How do field epidemiologists learn? A protocol for a qualitative inquiry into learning in field epidemiology training programmes.

INTRODUCTION: COVID-19 underscored the importance of field epidemiology training programmes (FETPs) as countries struggled with overwhelming demands. Experts are calling for more field epidemiologists with better training. Since 1951, FETPs have been building public health capacities across the globe, yet explorations of learning in these programmes are lacking. This qualitative study will (1) describe approaches to training field epidemiologists in FETP; (2) describe strategies for learning field epidemiology among FETP trainees and (3) explain the principles and practices aligning training approaches with learning strategies in FETP. METHODS AND ANALYSIS: The research design, implementation and interpretation are collaborative efforts with FETP trainers. Data collection will include interviews with FETP trainers and trainees and participant observations of FETP training and learning events in four FETP in the Western Pacific Region. Data analysis will occur in three phases: (1) we will use the constant comparison method of Charmaz's grounded theory during open coding to identify and prioritise categories and properties in the data; (2) during focused coding, we will use constant comparison and Polkinghorne's analysis of narratives, comparing stories of prioritised categories, to fill out properties of those categories and (3) we will use Polkinghorne's narrative analysis to construct narratives that reflect domains of interest, identifying correspondence among Carr and Kemmis's practices, understandings and situations to explain principles and processes of learning in FETP. ETHICS AND DISSEMINATION: We have obtained the required ethics approvals to conduct this research at The Australian National University (2021/771) and Taiwan's Ministry of Health and Welfare (112206). Data will not be available publicly, but anonymised findings will be shared with FETP for collaborative interpretation. Ultimately, findings and interpretations will appear in peer-reviewed journals and conferences.

COVID-19 public health surveillance and response in Taiwan: From containment to mitigation.

Taiwan learned from its 2003 SARS experience and established multiple surveillance systems to be able to detect and respond to COVID-19. With the find, test, trace, isolate, and support (FTTIS) strategy, Taiwan was successful in containing SARS-CoV-2 from spreading for two years. During the surge of the Omicron variant in the community, COVID-19 control strategy shifted from containment to mitigation in April 2022, to reduce morbidity and mortality. Lessons learned from COVID-19 response re-emphasizes the importance of having sensitive public health surveillance and linking surveillance with public health actions.

Wastewater sequencing uncovers early, cryptic SARS-CoV-2 variant transmission

As SARS-CoV-2 continues to spread and evolve, detecting emerging variants early is critical for public health interventions. Inferring lineage prevalence by clinical testing is infeasible at scale, especially in areas with limited resources, participation, or testing/sequencing capacity, which can also introduce biases. SARS-CoV-2 RNA concentration in wastewater successfully tracks regional infection dynamics and provides less biased abundance estimates than clinical testing. Tracking virus genomic sequences in wastewater would improve community prevalence estimates and detect emerging variants. However, two factors limit wastewater-based genomic surveillance: low-quality sequence data and inability to estimate relative lineage abundance in mixed samples. Here, we resolve these critical issues to perform a high-resolution, 295-day wastewater and clinical sequencing effort, in the controlled environment of a large university campus and the broader context of the surrounding county. We develop and deploy improved virus concentration protocols and deconvolution software that fully resolve multiple virus strains from wastewater. We detect emerging variants of concern up to 14 days earlier in wastewater samples, and identify multiple instances of virus spread not captured by clinical genomic surveillance. Our study provides a scalable solution for wastewater genomic surveillance that allows early detection of SARS-CoV-2 variants and identification of cryptic transmission.

Proactive and blended approach for COVID-19 control in Taiwan.

Coronavirus disease 2019 (COVID-19) has become the greatest threat to human society in a century. To better devise control strategies, policymakers should adjust policies based on scientific evidence in hand. Several countries have limited the epidemics of COVID-19 by prioritizing containment strategies to mitigate the impacts on public health and healthcare systems. However, asymptomatic/pre-symptomatic transmission of COVID-19 complicated traditional symptom-based approaches for disease control. In addition, drastic population-based interventions usually have significant societal and economic impacts. Therefore, in Taiwan, the containment strategies consisted of the more extended case-based interventions (e.g., case detection with enhanced surveillance and contact tracing with active monitoring and quarantine of close contacts) and more targeted population-based interventions (e.g., face mask use in recommended settings and risk-oriented border control with corresponding quarantine requirement). The success of the blended approach emphasizes not only the importance of evidence-supported policymaking but also the coordinated efforts between the government and the people.

Chikungunya infection: First autochthonous cases in Taiwan.

The first autochthonous case and the first outbreak of chikungunya in Taiwan occurred during July-October 2019, with a total of 21 cases confirmed. Genetic analysis revealed the strains belonged to East/Central/South African genotype and had 99.95%-100% identity with the strains from the imported cases from Myanmar in 2019. This event confirmed that the imported chikungunya cases has the potential to cause autochthonous transmission in Taiwan; intensified surveillance and vector control measures are essential to contain the outbreak.

Epidemiology of the first 100 cases of COVID-19 in Taiwan and its implications on outbreak control.

PURPOSE: To describe the epidemiology and outcome of the first 100 COVID-19 cases in Taiwan. METHODS: We included the first 100 patients with laboratory-confirmed SARS-CoV-2 infection in Taiwan. Demographic, clinical, epidemiological and laboratory data were extracted from outbreak investigation reports and medical records. RESULTS: Illness onset of the 100 patients was during January 11 to March 16, 2020. Twenty-nine (29%) had at least one underlying condition and ten (10%) were asymptomatic. Seventy-one were imported, including four clusters. Twenty-nine were locally-acquired, including four clusters. The median days from onset to report was longer in locally-acquired cases (10 vs 3 days). Three patients died (case fatality rate 3%) and all of them had underlying conditions. As of May 13, 2020, 93 had been discharged in stable condition; the median hospital stay was 30 days (range, 10-79 days). CONCLUSION: The first 100 cases of COVID-19 in Taiwan showed the persistent threat of imported cases from different countries. Even though sporadic locally-acquired disease has been identified, through contact investigation, isolation, quarantine and implementation of social distancing measures, the epidemic is contained to a manageable level with minimal local transmission.

Measles transmission at an international airport - Taiwan, March-April 2018.

During March-April 2018, an infectious measles index case traveling from Thailand led to two successive generations of measles transmission in Taiwan, with 21 cases confirmed. The median patient age was 30.5 years (range 22-47 years); six (27%) had documented receipt of one (n=3) or more (n=3) previous measles-containing vaccine doses at age ≥12 months. Epidemiological investigation and sequence analysis found that most (n=16, 76%) measles transmissions had occurred in airport and flight settings; secondary and tertiary cases included cabin crew (n=7), airport staff (n=2), and passengers who had been at the same airport or on the same flight (n=7). This investigation serves as a reminder that an international airport can be a hotspot for measles transmission. International travelers, airline cabin crew, and airport employees are recommended to check their vaccination status and ensure that they are fully vaccinated against measles. Furthermore, it is recommended that airline and airport employers have an occupational health vaccination program in place to ensure appropriate pre-employment assessment of measles immunity and vaccination.

Containing influenza outbreaks with antiviral use in long-term care facilities in Taiwan, 2008-2014.

BACKGROUNDS: Influenza can spread rapidly in long-term care facilities (LTCFs), and residents are usually at higher risk for influenza infections. OBJECTIVE: Our study aimed to evaluate the effectiveness of antiviral interventions on outbreak control. METHODS: Taiwan Centers for Disease Control used a syndromic surveillance system to monitor outbreaks in LTCFs. Local public health authorities verified those outbreaks and logged reports to the Epidemic Investigation Report Files Management System (EIRFMS). We conducted a retrospective cohort study by reviewing EIRFMS reports of influenza outbreaks in LTCFs during 2008-2014. An influenza outbreak was defined as 3 or more cases of influenza-like illness occurring within a 48-hours period with ≥1 case of real-time RT-PCR-confirmed influenza in the same LTCF. Antiviral interventions included providing antiviral treatment for patients and antiviral prophylaxis for contacts during outbreaks. RESULTS: Of 102 influenza outbreaks, median days from onset of the first patient to outbreak notification was 4 (range 0-22). Median attack rate was 24% (range 2.2%-100%). Median influenza vaccination coverage among residents was 81% (range 0%-100%); 43% occurred during the summer months. Even though antiviral treatment was provided in 87% of the outbreaks, antiviral prophylaxis was implemented in only 40%. Starting antiviral treatment within 2 days of outbreak onset was associated with keeping attack rates at <25% (OR 0.29, 95% CI: 0.12-0.71). CONCLUSIONS: Early initiation of antiviral treatment may reduce the magnitude of influenza outbreaks. Clinicians should identify patients with influenza and start antiviral use early to prevent large outbreaks in LTCFs.

A new reportable disease is born: Taiwan Centers for Disease Control's response to emerging Zika virus infection.

Zika virus infection, usually a mild disease transmitted through the bite of Aedes mosquitos, has been reported to be possibly associated with microcephaly and neurologic complications. Taiwan's first imported case of Zika virus infection was found through fever screening at airport entry in January 2016. No virus was isolated from patient's blood taken during acute illness; however, PCR products showed that the virus was of Asian lineage closely related to virus from Cambodia. To prevent Zika virus from spreading in Taiwan, the Taiwan Centers for Disease Control has strengthened efforts in quarantine and surveillance, increased Zika virus infection diagnostic capacity, implemented healthcare system preparedness plans, and enhanced vector control program through community mobilization and education. Besides the first imported case, no additional cases of Zika virus infection have been identified. Furthermore, no significant increase in the number of microcephaly or Guillain- Barré Syndrome has been observed in Taiwan. To date, there have been no autochthonous transmissions of Zika virus infection.

Multidrug-Resistant Tuberculosis Treatment Outcomes in Relation to Treatment and Initial Versus Acquired Second-Line Drug Resistance.

BACKGROUND: Resistance to second-line drugs develops during treatment of multidrug-resistant (MDR) tuberculosis, but the impact on treatment outcome has not been determined. METHODS: Patients with MDR tuberculosis starting second-line drug treatment were enrolled in a prospective cohort study. Sputum cultures were analyzed at a central reference laboratory. We compared subjects with successful and poor treatment outcomes in terms of (1) initial and acquired resistance to fluoroquinolones and second-line injectable drugs (SLIs) and (2) treatment regimens. RESULTS: Of 1244 patients with MDR tuberculosis, 973 (78.2%) had known outcomes and 232 (18.6%) were lost to follow-up. Among those with known outcomes, treatment succeeded in 85.8% with plain MDR tuberculosis, 69.7% with initial resistance to either a fluoroquinolone or an SLI, 37.5% with acquired resistance to a fluoroquinolone or SLI, 29.3% with initial and 13.0% with acquired extensively drug-resistant tuberculosis (P < .001 for trend). In contrast, among those with known outcomes, treatment success increased stepwise from 41.6% to 92.3% as the number of drugs proven effective increased from ≤1 to ≥5 (P < .001 for trend), while acquired drug resistance decreased from 12% to 16% range, depending on the drug, down to 0%-2% (P < .001 for trend). In multivariable analysis, the adjusted odds of treatment success decreased 0.62-fold (95% confidence interval, .56-.69) for each increment in drug resistance and increased 2.1-fold (1.40-3.18) for each additional effective drug, controlling for differences between programs and patients. Specific treatment, patient, and program variables were also associated with treatment outcome. CONCLUSIONS: Increasing drug resistance was associated in a logical stepwise manner with poor treatment outcomes. Acquired resistance was worse than initial resistance to the same drugs. Increasing numbers of effective drugs, specific drugs, and specific program characteristics were associated with better outcomes and less acquired resistance.

Management of Bacillus Calmette-Guérin osteomyelitis/osteitis in immunocompetent children-A systematic review.

BACKGROUND: Bacillus Calmette-Guérin (BCG) osteomyelitis/osteitis in immunocompetent children is a rare but serious complication of BCG immunization. Rationale for its treatment is unclear. METHODS: Due to the rarity of this complication, no randomized control trials has ever been conducted to evaluate methods of intervention. As such, we searched the literature for any reported BCG vaccination-related osteomyelitis/osteitis among immunecompetent children published before April 15, 2014. We summarized the data from different affected regions of the body by recording the number of reported cases, while noting outcomes and their medical and/or surgical interventions. RESULTS: From 34 eligible studies gleaned from a screening of 804 articles, a total of 331 cases were enrolled. Involvement of the lower limbs was present in 55.6%, followed by the axial skeleton (26.0%), the upper limbs (15.4%), and multiple bones (3.0%). Of the 64 patients having records of detailed chemotherapy regimens, 45 patients (70%) received two or fewer drugs. Among the 80 patients with detailed surgical records, 50 (62.5%) received surgical procedures for diagnostic purposes. While there were uneventful outcomes for those receiving diagnostic procedures, 7 of the 30 (23.3%) patients receiving surgical interventions had major complications (p=0.002, Fisher's exact test). The overall prognosis was good with a 97.6% cure rate. Nevertheless, eight patients (2.4%) suffered major complications. CONCLUSIONS: The rationale for treatment of BCG osteomyelitis/osteitis in immunocompetent children is highly subjective. However, patients receiving diagnostic procedures instead of surgical interventions may avoid major complications. Because only a few of the publications had detailed treatment information, further studies are needed to identify proper treatments, while infant BCG vaccination is still in use.

Public Health Responses to Reemergence of Animal Rabies, Taiwan, July 16-December 28, 2013.

Taiwan had been free of indigenous human and animal rabies case since canine rabies was eliminated in 1961. In July 2013, rabies was confirmed among three wild ferret-badgers, prompting public health response to prevent human rabies cases. This descriptive study reports the immediate response to the reemergence of rabies in Taiwan. Response included enhanced surveillance for human rabies cases by testing stored cerebrospinal fluids (CSF) from patients with encephalitides of unknown cause by RT-PCR, prioritizing vaccine use for postexposure prophylaxis (PEP) during periods of vaccine shortage and subsequent expansion of PEP, surveillance of animal bites using information obtained from vaccine application, roll out of preexposure prophylaxis (PrEP) with vaccine stock restoration, surveillance for adverse events following immunization (AEFI), and ensuring surge capacity to respond to general public inquiries by phone and training for healthcare professionals. Enhanced surveillance for human rabies found no cases after testing 205 stored CSF specimens collected during January 2010-July 2013. During July 16 to December 28, 2013, we received 8,241 rabies PEP application; 6,634 (80.5%) were consistent with recommendations. Among the 6,501 persons who received at least one dose of rabies vaccine postexposure, 4,953 (76.2%) persons who were bitten by dogs; only 59 (0.9%) persons were bitten by ferret-badgers. During the study period, 6,247 persons received preexposure prophylaxis. There were 23 reports of AEFI; but no anaphylaxis, Guillain-Barré syndrome, or acute disseminated encephalomyelitis were found. During the study period, there were 40,312 calls to the Taiwan Centers for Disease Control hotline, of which, 8,692 (22%) were related to rabies. Recent identification of rabies among ferret-badgers in a previously rabies-free country prompted rapid response. To date, no human rabies has been identified. Continued multifaceted surveillance and interministerial collaboration are crucial to achieve the goal of rabies-free status in Taiwan.

Diabetes and risk of tuberculosis relapse: nationwide nested case-control study.

The aim of this study was to investigate the association between diabetes mellitus (DM) and tuberculosis (TB) relapse using the nationwide TB registry in Taiwan. We conducted a case-control study nested within a nationwide cohort of all incident cases of pulmonary TB that were notified during 2006-2007 and had completed anti-TB treatment. The relapse of TB was confirmed by bacteriological or pathological findings. For each relapse case, one control was selected from the study cohort matching by time since treatment completion. DM status was ascertained by medical chart review and cross-matching with the National Health Insurance claims database. A total of 305 cases of relapse were identified after a median follow-up of 3 years (relapse rate: 488 per 100,000 person-year; 95% confidence interval (CI): 434-546). Presence of DM during previous anti-TB treatment was 34.0% and 22.7% in cases and controls, respectively. After adjusting for other potential confounders, DM was associated with increased risk of TB relapse (adjusted odds ratio: 1.96, 95% CI: 1.22-3.15). Only one-third of the DM-TB patients in our study received glycaemic monitoring using HbA1c during anti-TB treatment. Presence of DM was independently associated with risk of TB relapse. TB programs should seriously consider rigorous glucose control in DM-TB patients.

Health characteristics of postmenopausal women with breast implants.

BACKGROUND: Long-term health characteristics and quality of life in patients with breast implants are important issues in plastic surgery. METHODS: The authors evaluated characteristics of women who had breast implant surgery in the Women's Health Initiative observational study between 1993 and 1998. Most women in this study cohort had breast implant surgery 20 or more years before recruitment into the study. The women who were in the study who had not undergone breast implant surgery served as the comparison group. There were 86,686 women in the study who did not have breast implant surgery and an absent history of breast cancer, and 1257 women who had breast implant surgery and no prior breast cancer. RESULTS: Total mortality rates were substantially lower among women with breast implants, as was the incidence of coronary heart disease. Women with breast implants in this study had a lower body mass index throughout adult life and were more physically active than control subjects. After adjustment for these variables, differences in total mortality were no longer statistically significant. Women who had breast implants reported overall poorer quality of life and emotional well-being. These differences were small, but statistically significant. Among women with breast implant surgery, 7 percent of deaths were due to suicide (n = 3) versus 0.4 percent (n = 20) in controls. CONCLUSIONS: Significant differences in health characteristics and quality-of-life measures are seen in a cohort of women with breast implants decades after implant surgery. Further longitudinal studies need to focus on both physical and psychological health among women undergoing breast implant surgery.