Dried blood spots as a practical and inexpensive source for human immunodeficiency virus and hepatitis C virus surveillance

Passive surveillance of infectious diseases with a high percentage of asymptomatic cases or long incubation periods, such as acquired immunodeficiency syndrome (AIDS), does not reflect the current transmission dynamics. Thus, a multi-strategic surveillance, such as the human immunodeficiency virus (HIV) sentinel surveillance proposed by the World Health Organization (WHO), is necessary. The Brazilian HIV sentinel surveillance was started in May 1992 with this purpose. The objectives of this study were to evaluate the feasibility and costs of HIV and hepatitis C virus (HCV) surveillance using dried blood spots (DBS) collected for neonatal screening of metabolic diseases in the state of Minas Gerais, Brazil. This was accomplished through the comparison of HIV and HCV seroprevalence with previous Brazilian studies. From December 2001 to June 2002, 24,905 newborns were tested for HIV and 4211 for HCV. HIV seroprevalence was 0.25% and the 95% confidence interval (CI) was 0.18, 0.31%; and HCV seroprevalence was 0.71% and the 95% CI was 0.46, 0.97%. These numbers are similar to previous Brazilian studies. Cost in this study was approximately USD 3.10 per sample, which was roughly one third of the cost of the same exam at the Brazilian HIV sentinel surveillance. We conclude that it is possible and more cost-effective to use DBS for infectious diseases surveillance, albeit it is still necessary to compare these results with the usual sentinel methodology in a concomitant trial.     

Proteomics for the detection of indirect markers of steroids treatment in bovine muscle

Despite the ban by the European Union, anabolic steroids might still be illicitly employed in bovine meat production. The surveillance of misuse of such potentially harmful molecules is necessary to guarantee consumers’ health. Analytical methods for drug residue control are based on LC‐MS/MS, but their efficacy can be hindered due to undetectable residual concentrations as a result of low‐dosage treatments. Screening methods based on the recognition of indirect biological effects of growth promoters’ administration, such as the alteration of protein expression, can improve the efficacy of surveillance. The present study was aimed at identifying modifications in the muscle protein expression pattern between bulls treated with an ear implant (Revalor‐XS®) containing trenbolone acetate (200 mg) and estradiol (40 mg), and untreated animals. The analysis of skeletal muscle was carried out using a tandem mass tags shotgun proteomics approach. We defined 28 candidate protein markers with a significantly altered expression induced by steroids administration. A subset of 18 candidate markers was validated by SRM and allowed to build a predictive model based on partial least square discriminant analysis. Our findings confirm the effectiveness of the proteomics approach as potential tool to overcome analytical limitations of drug residue monitoring.     

Cost‐effectiveness of Endoscopic Surveillance for Gastric Intestinal Metaplasia

Background: Patients with intestinal metaplasia (IM) are at increased risk for gastric cancer. Endoscopic surveillance has been shown to anticipate cancer diagnosis in an earlier stage. Cost‐effectiveness of endoscopic surveillance in IM patients is unknown. To assess the efficacy and cost‐effectiveness of an yearly endoscopic surveillance in patients with IM. Methods: A decision analysis model was constructed in order to compare a strategy of performing an EGD every year for a 10‐year period (surveillance strategy) following a new diagnosis of IM to a policy of nonsurveillance in a simulated cohort of 10,000 American patients. A 1.8% 10‐year cumulative incidence of gastric cancer in IM patients was estimated from the literature. Endoscopic surveillance was simulated to downstage the detected cancers by 58–84%. Costs of EGD and cancer care were estimated from Medicare reimbursement data. The main outcome measurement was the incremental cost‐effectiveness ratio. Results: The number of EGDs required to detect one cancer and to prevent one gastric cancer‐related death in the surveillance arm were 556 and 3738, respectively. The incremental cost‐effectiveness ratio of endoscopic surveillance as compared to a nonsurveillance policy was $72,519 per life‐year gained (5–95% percentiles Monte Carlo analysis: $54,843–$98,853). At sensitivity analysis, cancer incidence and the rate of downstaging were the most important variables. Conclusions: According to our simulation, the relatively high risk of cancer in patients with IM and the substantial efficacy of endoscopic surveillance in reducing cancer‐related mortality would support the cost‐effectiveness of an endoscopic surveillance program in patients with IM. Further research is needed before implementing it in the clinical practice.     

Quantitative evaluation of complex surveillance systems for pest and disease detection

Surveillance for disease detection is used primarily for early detection of incursions and to support assertions of freedom from disease.Analytical techniques used to evaluate the efficacy of such surveillance are equally applicable across the domains of invasive species (both plant and animal), diseases and pests of agriculture crops, livestock, and of wildlife. Scenario tree models of surveillance activities may be used to estimate their diagnostic sensitivities, or the probability that the target organism will be detected given that it is present at a defined level. This paper will outline techniques for estimating the sensitivity of both targeted and general surveillance activities, and for the surveillance system as a whole. Probability of freedom from the target organism may be estimated from the surveillance sensitivity, and this Bayesian approach may be extended to estimate current probability of freedom from appropriate use of historical and ongoing surveillance evidence.     

Wildtool,a flexible,first-line risk assessment system for wildlife-borne pathogens

We describe the prototype of an electronic tool for risk assessment with dynamic ranking of wildlife-borne pathogens in function of their need for surveillance. Data about pathogens, their hosts and occurrences are obtained from literature and are classified as qualitative scores under six main criteria with their sub-criteria, corresponding to the elements of a standard risk assessment. Pathogen-specific data are reviewed by experts. The information is processed per pathogen through an algorithm and through summing up of the values obtained by converting four-tiered qualitative sub-criteria scores to weighted five-tiered numerical values. For a consistent comparison between pathogens, the “unknown” sub-criteria scores are assigned a median value of 3, allowing preservation of the sub-criteria concerned and their weights for the risk assessment, but minimizing the effect of this score on the outcome. Irregular data availability is further accommodated by a different data processing for comprehensiveness and refinement requirements, which is realised by a respective first- and second-level ranking of pathogens, the latter using additional quantitative and qualitative data for the release assessment. Continuous data updates are necessary to reflect the current situation in the field. Output flexibility is implemented by the possibility to run queries based on the choice of a region, a specific target group susceptible to the pathogens and a set of weights for the sub-criteria.     

An epidemiological analysis of postoperative suppurative pathology in surgical hospitals]

Approaches to the epidemiological analysis of postoperative wound complications in surgical hospitals are summarized. The indices for the evaluation of the epidemic situation in surgical departments (the ratio of severe and mild forms of complications, severe and posthospital complications) are proposed. To determine the site of infection, the method of graphic analysis, involving the fixation of dates of the operation and the appearance of the complication and taking into account regularities in the development of the outbreak, the depth and severity of the lesion, is proposed. Epidemiological surveillance at medical institutions permits the prognostication of the epidemiological situation. The realization of epidemiological surveillance at the level of individual medical institutions is the prerequisite of effective functioning of the program of epidemiological surveillance at a given territory.     

The HIV epidemic in China: history, response, and challenge

The first case of AIDS was reported in 1985 in China, but by the early 21st century, the government estimated that there were 840,000 citizens living with HIV/AIDS. The number is increasing rapidly. The major risk groups are injection drug users (IDUSs; 43%) and former plasma donors (27%), but rates among heterosexual groups are rising rapidly.Sentinel surveillance was initiated in 1986, and now includes IDUs, men-who-have-sex-with-men, sexually transmitted disease clinic attendees, antenatal women, long-distance truck drivers, and .sex workers. Although the government was slow to respond to the epidemic in the late 20th century, it has made a vigorous response in the early 21st century.Components of that response include implementation and evaluation of harm reduction programs for IDUs, education to increase knowledge and reduce stigma, treatment and social support for rural and poor HIV/AIDS patients, widespread testing, and increased funding for HIV/AIDS programs. International agencies have been generous in their support of the government initiatives. To successfully combat the epidemic, China needs to develop and train the necessary infrastructure to implement its intervention programs, particularly in the rural areas, to vigorously combat stigma and discrimination, support research especially in the universities and research institutions other than the China Centers for Disease Control, develop a system for efficient exchange of research and program information, and update legislation to reflect the current situation.     

The HIV epidemic in China: history, response, and challenge

The first case of AIDS was reported in 1985 in China, but by the early 21st century, the government estimated that there were 840,000 citizens living with HIV/AIDS. The number is increasing rapidly. The major risk groups are injection drug users (IDUSs; 43%) and former plasma donors (27%), but rates among heterosexual groups are rising rapidly. Sentinel surveillance was initiated in 1986, and now includes IDUs, men-who-have-sex-with-men, sexually transmitted disease clinic attendees, antenatal women, long-distance truck drivers, and sex workers. Although the government was slow to respond to the epidemic in the late 20th century, it has made a vigorous response in the early 21st century. Components of that response include implementation and evaluation of harm reduction programs for IDUs, education to increase knowledge and reduce stigma, treatment and social support for rural and poor HIV/AIDS patients, widespread testing, and increased funding for HIV/AIDS programs. International agencies have been generous in their support of the government initiatives. To successfully combat the epidemic, China needs to develop and train the necessary infrastructure to implement its intervention programs, particularly in the rural areas, to vigorously combat stigma and discrimination, support research especially in the universities and research institutions other than the China Centers for Disease Control, develop a system for efficient exchange of research and program information, and update legislation to reflect the current situation.     

The HIV epidemic in China: history, response, and challenge

INTRODUCTION One-quarter of the world’s population, 1.3 billion people, live in China. The majority of the population is Han Chi- nese (91.9%), while the rest are a mix of different minor- ity groups living primarily in southern and western China [1]. The GDP per capita is $5,600 per year, but at least 10% of the population lives below the poverty line. Just less than 15% of the GDP is in agriculture, with the re- mainder in industry/construction and services. The total health expend…     

A Cost-Effectiveness Analysis Evaluating Endoscopic Surveillance for Gastric Cancer for Populations with Low to Intermediate Risk

Background

Gastric cancer (GC) surveillance based on oesophagogastroduodenoscopy (OGD) appears to be a promising strategy for GC prevention. By evaluating the cost-effectiveness of endoscopic surveillance in Singaporean Chinese, this study aimed to inform the implementation of such a program in a population with a low to intermediate GC risk.

Methods

Using a reference strategy of no OGD intervention, we evaluated four strategies: 2-yearly OGD surveillance, annual OGD surveillance, 2-yearly OGD screening and 2-yearly screening plus annual surveillance in Singaporean Chinese aged 50-69 years. From a perspective of the healthcare system, Markov models were built to simulate the life experience of the target population. The models projected discounted lifetime costs ($), quality adjusted life year (QALY), and incremental cost-effectiveness ratio (ICER) indicating the cost-effectiveness of each strategy against a Singapore willingness-to-pay of $46,200/QALY. Deterministic and probabilistic sensitivity analyses were used to identify the influential variables and their associated thresholds, and to quantify the influence of parameter uncertainties respectively.

Results

With an ICER of $44,098/QALY, the annual OGD surveillance was the optimal strategy while the 2-yearly surveillance was the most cost-effective strategy (ICER  =  $25,949/QALY). The screening-based strategies were either extendedly dominated or cost-ineffective. The cost-effectiveness heterogeneity of the four strategies was observed across age-gender subgroups. Eight influential parameters were identified each with their specific thresholds to define the choice of optimal strategy. Accounting for the model uncertainties, the probability that the annual surveillance is the optimal strategy in Singapore was 44.5%.

Conclusion

Endoscopic surveillance is potentially cost-effective in the prevention of GC for populations at low to intermediate risk. Regarding program implementation, a detailed analysis of influential factors and their associated thresholds is necessary. Multiple strategies should be considered in order to recommend the right strategy for the right population.     

Overview of recent clinical trials of acellular pertussis vaccines.

The evidence from pre-licensure studies does not suggest that there are clinically important differences in reactogenicity between acellular vaccines. The merits of different acellular products will therefore have to be compared on efficacy criteria. Ideally, acellular vaccines with the minimum antigen content necessary to ensure optimum protection should be used in order to avoid administration of superfluous antigens to children and to simplify licensing and batch release procedures.On the basis of the evidence so far available it seems unlikely that monocomponent pertussis toxin (PT) vaccines provide optimal protection and that multicomponent vaccines are needed to achieve a level of disease control that approaches that of a good whole-cell vaccine. It is unclear whether all two component vaccines containing PT and filamentous haemagglutinin (FHA) have similar efficacy but on the available evidence the safest option for policy makers would seem to be to use a vaccine with at least three components, PT+FHA+pertactin. There is now good evidence that the five component vaccine which contains agglutinogens 2 and 3 in addition to PT/FHA and pertactin provides the best protection and is the only acellular vaccine whose efficacy matches that of a good whole cell vaccine. However, the public health advantage of the five component vaccine over other acellular vaccines may not become apparent until they have been in routine use for some decades and their ability to protect against transmission as well as clinical pertussis has emerged.The decision to replace an effective whole-cell vaccine by an acellular vaccine for primary immunisation needs careful consideration. Apart from the probable sacrifice of efficacy for reduced reactogenicity (at least for vaccines which do not contain agglutinogens 2 and 3) there is the question of value for money and the ease with which acellular DTP vaccines can be combined with conjugate polysaccharide vaccines such as Haemophilus influenzae type b.Whatever the decision of policy makers, the need for continued follow up of trial cohorts and active surveillance of the efficacy and safety of those acellular vaccines that are introduced into routine use must be accorded a high priority.     

Sensitivity of Bovine Tuberculosis Surveillance in Wildlife in France: A Scenario Tree Approach

Bovine tuberculosis (bTB) is a common disease in cattle and wildlife, with an impact on animal and human health, and economic implications. Infected wild animals have been detected in some European countries, and bTB reservoirs in wildlife have been identified, potentially hindering the eradication of bTB from cattle populations. However, the surveillance of bTB in wildlife involves several practical difficulties and is not currently covered by EU legislation. We report here the first assessment of the sensitivity of the bTB surveillance system for free-ranging wildlife launched in France in 2011 (the Sylvatub system), based on scenario tree modelling. Three surveillance system components were identified: (i) passive scanning surveillance for hunted wild boar, red deer and roe deer, based on carcass examination, (ii) passive surveillance on animals found dead, moribund or with abnormal behaviour, for wild boar, red deer, roe deer and badger and (iii) active surveillance for wild boar and badger. The application of these three surveillance system components depends on the geographic risk of bTB infection in wildlife, which in turn depends on the prevalence of bTB in cattle. We estimated the effectiveness of the three components of the Sylvatub surveillance system quantitatively, for each species separately. Active surveillance and passive scanning surveillance by carcass examination were the approaches most likely to detect at least one infected animal in a population with a given design prevalence, regardless of the local risk level and species considered. The awareness of hunters, which depends on their training and the geographic risk, was found to affect surveillance sensitivity. The results obtained are relevant for hunters and veterinary authorities wishing to determine the actual efficacy of wildlife bTB surveillance as a function of geographic area and species, and could provide support for decision-making processes concerning the enhancement of surveillance strategies.     

Changes in visual fields associated with web reduction in the spider family uloboridae

When visual fields of the primitive orb-weaver, Waitkera waitkerensis, are reconstructed using measurements taken from intact lenses and cross and longitudinal sections of the prosoma, they show that this species has complete visual surveillance, but that none of the visual fields of its eight eyes overlap. The more advanced orb-weaver, Uloborus glomosus, also has eight eyes, but each eye has a greater visual angle, giving this species a complex pattern of overlapping visual fields. Uloborids that spin reduced webs are characterized by reduction or loss of the four anterior eyes and other carapace modifications necessary for them to effectively monitor and manipulate their reduced webs. The eyes of these uloborids have greater visual angles than those of orb-weavers, resulting primarily from perimetric expansion of their retinal hemispheres. Additionally, the axes of their visual fields are more ventrally directed due to greater dorsal than ventral retinal expansion and to ventral redirection of the entire eye. Consequently, even though the anterior lateral eyes of the triangle-weaver Hyptiotes cavatus lack retinae, the species' six functional eyes permit complete visual surveillance and exhibit visual overlap. The single-line-weaver, Miagrammopes animotus, has lost its four anterior eyes, and with them much of the anterior vision and all of the visual overlap found in the other species. However, changes similar to those of H. cavatus permit this species to retain most if its dorsal and ventral visual surveillance. Thus, ocular changes act in consort to maintain relatively complete visual surveillance in the face of eye loss and other major carapace modifications necessary for the operation of reduced webs.     

Real-time investigation of measles epidemics with estimate of vaccine efficacy

As part of measles elimination effort, evaluation of the vaccination program and real-time assessment of the epidemic dynamics constitute two important tasks to improve and strengthen the control. The present study aimed to develop an epidemiological modeling method which can be applied to estimating the vaccine efficacy at an individual level while conducting the timely investigation of the epidemic. The multivariate renewal process model was employed to describe the temporal evolution of infection by vaccination history, jointly estimating the time-dependent reproduction number and the vaccine efficacy. Analyzing the enhanced surveillance data of measles in Aichi prefecture, Japan from 2007-08, the vaccine efficacy was estimated at 96.7% (95% confidence interval: 95.8, 97.4). Using an age structured model, the vaccine efficacy among those aged from 5-19 years was shown to be smaller than that among those from 0-4 years. The age-dependent vaccine efficacy estimate informs the age-groups to be targeted for revaccination. Because the estimation method can rest on readily available epidemiological data, the proposed model has a potential to be integrated with routine surveillance.     

The value of constant surveillance in a risky environment

In risky environments, where threats are unpredictable and the quality of information about threats is variable, all individuals face two fundamental challenges: balancing vigilance against other activities, and determining when to respond to warning signals. The solution to both is to obtain continuous estimates of background risk, enabling vigilance to be concentrated during the riskiest periods and informing about the likely cost of ignoring warnings. Human surveillance organizations routinely produce such estimates, frequently derived from indirect cues. Here we show that vigilant individuals in an animal society (the pied babbler, Turdoides bicolor) perform a similar role. We ask (i) whether, in the absence of direct predator threats, pied babbler sentinels react to indirect information associated with increased risk and whether they communicate this information to group mates; (ii) whether group mates use this information to adjust their own vigilance, and whether this influences foraging success; and (iii) whether information provided by sentinels reduces the likelihood of inappropriate responses to alarm calls. Using playback experiments, we show that: (i) sentinels reacted to indirect predator cues (in the form of heterospecific alarm calls) by giving graded surveillance calls; (ii) foragers adjusted their vigilance in reaction to changes in surveillance calls, with substantial effects on foraging success; and (iii) foragers reduced their probability of responding to alarm calls when surveillance calls indicated lowered risk. These results demonstrate that identifying attacks as they occur is only part of vigilance: equally important is continuous surveillance providing information necessary for individuals to make decisions about their own vigilance and evasive action. Moreover, they suggest that a major benefit of group living is not only the increased likelihood of detecting threats, but a marked improvement in the quality of information available to each individual.     

The future of electrical defibrillators for the heart]

The aim of electric defibrillation of the heart is to salvage a greater percentage of victims of cardiac arrest in the future. An initial decisive pathway towards this goal is to get a defibrillator to the victim as quickly as possible and apply an electric shock. This has now been implemented on a large scale--by means of the widespread propagation of (semi-)automatic external defibrillators (AED) and their PAD (Public Access Defibrillator) variant for use by laypersons. This is an initial necessary prerequisite which, however, is not sufficient to have a real impact on saving lives. For experience has shown that, despite the early use of AEDs, an appreciable proportion of the victims cannot be saved. The intention is to improve this situation by increasing the efficacy and reducing the harmful downside of the defibrillation waveforms applied. The solution is optimally dimensioned biphasic waveforms with high efficacy at low energy levels. In this connection, it is shown that the efficacy of high-energy defibrillation shocks is exceeded by their injurious effects, thus thwarting life-saving defibrillation. Examples of new waveforms of particularly high efficacy are presented. It is shown how such impulses should be physiologically dimensioned, and clinical results of cardioversion (atrial defibrillation) and initial out-of-hospital results of emergency defibrillation are discussed. In addition, new approaches for future waveforms enabling pulsed pulse-pause-modulated biphasic shocks are described. In this way, waveforms with a physiologically optimal effect on the heart can be produced which were previously impossible with portable defibrillators. Waveforms that have already been tested or are still in the research stage, justify hopes that improved survival of cardiac arrest victims may be expected. These new waveforms may also be of benefit in other types of defibrillators (e.g. cardioversion or implanted defibrillators).     

Streamlining 'search and destroy': cost-effective surveillance for invasive species management

Invasive species surveillance has typically been targeted to where the species is most likely to occur. However, spatially varying environmental characteristics and land uses may affect more than just the probability of occurrence. Biodiversity or economic value, and the ease of detection and control are also likely to vary. We incorporate these factors into a detection and treatment model of a low-density invader to determine the surveillance strategy that minimizes expected management costs. Sites with a high probability of invader occurrence and great benefits associated with detection warrant intensive surveillance; however, the optimum investment is a nonlinear function of these factors. Environments where the invader is relatively easy to detect are prioritized for surveillance, although only a moderate investment is necessary to ensure a high probability of detection. Intensive surveillance effort may be allocated to other sites if the probability of occurrence, budget and/or expected benefits is sufficiently high.     

Varicella Coinfection in Patients with Active Monkeypox in the Democratic Republic of the Congo

From 2006 to 2007, an active surveillance program for human monkeypox (MPX) in the Democratic Republic of the Congo identified 151 cases of coinfection with monkeypox virus and varicella zoster virus from 1158 suspected cases of human MPX (13%). Using clinical and socio-demographic data collected with standardized instruments by trained, local nurse supervisors, we examined a variety of hypotheses to explain the unexpectedly high proportion of coinfections among the sample, including the hypothesis that the two viruses occur independently. The probabilities of disease incidence and selection necessary to yield the observed sample proportion of coinfections under an assumption of independence are plausible given what is known and assumed about human MPX incidence. Cases of human MPX are expected to be underreported, and more coinfections are expected with improved surveillance.     

Situation of brucellosis in the regions of Stavropol Territory affected by the flood of 2002

The emergency situation caused by inundations and high floods on the rivers in the affected regions exerts no direct influence on brucellosis morbidity among humans. Still the urgent evacuation of agricultural animals in connection with the natural calamity, their displacement and regrouping give grounds to prognosticate the deterioration of the epizootic situation in this infection in a number of regions of the territory where no sufficient veterinary surveillance has been ensured.     

Comparative assessment of passive surveillance in disease-free and endemic situation: Example of <Emphasis Type="Italic">Brucella melitensis</Emphasis> surveillance in Switzerland and in Bosnia and Herzegovina

Background

Globalization and subsequent growth in international trade in animals and animal products has increased the importance of international disease reporting. Efficient and reliable surveillance systems are needed in order to document the disease status of a population at a given time. In this context, passive surveillance plays an important role in early warning systems. However, it is not yet routinely integrated in the assessment of disease surveillance systems because different factors like the disease awareness (DA) of people reporting suspect cases influence the detection performance of passive surveillance. In this paper, we used scenario tree methodology in order to evaluate and compare the quality and benefit of abortion testing (ABT) for Brucella melitensis (Bm) between the disease free situation in Switzerland (CH) and a hypothetical disease free situation in Bosnia and Herzegovina (BH), taking into account DA levels assumed for the current endemic situation in BH.

Results

The structure and input parameters of the scenario tree were identical for CH and BH with the exception of population data in small ruminants and the DA in farmers and veterinarians. The sensitivity analysis of the stochastic scenario tree model showed that the small ruminant population structure and the DA of farmers were important influential parameters with regard to the unit sensitivity of ABT in both CH and BH. The DA of both farmers and veterinarians was assumed to be higher in BH than in CH due to the current endemic situation in BH. Although the same DA cannot necessarily be assumed for the modelled hypothetical disease free situation as for the actual endemic situation, it shows the importance of the higher vigilance of people reporting suspect cases on the probability that an average unit processed in the ABT-component would test positive.

Conclusion

The actual sensitivity of passive surveillance approaches heavily depends on the context in which they are applied. Scenario tree modelling allows for the evaluation of such passive surveillance system components under assumed disease free situation. Despite data gaps, this is a real opportunity to compare different situations and to explore consequences of changes that could be made.