increasingly threatened by the emergence and spread of antibiotic resistance. Inappropriate use of antibiotic treatments commonly contributes to this threat, but it is also becoming apparent that multiple, interconnected environmental factors can play a significant role. Thus, a One Health approach is required for a comprehensive understanding of the environmental dimensions of antibiotic resistance and inform science-based decisions and actions. The broad and multidisciplinary nature of the problem poses several open questions drawing upon a wide heterogeneous range of studies.

OBJECTIVE

This study seeks to collect and catalogue the evidence of the potential effects of environmental factors on the abundance or detection of antibiotic resistance determinants in the outdoor environment, i.e., antibiotic resistant bacteria and mobile genetic elements carrying antibiotic resistance genes, and the effect on those caused by local environmental conditions of either natural or anthropogenic origin.

METHODS

Here, we describe the protocol for a systematic evidence map to address this, which will be performed in adherence to best practice guidelines. We will search the literature from 1990 to present, using the following electronic databases: MEDLINE, Embase, and the Web of Science Core Collection as well as the grey literature. We shall include full-text, scientific articles published in English. Reviewers will work in pairs to screen title, abstract and keywords first and then full-text documents. Data extraction will adhere to a code book purposely designed. Risk of bias assessment will not be conducted as part of this SEM. We will combine tables, graphs, and other suitable visualisation techniques to compile a database i) of studies investigating the factors associated with the prevalence of antibiotic resistance in the environment and ii) map the distribution, network, cross-disciplinarity, impact and trends in the literature.

Adherence to Choosing Wisely Campaign Guidelines at Three Health Systems

Introduction/Objective

With rising healthcare costs in the United States, there has been a push for lab stewardship to improve the quality of patient care while reducing costs. To optimize the use of clinical laboratory testing, the ASCP working with other medical specialty organizations, developed the Choosing Wisely Campaign to promulgate evidence-based guidelines to optimize clinical laboratory testing.

Methods/Case Report

We examined adherence to three Choosing Wisely guidelines over a four-year period (2017- 2020), through queries of internal cost accounting databases to return aggregate volumes as well as variable and total costs at three large academic health systems. We measured concurrent orders for: 1) erythrocyte sedimentation rate (ESR) with C-reactive protein (CRP), 2) serum/plasma amylase with lipase, and 3) free thyroxine (FT4) and/or total triiodothyronine (TT3) with thyroid stimulating hormone (TSH) when the TSH is within the reference range (using an frequency estimate of 85% based on other studies). We also examined another guideline for concurrent orders for serum aldolase with creatine kinase (CK). We also quantified aggregate variable costs for the non-recommended test in each Choosing Wisely guideline (amylase, ESR, FT4 and/or TT3), and for serum aldolase when ordered with CK.

Results (if a Case Study enter NA)

Over the four-year period, there were 322,853 unnecessary tests based on these four guidelines (120,587 ESR and CRP, 30,444 amylase and lipase, 164,818 FT4 and/or TT3 with TSH, and 7,004 aldolase). Overall, unnecessary testing decreased between 2017 and 2020 for amylase with lipase, remained essentially unchanged for aldolase, and increased for the other two test guideline scenarios. The largest changes were concurrent orders for amylase and lipase at one health system (38% decrease), and orders for TT3 with a normal TSH result at another health system (324% increase). The four-year variable cost of these unnecessary tests was $1,215,309 ($303,827 mean annual cost), resulting in potential annual variable cost savings of $101,276 for each health system for the four guidelines we examined. Variable costs for unnecessary testing increased by 16.5% ($45,571) over the four-year period.

Conclusion

Guideline-based unnecessary testing remains as a target to improve laboratory diagnostic testing. There is potential to realize significant achievable cost savings if guidelines are implemented and maintained.

Marine harmful algal blooms and human health: A systematic scoping review

Exposure to harmful algal blooms (HABs) can lead to well recognised acute patterns of illness in humans. The objective of this scoping review was to use an established methodology and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting framework to map the evidence for associations between marine HABs and observed both acute and chronic human health effects. A systematic and reproducible search of publications from 1985 until May 2019 was conducted using diverse electronic databases. Following de-duplication, 5301 records were identified, of which 380 were included in the final qualitative synthesis. The majority of studies (220; 57.9%) related to Ciguatera Poisoning. Anecdotal and case reports made up the vast majority of study types (242; 63.7%), whereas there were fewer formal epidemiological studies (35; 9.2%). Only four studies related to chronic exposure to HABs. A low proportion of studies reported the use of human specimens for confirmation of the cause of illness (32; 8.4%). This study highlighted gaps in the evidence base including a lack of formal surveillance and epidemiological studies, limited use of toxin measurements in human samples, and a scarcity of studies of chronic exposure. Future research and policy should provide a baseline understanding of the burden of human disease to inform the evaluation of the current and future impacts of climate change and HABs on human health.

Exploring Campylobacter seasonality across Europe using The European Surveillance System (TESSy), 2008 to 2016

BackgroundCampylobacteriosis is the most commonly reported food-borne infection in the European Union, with an annual number of cases estimated at around 9 million. In many countries, campylobacteriosis has a striking seasonal peak during early/mid-summer. In the early 2000s, several publications reported on campylobacteriosis seasonality across Europe and associations with temperature and precipitation. Subsequently, many European countries have introduced new measures against this food-borne disease.AimTo examine how the seasonality of campylobacteriosis varied across Europe from 2008-16, to explore associations with temperature and precipitation, and to compare these results with previous studies. We also sought to assess the utility of the European Surveillance System TESSy for cross-European seasonal analysis of campylobacteriosis.MethodsWard's Minimum Variance Clustering was used to group countries with similar seasonal patterns of campylobacteriosis. A two-stage multivariate meta-analysis methodology was used to explore associations with temperature and precipitation.ResultsNordic countries had a pronounced seasonal campylobacteriosis peak in mid- to late summer (weeks 29-32), while most other European countries had a less pronounced peak earlier in the year. The United Kingdom, Ireland, Hungary and Slovakia had a slightly earlier peak (week 24). Campylobacteriosis cases were positively associated with temperature and, to a lesser degree, precipitation.ConclusionAcross Europe, the strength and timing of campylobacteriosis peaks have remained similar to those observed previously. In addition, TESSy is a useful resource for cross-European seasonal analysis of infectious diseases such as campylobacteriosis, but its utility depends upon each country's reporting infrastructure.

Pathogen seasonality and links with weather in England and Wales: a big data time series analysis

Background

Many infectious diseases of public health importance display annual seasonal patterns in their incidence. We aimed to systematically document the seasonality of several human infectious disease pathogens in England and Wales, highlighting those organisms that appear weather-sensitive and therefore may be influenced by climate change in the future.

Methods

Data on infections in England and Wales from 1989 to 2014 were extracted from the Public Health England (PHE) SGSS surveillance database. We conducted a weekly, monthly and quarterly time series analysis of 277 pathogen serotypes. Each organism’s time series was forecasted using the TBATS package in R, with seasonality detected using model fit statistics. Meteorological data hosted on the MEDMI Platform were extracted at a monthly resolution for 2001–2011. The organisms were then clustered by K-means into two groups based on cross correlation coefficients with the weather variables.

Results

Examination of 12.9 million infection episodes found seasonal components in 91/277 (33%) organism serotypes. Salmonella showed seasonal and non-seasonal serotypes. These results were visualised in an online Rshiny application. Seasonal organisms were then clustered into two groups based on their correlations with weather. Group 1 had positive correlations with temperature (max, mean and min), sunshine and vapour pressure and inverse correlations with mean wind speed, relative humidity, ground frost and air frost. Group 2 had the opposite but also slight positive correlations with rainfall (mm, > 1 mm, > 10 mm).

Conclusions

The detection of seasonality in pathogen time series data and the identification of relevant weather predictors can improve forecasting and public health planning. Big data analytics and online visualisation allow the relationship between pathogen incidence and weather patterns to be clarified.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5931-6) contains supplementary material, which is available to authorized users.

Association between heavy precipitation events and waterborne outbreaks in four Nordic countries, 1992-2012

We conducted a matched case-control study to examine the association between heavy precipitation events and waterborne outbreaks (WBOs) by linking epidemiological registries and meteorological data between 1992 and 2012 in four Nordic countries. Heavy precipitation events were defined by above average (exceedance) daily rainfall during the preceding weeks using local references. We performed conditional logistic regression using the four previous years as the controls. Among WBOs with known onset date (n = 89), exceedance rainfall on two or more days was associated with occurrence of outbreak, OR = 3.06 (95% CI 1.38-6.78), compared to zero exceedance days. Stratified analyses revealed a significant association with single household water supplies, ground water as source and for outbreaks occurring during spring and summer. These findings were reproduced in analyses including all WBOs with known outbreak month (n = 186). The vulnerability of single households to WBOs associated with heavy precipitation events should be communicated to homeowners and implemented into future policy planning to reduce the risk of waterborne illness.

A Unified Framework for the Infection Dynamics of Zoonotic Spillover and Spread

A considerable amount of disease is transmitted from animals to humans and many of these zoonoses are neglected tropical diseases. As outbreaks of SARS, avian influenza and Ebola have demonstrated, however, zoonotic diseases are serious threats to global public health and are not just problems confined to remote regions. There are two fundamental, and poorly studied, stages of zoonotic disease emergence: ‘spillover’, i.e. transmission of pathogens from animals to humans, and ‘stuttering transmission’, i.e. when limited human-to-human infections occur, leading to self-limiting chains of transmission. We developed a transparent, theoretical framework, based on a generalization of Poisson processes with memory of past human infections, that unifies these stages. Once we have quantified pathogen dynamics in the reservoir, with some knowledge of the mechanism of contact, the approach provides a tool to estimate the likelihood of spillover events. Comparisons with independent agent-based models demonstrates the ability of the framework to correctly estimate the relative contributions of human-to-human vs animal transmission. As an illustrative example, we applied our model to Lassa fever, a rodent-borne, viral haemorrhagic disease common in West Africa, for which data on human outbreaks were available. The approach developed here is general and applicable to a range of zoonoses. This kind of methodology is of crucial importance for the scientific, medical and public health communities working at the interface between animal and human diseases to assess the risk associated with the disease and to plan intervention and appropriate control measures. The Lassa case study revealed important knowledge gaps, and opportunities, arising from limited knowledge of the temporal patterns in reporting, abundance of and infection prevalence in, the host reservoir.

Many dangerous diseases emerge via spillover from animals, with limited human-to-human infection (stuttering-transmission) often being the first stage of human disease spread. Understanding the conditions (biological, environmental and socio-economic factors) that regulate spillover and disease spread is key to its mitigation. Here we are interested in questions such as: If we have quantified pathogen dynamics in the reservoir, with some knowledge of the mechanism of contact, can we estimate the likelihood of spillover events? Can we tease apart how much the disease is transmitted by animals and how much by humans? We developed a unified mathematical framework, based on Poisson processes with memory of past events, to understand the dynamics of spillover and stuttering-transmission. This framework, which can be applied across the disease transmission spectrum, allows the teasing apart of the disease burden attributed to animal-human and human-human transmission. Using this model, we can infer human disease risk based on knowledge of infection patterns in the animal reservoir host and the contact mechanisms required for transmission to humans.

Waterborne outbreaks in the Nordic countries, 1998 to 2012

A total of 175 waterborne outbreaks affecting 85,995 individuals were notified to the national outbreak surveillance systems in Denmark, Finland and Norway from 1998 to 2012, and in Sweden from 1998 to 2011. Between 4 and 18 outbreaks were reported each year during this period. Outbreaks occurred throughout the countries in all seasons, but were most common (n = 75/169, 44%) between June and August. Viruses belonging to the Caliciviridae family and Campylobacter were the pathogens most frequently involved, comprising n = 51 (41%) and n = 36 (29%) of all 123 outbreaks with known aetiology respectively. Although only a few outbreaks were caused by parasites (Giardia and/or Cryptosporidium), they accounted for the largest outbreaks reported during the study period, affecting up to 53,000 persons. Most outbreaks, 124 (76%) of those with a known water source (n = 163) were linked to groundwater. A large proportion of the outbreaks (n = 130/170, 76%) affected a small number of people (less than 100 per outbreak) and were linked to single-household water supplies. However, in 11 (6%) of the outbreaks, more than 1,000 people became ill. Although outbreaks of this size are rare, they highlight the need for increased awareness, particularly of parasites, correct water treatment regimens, and vigilant management and maintenance of the water supply and distribution systems.

An Outbreak of Cryptosporidium parvum across England & Scotland Associated with Consumption of Fresh Pre-Cut Salad Leaves, May 2012

BACKGROUND

We report a widespread foodborne outbreak of Cryptosporidium parvum in England and Scotland in May 2012. Cases were more common in female adults, and had no history of foreign travel. Over 300 excess cases were identified during the period of the outbreak. Speciation and microbiological typing revealed the outbreak strain to be C. parvum gp60 subtype IIaA15G2R1.

METHODS

Hypothesis generation questionnaires were administered and an unmatched case control study was undertaken to test the hypotheses raised. Cases and controls were interviewed by telephone. Controls were selected using sequential digit dialling. Information was gathered on demographics, foods consumed and retailers where foods were purchased.

RESULTS

Seventy-four laboratory confirmed cases and 74 controls were included in analyses. Infection was found to be strongly associated with the consumption of pre-cut mixed salad leaves sold by a single retailer. This is the largest documented outbreak of cryptosporidiosis attributed to a food vehicle.

Analytical studies assessing the association between extreme precipitation or temperature and drinking water-related waterborne infections: a review

Determining the role of weather in waterborne infections is a priority public health research issue as climate change is predicted to increase the frequency of extreme precipitation and temperature events. To document the current knowledge on this topic, we performed a literature review of analytical research studies that have combined epidemiological and meteorological data in order to analyze associations between extreme precipitation or temperature and waterborne disease.A search of the databases Ovid MEDLINE, EMBASE, SCOPUS and Web of Science was conducted, using search terms related to waterborne infections and precipitation or temperature. Results were limited to studies published in English between January 2001 and December 2013.Twenty-four articles were included in this review, predominantly from Asia and North-America. Four articles used waterborne outbreaks as study units, while the remaining articles used number of cases of waterborne infections. Results presented in the different articles were heterogeneous. Although most of the studies identified a positive association between increased precipitation or temperature and infection, there were several in which this association was not evidenced. A number of articles also identified an association between decreased precipitation and infections. This highlights the complex relationship between precipitation or temperature driven transmission and waterborne disease. We encourage researchers to conduct studies examining potential effect modifiers, such as the specific type of microorganism, geographical region, season, type of water supply, water source or water treatment, in order to assess how they modulate the relationship between heavy rain events or temperature and waterborne disease. Addressing these gaps is of primary importance in order to identify the areas where action is needed to minimize negative impact of climate change on health in the future.

Dolutegravir: clinical and laboratory safety in integrase inhibitor-naive patients

BACKGROUND

The efficacy of dolutegravir (DTG) has been demonstrated in 5 randomized studies in integrase inhibitor (INI)-naive adult populations. To date, a detailed safety review of DTG has not been provided in the literature.

OBJECTIVE

To describe the safety and tolerability profile of DTG in adults based on 5 randomized, controlled trials and comparison with drugs in 3 major antiretroviral (ARV) classes.

METHODS

Safety data from phase IIb/III/IIIb trials in ART-naive and ART-experienced, INI-naive adults were integrated.

RESULTS

In 4 ART-naive (SPRING-1, SPRING-2, SINGLE, FLAMINGO) and 1 ART-experienced, INI-naive study (SAILING), 1,579 individuals received a DTG-containing regimen. The proportion of individuals from DTG treatment arms who withdrew due to adverse events (AEs) was low (≤2%) compared to raltegravir (RAL; 2% SPRING-2, 4% SAILING), efavirenz (EFV)-containing comparator arm (10% SINGLE), and darunavir + ritonavir (DRV/r; 4% FLAMINGO). The most frequently observed AEs (diarrhea, nausea, headache), typically grade 1 or 2 in severity, did not lead to study discontinuation. Psychiatric and nervous system disorders with DTG were comparable to RAL- and DRV/r-containing regimens and favorable to EFV-containing regimens. In hepatitis B and/or C coinfected ART-naive individuals, the incidence of transaminase elevations was lower with DTG versus RAL and EFV comparators, but was similar to DRV/r. In SAILING, transaminase elevations were more commonly observed with DTG, particularly in the setting of inadequate hepatitis B therapy or immune reconstitution. On DTG treatment, mild creatinine elevations occurred and stabilized early. Few cases of hypersensitivity reaction and/or severe rash were seen. Rates of these events were comparable to or lower than with RAL-, EFV-, and DRV/r-containing regimens.

CONCLUSIONS

The safety profile for DTG 50 mg once daily in INI-naive individuals was comparable to RAL- and DRV/r-containing regimens and generally favorable compared with EFV-containing regimens.

Precision measurement of the growth rate and mechanism of ibuprofen {001} and {011} as a function of crystallization environment

The growth rates of the {001} and {011} crystal faces of ibuprofen were measured as a function of the solution crystallisation environment from which the likely interfacial kinetic growth mechanisms were characterised.

Actions for prevention and control of health threats related to maritime transport in European Union

BACKGROUND

Actions at European Union level for International Health Regulations (IHR) 2005 implementation and maritime transport were focused on two European projects implemented between 2006 and 2011.

METHOD

Situation analysis and needs assessment were conducted, a Manual including European standards and best practice and training material was developed and training courses were delivered. Ship-to-port and port-to-port communication web-based network and database for recording IHR Ship Sanitation Certificates (SSC) were established.

RESULTS

Fifty pilot inspections based on the Manual were conducted on passenger ships. A total of 393 corrective actions were implemented according to recommendations given to Captains during pilot inspections. The web-based communication network of competent authorities at ports in EU Member States was used to manage 13 events/outbreaks (dengue fever, Legionnaires' disease, gastroenteritis, meningitis, varicella and measles). The European information database system was used for producing and recording 1018 IHR SSC by 156 inspectors in 6 countries in accordance with the WHO Handbook for inspection of ships and issuance of SSC.

CONCLUSIONS

Implementation of corrective actions after pilot inspections increased the level of compliance with the hygiene standards in passenger ships sailing within the EU waters and improved hygiene conditions. The communication tool contributed to improvement of outbreak identification and better management through rapid sharing of public health information, allowing a more timely and coordinated response. After the implementation of actions on passenger ships, the European Commission co-funded a Joint action that will expand the activities to all types of ships and chemical, biological and radio-nuclear threats (deliberate acts/accidental).

Increasing Pneumocystis pneumonia, England, UK, 2000-2010

After an increase in the number of reported cases of Pneumocystis jirovecii pneumonia in England, we investigated data from 2000-2010 to verify the increase. We analyzed national databases for microbiological and clinical diagnoses of P. jirovecii pneumonia and associated deaths. We found that laboratory-confirmed cases in England had increased an average of 7% per year and that death certifications and hospital admissions also increased. Hospital admissions indicated increased P. jirovecii pneumonia diagnoses among patients not infected with HIV, particularly among those who had received a transplant or had a hematologic malignancy. A new risk was identified: preexisting lung disease. Infection rates among HIV-positive adults decreased. The results confirm that diagnoses of potentially preventable P. jirovecii pneumonia among persons outside the known risk group of persons with HIV infection have increased. This finding warrants further characterization of risk groups and a review of P. jirovecii pneumonia prevention strategies.

Simultaneous increase of Cryptosporidium infections in the Netherlands, the United Kingdom and Germany in late summer season, 2012

Binary file ES_Abstracts_Final_ECDC.txt matches

Simultaneous increase of Cryptosporidium infections in the Netherlands, the United Kingdom and Germany in late summer season, 2012

Starting August 2012, an increase in Cryptosporidium infections was reported in the Netherlands, the United Kingdom and Germany. It represented a 1.8 to 4.9-fold increase compared to previous years. Most samples were C. hominis IbA10G2. A case–control study was performed in the Netherlands but did not identify an endemic source. A case–case study in the north of England found travel abroad to be the most common risk factor.

Climate change and food security: health impacts in developed countries

BACKGROUND

Anthropogenic climate change will affect global food production, with uncertain consequences for human health in developed countries.

OBJECTIVES

We investigated the potential impact of climate change on food security (nutrition and food safety) and the implications for human health in developed countries.

METHODS

Expert input and structured literature searches were conducted and synthesized to produce overall assessments of the likely impacts of climate change on global food production and recommendations for future research and policy changes.

RESULTS

Increasing food prices may lower the nutritional quality of dietary intakes, exacerbate obesity, and amplify health inequalities. Altered conditions for food production may result in emerging pathogens, new crop and livestock species, and altered use of pesticides and veterinary medicines, and affect the main transfer mechanisms through which contaminants move from the environment into food. All these have implications for food safety and the nutritional content of food. Climate change mitigation may increase consumption of foods whose production reduces greenhouse gas emissions. Impacts may include reduced red meat consumption (with positive effects on saturated fat, but negative impacts on zinc and iron intake) and reduced winter fruit and vegetable consumption. Developed countries have complex structures in place that may be used to adapt to the food safety consequences of climate change, although their effectiveness will vary between countries, and the ability to respond to nutritional challenges is less certain.

CONCLUSIONS

Climate change will have notable impacts upon nutrition and food safety in developed countries, but further research is necessary to accurately quantify these impacts. Uncertainty about future impacts, coupled with evidence that climate change may lead to more variable food quality, emphasizes the need to maintain and strengthen existing structures and policies to regulate food production, monitor food quality and safety, and respond to nutritional and safety issues that arise.

Climate change and food security: health impacts in developed countries

BACKGROUND

Anthropogenic climate change will affect global food production, with uncertain consequences for human health in developed countries.

OBJECTIVES

We investigated the potential impact of climate change on food security (nutrition and food safety) and the implications for human health in developed countries.

METHODS

Expert input and structured literature searches were conducted and synthesized to produce overall assessments of the likely impacts of climate change on global food production and recommendations for future research and policy changes.

RESULTS

Increasing food prices may lower the nutritional quality of dietary intakes, exacerbate obesity, and amplify health inequalities. Altered conditions for food production may result in emerging pathogens, new crop and livestock species, and altered use of pesticides and veterinary medicines, and affect the main transfer mechanisms through which contaminants move from the environment into food. All these have implications for food safety and the nutritional content of food. Climate change mitigation may increase consumption of foods whose production reduces greenhouse gas emissions. Impacts may include reduced red meat consumption (with positive effects on saturated fat, but negative impacts on zinc and iron intake) and reduced winter fruit and vegetable consumption. Developed countries have complex structures in place that may be used to adapt to the food safety consequences of climate change, although their effectiveness will vary between countries, and the ability to respond to nutritional challenges is less certain.

CONCLUSIONS

Climate change will have notable impacts upon nutrition and food safety in developed countries, but further research is necessary to accurately quantify these impacts. Uncertainty about future impacts, coupled with evidence that climate change may lead to more variable food quality, emphasizes the need to maintain and strengthen existing structures and policies to regulate food production, monitor food quality and safety, and respond to nutritional and safety issues that arise.

SU-E-T-588: A Treatment Planning Comparison of Dual-Arc VMAT Vs. Helical Tomotherapy for Post-Mastectomy Radiotherapy

PURPOSE

To investigate the feasibility of volumetric modulated arc therapy (VMAT) for post-mastectomy radiotherapy (PMRT) and to compare dual- arc VMAT treatment plans to helical tomotherapy (HT) plans on the basis of dosimetric quality, radiobiological calculations and delivery efficiency.

METHODS

Dual-arc VMAT and HT treatment plans were created for fifteen patients previously treated at our clinic. Planning target volumes (PTV) included the chest wall (CW) and regional lymph nodes. The following metrics were used to compare treatment plans for each patient: dose homogeneity index (DHI) and conformity index (CI); coverage of the PTV; dose to organs at risk (OAR); tumor control probability (TCP), normal tissue complication probability (NTCP) and secondary cancer complication probability (SCCP); and treatment delivery time. Differences between treatment plans were tested for significance using the paired Student's t-test.

RESULTS

Both modalities produced clinically acceptable PMRT plans. VMAT plans showed better CI (p < 0.01), and better OAR sparing at low doses than HT plans. For example, VMAT plans showed a 26% (p < 0.01) and 9% (p < 0.01) decrease in V5Gy in the lungs and heart respectively. On the other hand, HT plans showed better DHI (p < 0.01) and PTV coverage (p < 0.01). HT plans also showed slightly better OAR sparing at higher doses, including 8% (p < 0.01) and 9% (p < 0.01) lower maximum doses to the lungs and heart, respectively. Both modalities achieved nearly 100% tumor control and approximately 1% NTCP in the lungs and heart, with VMAT showing lower SCCP (p < 0.01). VMAT plans also required 66.2% less time to deliver.

CONCLUSIONS

Both VMAT and HT are suitable treatment options for PMRT. Our study showed that VMAT"'in addition to being significantly faster'"achieved better CI and low dose OAR sparing while HT achieved better DHI. This work was supported in part by a research support from Elekta, Ltd. However, Elekta, Ltd., did not participate in the study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; or in the decision to submit.

Surveillance and control of communicable diseases related to passenger ships in Europe

This study was conducted within the European SHIPSAN (ship sanitation) project and aims at exploring the legislative framework and current practices related to surveillance of communicable diseases and response aboard passenger ships in Europe. A detailed questionnaire was disseminated and completed by 59 competent authorities in 27 European countries. The majority of competent authorities used national legislation without special provisions for passenger ships. Only 20% had specific provisions for ships regarding quarantine, while a smaller proportion of new Member States (MS) have specific legislation in comparison with old MS (p = 0.01). The Maritime Declaration of Health (MDH) was the main reporting tool used. About 30.5% of the competent authorities declared that they require submission of MDH by all arriving ships, but 28.8% only from affected areas, and 11.9% never require MDH. A total of 45 outbreaks or incidents (36 gastrointestinal, 1 incident of legionellosis, 3 respiratory, and 1 influenza-like illness outbreak, occupational tuberculosis, varicella, scabies, and meningitis) were reported to EU competent authorities during 2006. About 75% of the responders stated that there are gaps in the surveillance and control of communicable diseases. A diversity of approaches in EU countries, and gaps regarding surveillance and response and training needs of personnel were identified.

EU legislation on food and potable water safety which could be potentially applied on board ferries and cruise ships: a comparison with US legislation

The high number of people moving around by ferries and cruise ships in conjunction with great amounts of food and potable water transported (occasionally overloaded) and consumed by passengers constitute a possible risk for communicable diseases. Another issue of equally great importance is the food handlers who come from diverse origin and have a different mentality, habits, and background. In this paper an attempt is made to present comparatively EU and US legislation that could be potentially applicable to passenger ships food premises and potable water supplies. Moreover, food and water related hazards, not currently covered by EU legislation, were assessed together with US legislation and other guidelines for cruise ships.

COLLAGENOLYTIC ACTIVITY IN RAT BONE CELLS : Characteristics and Intracellular Location

An assay system for estimating quantitatively collagenase-like activity present in bone cells has been developed as part of a more general investigation of mechanisms of bone resorption. Methods are described for preparing from bone a C(14)-labeled collagen which is relatively pure and highly resistant to degradation by trypsin although readily broken down by bacterial collagenase. Collagenolytic activity in homogenates of bone cells harvested from rat metaphyseal bone was measured as the number of counts per minute released in ultrafiltrable form from the C(14)-labeled collagen substrate after 40 minutes' incubation at 37 degrees C and pH 7.3. Using these techniques, the presence of collagenase-like activity in whole bone cell homogenates was confirmed and the heat lability, partial cation dependence, pH optimum, and some other characteristics of the crude material were determined. Moreover, the major portion of the homogenate activity was found in a particulate fraction sedimenting in a centrifugal field between 700 and 15,000 g. The marked enhancement and solubilization of this activity by surface-active agents or freeze-thawing, together with the presence of considerable acid phosphatase activity in the same fraction and its sedimentation characteristics, suggested that it might be contained in lysosomes or similar bodies. The implications of these observations with respect to the physiology of collagen resorption in general and bone resorption in particular are discussed.

Impacts of climate change on indirect human exposure to pathogens and chemicals from agriculture

Climate change is likely to affect the nature of pathogens/ chemicals in the environment and their fate and transport. We assess the implications of climate change for changes in human exposures to pathogens/chemicals in agricultural systems in the UK and discuss the effects on health impacts, using expert input and literature on climate change; health effects from exposure to pathogens/chemicals arising from agriculture; inputs of chemicals/pathogens to agricultural systems; and human exposure pathways for pathogens/chemicals in agricultural systems. We established the evidence base for health effects of chemicals/pathogens in the agricultural environment; determined the potential implications of climate change on chemical/pathogen inputs in agricultural systems; and explored the effects of climate change on environmental transport and fate of various contaminants. We merged data to assess the implications of climate change in terms of indirect human exposure to pathogens/chemicals in agricultural systems, and defined recommendations on future research and policy changes to manage adverse increases in risks.

Hygiene inspections on passenger ships in Europe - an overview

BACKGROUND

Hygiene inspections on passenger ships are important for the prevention of communicable diseases. The European Union (EU) countries conduct hygiene inspections on passenger ships in order to ensure that appropriate measures have been taken to eliminate potential sources of contamination which could lead to the spread of communicable diseases. This study was implemented within the framework of the EU SHIPSAN project and it investigates the legislation applied and practices of hygiene inspections of passenger ships in the EU Member States (MS) and European Free Trade Association countries.

METHODS

Two questionnaires were composed and disseminated to 28 countries. A total of 92 questionnaires were completed by competent authorities responsible for hygiene inspections (n = 48) and the creation of legislation (n = 44); response rates were 96%, and 75.9%, respectively.

RESULTS

Out of the 48 responding authorities responsible for hygiene inspections, a routine programme was used by 19 (39.6%) of these to conduct inspections of ships on national voyages and by 26 (54.2%) for ships on international voyages. Standardised inspection forms are used by 59.1% of the authorities. A scoring inspection system is applied by five (11.6%) of the 43 responding authorities. Environmental sampling is conducted by 84.1% of the authorities (37 out of 44). The inspection results are collected and analysed by 54.5% (24 out of 44) of the authorities, while 9 authorities (20.5%) declared that they publish the results. Inspections are conducted during outbreak investigations by 75% and 70.8% of the authorities, on ships on national and international voyages, respectively. A total of 31 (64.6%) and 39 (81.3%) authorities conducted inspections during complaint investigations on ships on international and on national voyages, respectively. Port-to-port communication between the national port authorities was reported by 35.4% (17 out of 48) of the responding authorities and 20.8% (10 out of 48) of the port authorities of other countries.

CONCLUSION

This study revealed a diversity of approaches and practices in the conduct of inspections, differences in the qualifications/knowledge/experience of inspectors, the legislation applied during inspections, and the lack of communication and training among many EU countries. An integrated European inspection programme involving competent expert inspectors in each EU Member States and special training for ship hygiene delivered to crew members and inspectors would help to minimize the risk of communicable diseases. Common inspection tools at a European level for hygiene inspection practices and port-to-port communication are needed.

Occupational health legislation and practices related to seafarers on passenger ships focused on communicable diseases: results from a European cross-sectional study (EU SHIPSAN PROJECT)

BACKGROUND

Seafarers play an important role in the transmission of communicable diseases. The aim of the present study is to draw information and identify possible gaps on occupational health practices related to seafarers sailing on ships within the European Union Member States (EU MS) with focus on communicable diseases.

METHODS

A structured questionnaire was sent to competent authorities from 21 EU MS. The questionnaire included questions about occupational health policies, medical certification of seafarers, communicable diseases reporting and relevant legislation. Descriptive analysis of the data was conducted by the use of Epi Info software: EU MS were categorized in four priority groups (A, B, C, D) based on: number of passenger ships visits, volume of passengers, and number of ports in each country. Moreover, EU MS were categorized to old and new, based on the date of entry in the EU.

RESULTS

All 21 countries with relevant competent authorities responded to the questionnaire. The existence of specific national legislation/regulation/guidelines related to vaccination of seafarers was reported by three out of the 21 (14%) responding authorities. Surveillance data of communicable diseases related to seafarers are collected and analyzed by 4 (19%) authorities. Five out of 21 of the responding countries (24%) reported that tuberculin test result is required for the issuance of seafarer's medical certificate while a great variety of medical examination is required for the issuance of this certificate among countries.Gaps on occupational health services focused on communicable diseases related to maritime occupation have been reported by 33% of the responding countries.Responding authorities from Group A and B had the highest percentage of reported gaps followed by groups C and D. Old MS reported a higher frequency regarding gaps on occupational health services in comparison to new MS.

CONCLUSION

Our results revealed heterogeneity regarding occupational health of maritime employees in EU MS. This work provides some evidence that further work at international and European level could be considered, in order to explore the potential for harmonized initiatives regarding occupational health of seafarers.

The decision making process on public health measures related to passenger ships: the example of influenza pandemic 2009

BACKGROUND

Public health measures at sea ports have posed a challenge for public health competent authorities, especially in the context of the influenza pandemic of 2009. This paper discusses the response of authorities to notifications of infectious diseases on passenger ships and the importance of assessing the risks related to cases of influenza. It further provides options for health measures and considerations for decision making during a pandemic such as the influenza pandemic of 2009.

DISCUSSION

Prevention and control of influenza have included action taken by both competent port authorities and ships' crews. Assessing the public health risk of each event reported from ships to competent authorities at ports is important before advice is given on implementation of control measures. Public health risk assessment involves appraisal of threats to passengers and crew on board the ship as well as to the population in the community.

SUMMARY

Any public health measures taken should be necessary and proportional to the threat. Measures at ports cannot alone be effective in the prevention of the spread of a disease to the community since other means of transport play a major role. Measures taken on board ships can be effective in containing the disease. Consistent policy based on common protocols and carried out by competent authorities at local, national, European, or international levels are essential.

State of the art: public health and passenger ships

BACKGROUND

The purpose of this report is to describe issues relevant to public health and to review all passenger ship associated diseases and outbreaks. Moreover, legislation and practices on sanitation and diseases surveillance related to ships internationally were also reviewed. Some relevant historical information about infections on merchant ships is provided as well.

MATERIAL AND METHODS

The methods used to develop the state-of-the-art report included a scientific literature review and an extensive and thorough search of the websites of organisations and government departments. A considerable effort was made to capitalise on previous experience in the field. In particular, for the literature review, a total of 158 scientific articles were used including 91 full papers and 67 abstracts, 7 guidelines published by the WHO, and 13 guideline documents published by other organisations. Moreover, 5 international conventions relevant to passenger ships were identified.

RESULTS

At the international level, public health issues related to ships are regulated by the revised International Health Regulations (2005). Other conventions of the International Maritime Organization regulate safety on board ships and waste and ballast water management, while conventions of the International Labour Organization regulates issues related to working conditions on board ships. Guidelines for preventing and controlling public health threats on board ships can be found in seven Guidelines published by the World Health Organization, including the WHO Guide to Ship Sanitation, which provides a framework for policy making and local decision making. The literature review results revealed that the infections/outbreaks that occur on passenger ships include Norovirus, Legionella spp., Salmonella spp., E. coli, Vibrio spp., and influenza A and B virus. The modes of transmission include person to person, waterborne, foodborne, airborne, and vector-borne, and shore excursions are responsible for some outbreaks.

CONCLUSIONS

The industry (especially the ferry industry) and sanitary organisations can enhance collaboration in order to implement integrated hygiene programmes and prevent the occurrence of communicable diseases aboard passenger ships.

Preparedness for the prevention and control of influenza outbreaks on passenger ships in the EU: the SHIPSAN TRAINET project communication

Passenger ships carry a large number of people in confined spaces. A case of the new influenza A (H1N1) virus aboard a passenger ship is an expected event and would lead to rapid spread of the virus, if preventive measures are not in place. However, many cruise lines have detailed policies and procedures to deal with cases of influenza like illness (ILI). The EU SHIPSAN and SHIPSAN TRAINET projects include in their objectives guidelines for the prevention and control of communicable diseases aboard passenger ships. A literature review showed that from 1997 to 2005, nine confirmed outbreaks of influenza were linked to passenger ships, with attack rates up to 37%. It is important to establish and maintain a surveillance system for ILI aboard passenger ships, in order to systematically collect data that can help to determine the baseline illness levels. Monitoring these will enable early identification of outbreaks and allow timely implementation of control measures.

Microbiological surveillance of private water supplies in England: the impact of environmental and climate factors on water quality

A passive surveillance system captured information on 34,904 microbiological samples from 11,233 private drinking water supplies within England as well as the associated constructional, climatic and environmental variables. Escherichia coli was detected in 6588 (18.87%) of samples and at least one positive sample was detected from 3638 (32.39%) of sites. However, this estimate of supplies failing to meet the European drinking water E. coli standard was probably an underestimate as the more samples taken per supply, the more likely the supply was to fail. A multivariable model of private water supplies data showed a strong seasonal impact, with samples between January and May being significantly less contaminated with E. coli than samples between June and December. Samples from springs (OR 2.5, CI 2.0-3.1) or surface waters (OR 2.4, CI 0.8-7.0) were more likely to fail than groundwater sources, as were supplies with no effective treatment (OR1.8, CI 1.5-2.3). Commercial supplies were less likely to fail than domestic supplies (OR 0.63, CI 0.48-0.83) and the probability of failure was linearly associated with the density of sheep in the area and rainfall on the previous day. A Monte Carlo modelling approach was used to estimate that, had sufficient samples been taken, 54% (95% confidence intervals 49-59%) of all private water supplies in England were likely to be unsatisfactory. These findings will be able to inform risk assessments of private water supplies prior to microbiological results being available.

Impacts of climate change on indirect human exposure to pathogens and chemicals from agriculture

OBJECTIVE

Climate change is likely to affect the nature of pathogens and chemicals in the environment and their fate and transport. Future risks of pathogens and chemicals could therefore be very different from those of today. In this review, we assess the implications of climate change for changes in human exposures to pathogens and chemicals in agricultural systems in the United Kingdom and discuss the subsequent effects on health impacts.

DATA SOURCES

In this review, we used expert input and considered literature on climate change; health effects resulting from exposure to pathogens and chemicals arising from agriculture; inputs of chemicals and pathogens to agricultural systems; and human exposure pathways for pathogens and chemicals in agricultural systems.

DATA SYNTHESIS

We established the current evidence base for health effects of chemicals and pathogens in the agricultural environment; determined the potential implications of climate change on chemical and pathogen inputs in agricultural systems; and explored the effects of climate change on environmental transport and fate of different contaminant types. We combined these data to assess the implications of climate change in terms of indirect human exposure to pathogens and chemicals in agricultural systems. We then developed recommendations on future research and policy changes to manage any adverse increases in risks.

CONCLUSIONS

Overall, climate change is likely to increase human exposures to agricultural contaminants. The magnitude of the increases will be highly dependent on the contaminant type. Risks from many pathogens and particulate and particle-associated contaminants could increase significantly. These increases in exposure can, however, be managed for the most part through targeted research and policy changes.

Rainfall and outbreaks of drinking water related disease and in England and Wales

A case-crossover study compared rainfall in the 4 weeks before drinking water related outbreaks with that in the five previous control years. This included public and private drinking water related outbreaks in England and Wales from 1910 to 1999. Of 111 outbreaks, 89 met inclusion criteria and the implicated pathogens included Giardia, Cryptosporidium, E. coli, S. Typhi, S. Paratyphi, Campylobacter and Streptobacillus moniliformis. Weather data was derived from the British Atmospheric Data Centre There was a significant association between excess cumulative rainfall in the previous 7 days and outbreaks (p=0.001). There was an excess of rainfall below 20 mm for the three weeks previous to this in outbreak compared to control weeks (p=0.002). Cumulative rainfall exceedances were associated with outbreak years. This study provides evidence that both low rainfall and heavy rain precede many drinking water outbreaks and assessing the health impacts of climate change should examine both.

The microbiological quality of potable water on board ships docking in the UK and the Channel Islands: an association of Port Health Authorities and Health Protection Agency Study

Providing safe potable water onboard vessels presents particular challenges and contamination can occur directly from source waters as well as during loading, storage and distribution. Between May and October 2005, 950 potable water samples were collected from 342 ships docking at ports. Comparison with Guidelines found 9% of samples contained coliforms, Escherichia coli or enterococci and 2.8% had faecal indicators (E. coli or enterococci). Action levels of aerobic colony count (ACC) bacteria were detected in 20% (22 degrees C) and 21.5% (37 degrees C) of samples. ACC results from one-off sampling are not informative as this does not enable port health authorities to monitor ACC trends. They should be removed as a routine criterion for remedial action and vessels should adopt the WHO Water Safety Plan approach, whilst continuing to monitor water quality with public health-based indicators (e.g. chlorine residual, coliforms, E. coli and enterococci). Logistic regression analyses identified practices associated with water quality. Practices protective against coliforms, E. coli or enterococci in potable supplies were: good hose hygiene, processing water onboard, maintaining free chlorine residual at >or=0.2 mg/L. This emphasizes the importance of good hygiene during potable water loading and maintaining adequate disinfection of supplies onboard.

Case-control study of environmental and social factors influencing cryptosporidiosis

We report on the first case-control study to investigate the role of wider environmental and socioeconomic factors upon human cryptosporidiosis. Using GIS the detailed locations of 3368 laboratory-confirmed cases were compared to the locations of an equal number of controls. All cases were genotyped enabling Cryptosporidium hominis and Cryptosporidium parvum to be examined separately. When all cryptosporidiosis cases were analyzed, several location variables were strongly associated with illness: areas with many higher socioeconomic status individuals, many individuals aged less than 4 years, areas with a high estimate of Cryptosporidium applied to land from manure, and areas with poorer water treatment. For C. hominis cases, the strongly significant risk factors were areas with many higher socioeconomic status individuals, areas with many young children and urban areas. Socioeconomic status and areas with many individuals aged less then 4 years had a greater impact for infection with C. hominis than for C. parvum. Policy implications are discussed.

Cryptosporidiosis decline after regulation, England and Wales, 1989-2005

Since new drinking water regulations were implemented in England and Wales in 2000, cryptosporidiosis has been significantly reduced in the first half of the year but not in the second. We estimate an annual reduction in disease of 905 reported cases and ≈6,700 total cases.