Implementing Integrated Disease Surveillance and Response: Four African countries' experience, 1998-2005.

The Integrated Disease Surveillance and Response (IDSR) strategy was developed by the Africa Regional Office (AFRO) of the World Health Organisation (WHO) and proposed for adoption by member states in 1998. The goal was to build WHO/AFRO countries' capacity to detect, report and effectively respond to priority infectious diseases. This evaluation focuses on the outcomes in four countries that implemented this strategy. Major successes included: integration of the surveillance function of most of the categorical disease control programmes; implementation of standard surveillance, laboratory and response guidelines; improved timeliness and completeness of surveillance data and increased national-level review and use of surveillance data for response. The most challenging aspects were: strengthening laboratory networks; providing regular feedback and supervision on surveillance and response activities; routine monitoring of IDSR activities and extending the strategy to sub-national levels.

An ecological analysis of sociodemographic factors associated with the incidence of salmonellosis, shigellosis, and E. coli O157:H7 infections in US counties.

Identifying county-level sociodemographic and economic factors associated with the incidence of enteric disease may provide new insights concerning the dynamics of community transmission of these diseases as well as opportunities for prevention. We used data from the National Notifiable Diseases Surveillance System, the U.S. Census Bureau, and the Health Resources and Services Administration to conduct an ecological analysis of 26 sociodemographic and economic factors associated with the incidence of salmonellosis, shigellosis, and E. coli O157:H7 infections in US counties for the period 1993 to 2002. Our study indicates that race, ethnicity, place of residence, age, educational attainment, and poverty may affect the risk of acquiring one of these enteric bacterial diseases. The lack of specificity of information regarding salmonellae and shigellae serotypes may have led to less specific associations between community-level determinants and reported incidence of those diseases. Future ecological analyses should use serotype-specific data on incidence, which may be available from laboratory-based surveillance systems.

Screening of males for Chlamydia trachomatis and Neisseria gonorrhoeae infections at STD clinics in three US cities -- Indianapolis, New Orleans, Seattle.

We assessed prevalence and risk factor data for men routinely screened for Chlamydia trachomatis and Neisseria gonorrhoeae in STD clinics in four US cities from May 1995-March 1999. Data were analysed separately for 'test-visits' (self-reported symptoms, clinical signs or sexual contact to an STD) and 'screen-visits' (STD screen only) for 32,595 men with 45,390 visits. Among test-visits in Seattle, Indianapolis and New Orleans, 8.7% (807/9285), 15.3% (1305/8519), and 10.1% (1551/15,296) of men were positive for C. trachomatis, and 10.2% (773/7543), 24.9% (2108/8478), and 30.4% (4746/ 15,629) for N. gonorrhoeae. Among screen-visits, 2.1% (88/4103), 7.3% (130/1790), and 5.6% (292/5183) of men were positive for C. trachomatis, and 1.8% (46/2576), 1.7% (31/ 1786), and 5.2% (274/5235) for N. gonorrhoeae. Positivity for screen-visits was particularly high among young men (15-24 years), and those reporting > 1 sex partner in the past 60 days. Substantial variation among sites in positivity warrants local determination of prevalence and risk factors to inform screening strategies.

Prevalence of genital chlamydial infection in young women entering a national job training program, 1990-1997.

OBJECTIVES: This analysis describes trends in the prevalence of genital chlamydial infection in economically disadvantaged young women entering a national job training program. METHODS: We examined chlamydia test data for May 1990 through June 1997 for women aged 16 to 24 years who enrolled in the program. The significance of trends was evaluated with the chi 2 test for trend. RESULTS: Prevalence of chlamydial infection declined 32.9%, from 14.9% in 1990 to 10.0% in 1997 (P < .001). Prevalence decreased significantly in all age groups, racial/ethnic groups, and geographic regions. CONCLUSIONS: The decrease in prevalence of chlamydial infection suggests that prevention activities have reached disadvantaged women across the United States; however, prevalence of chlamydial infection remains high, and enhanced prevention efforts in disadvantaged communities are urgently needed.

Estimated incidence and prevalence of genital Chlamydia trachomatis infections in the United States, 1996.

BACKGROUND AND OBJECTIVE: Because genital Chlamydia trachomatis infections and their sequelae have a major impact on individuals and the health care system, it is important to periodically update estimates of chlamydia incidence and prevalence in the United States. STUDY DESIGN: Chlamydia incidence and prevalence were estimated using: (1) a method based on estimates of population-specific chlamydia prevalence, and (2) a method based on the chlamydia-to-gonorrhea case rate ratio. RESULTS: Using the prevalence-based method, point prevalence among persons 15 to 44 years of age was estimated to be 1.6 million chlamydial infections, and annual incidence, 2.4 million cases per year. Using a method based on the ratio of reported gonorrhea to chlamydia, incidence was estimated to be 2.8 million infections per year, and prevalence, 1.9 million. Adjustment for sensitivity of diagnostic tests yielded annual incidence estimates of 2.5 to 3.3 million infections. CONCLUSIONS: Using two methods, we estimated the annual incidence of chlamydial infections in the United States among persons 15 to 44 years of age to be approximately 3 million infections. Critical data needed for more precise estimates include: sensitivity of current diagnostics, better data on infections in males, the current extent of underdetection and underreporting, and better data on duration of infection in men and women.

Impact of increased legal access to needles and syringes on community pharmacies' needle and syringe sales--Connecticut, 1992-1993.

In May 1992, the Connecticut legislature passed new laws aimed at increasing injecting drug users' (IDUs) access to sterile needles and syringes (syringes); as of July 1992, pharmacists were permitted to sell and individuals were permitted to possess up to 10 syringes without medical prescriptions (nonprescription syringes). We evaluated the impact of the new laws by conducting (1) prospective surveillance of syringe sales and policies at selected community pharmacies (pharmacies) and (2) a telephone survey of pharmacy managers' reports of syringe sales and policies at a statewide stratified random sample of pharmacies. Our data provide direct evidence that most, but not all, Connecticut pharmacies sold nonprescription syringes when permitted to do so by the new laws. For example, using the telephone survey data, we estimate that during November, 1993, 83% [95% CI: 77-89%] of all Connecticut pharmacies sold nonprescription syringes and 56,000 [95% CI: 44,000-68,000] nonprescription syringes were sold, during November 1993. Our data provide indirect evidence that IDUs were purchasing nonprescription syringes at pharmacies. For example, in five Hartford pharmacies located in neighborhoods where injection drug use was prevalent, the total number of nonprescription syringes sold per month increased significantly from 460 in July 1992 to 2,482 in June 1993 (p = 0.0001). The data suggest that the new laws increased IDUs' access to sterile syringes in Connecticut.

Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers--Connecticut, 1992-1993.

To determine whether the simultaneous, partial repeal of needle prescription and drug paraphernalia laws in Connecticut affected purchasing and usage of needles and syringes (syringes) by injecting-drug users (IDUs) and risk of needlestick injuries to police officers, we conducted two serial cross-sectional surveys with IDUs recruited in drug treatment centers, correctional facilities, and health department settings. Reports of needlestick injuries among Hartford police officers were reviewed before and after the new laws. Among IDUs who reported ever sharing a syringe, syringe-sharing decreased after the new laws (52% before vs. 31% after; p = 0.02). Fewer IDUs reported purchasing syringes on the street after the new laws (74% before vs. 28% after; p < 0.0001). More IDUs reported purchasing syringes from a pharmacy after the new laws (19% before vs. 78% after; p < 0.0001). Eight to eleven months after the new laws were enacted, over two thirds (91 of 134) of active IDUs interviewed were aware of both new laws. Needlestick injury rates among Hartford police officers were lower after the new laws (six injuries in 1,007 drug-related arrests for 6-month period before new laws vs. two in 1,032 arrests for 6-month period after new laws). The changes in Connecticut laws were associated with decreases in self-reported syringe-sharing and increases in purchasing by IDUs of sterile syringes from reliable sources, suggesting that the simultaneous repeal of both prescription and paraphernalia laws is an important HIV prevention strategy.

Characterization of patients accepting and refusing routine, voluntary HIV antibody testing in public sexually transmitted disease clinics.

BACKGROUND AND OBJECTIVES: To determine the proportion of HIV-infected sexually transmitted disease (STD) clinic patients identified during routine, voluntary HIV counseling and testing and to characterize patients accepting and refusing counseling and testing, we linked data from a blinded HIV seroprevalence survey to data from the HIV counseling and testing program. GOAL OF THIS STUDY: This study characterizes patients accepting and refusing routine HIV counseling and testing in two public STD clinics. STUDY DESIGN: A cross-sectional, blinded HIV seroprevalence survey was conducted of 1,232 STD clinic patients offered HIV counseling and testing. RESULTS: HIV seroprevalence was higher among patients who refused voluntary testing (7.8% versus 3.6%, P = 0.001). Patients who refused testing were more likely to report a prior HIV test (45.6% versus 27.2%; P < 0.001). Among patients reporting a prior HIV test, differences were noted between reported prior results, both positive and negative, and blinded results. CONCLUSIONS: HIV-infected STD patients may not be detected by routine HIV testing, and self-reported HIV results should be confirmed.

Active morbidity surveillance after Hurricane Andrew--Florida, 1992.

OBJECTIVE: To describe the health status of and to detect disease outbreaks in the population affected by Hurricane Andrew in south Dade County, Florida. DESIGN: The Florida Department of Health and Rehabilitative Services and the US Army conducted active surveillance for gastrointestinal illness, respiratory illness, injury, and other index conditions by monitoring civilian and service member visits to care sites (civilian and military free care sites and hospital emergency departments) from August 30 (1 week after the hurricane's landfall) through September 30, 1992. SETTING: South Dade County, Florida. MAIN OUTCOME MEASURES: Proportional morbidity: the number of daily visits for each index condition divided by the total number of visits, expressed as a percentage. Morbidity rate: the total number of daily visits by service members divided by the total number of service members, expressed as a percentage. RESULTS: Six index conditions accounted for 41.3% of visits to civilian free care sites: diarrhea (4.7%), cough (4.7%), other infection (9.6%), rash (5.4%), animal bite (1.2%), and injury (15.7%). At military free care sites, five index conditions accounted for 75.7% of civilian visits: injury (23.7%), dermatologic illness (12.4%), respiratory illness (9.9%), gastrointestinal illness (5.3%), and other medical conditions (24.4%). Two index conditions accounted for 54.1% of service member visits: injury (36.2%) and dermatologic illness (17.9%). During the 5 weeks after the hurricane, proportional morbidity from injury decreased; proportional morbidity from respiratory illness increased; and proportional morbidity from diarrhea was stable. No infectious disease outbreaks occurred. CONCLUSIONS: Injuries were an important source of morbidity throughout the surveillance period, especially among service members. Enteric and respiratory agents did not cause disease outbreaks, despite alarming rumors to the contrary.

Evolution of the human immunodeficiency virus epidemic among patients attending sexually transmitted disease clinics: a decade of experience.

Since human immunodeficiency virus (HIV) is predominantly sexually transmitted, serologic surveys for HIV infection in sexually transmitted disease (STD) clinics provide sentinel observations regarding HIV epidemiology. Over the past decade, 17,207 systematically collected sera from patients attending Baltimore STD clinics were analyzed. From 1979 through 1989, HIV seroprevalence rose from 0.23% to 5.35%, increasing significantly in both men and women (P less than .001). Due to a marked increase in HIV infection among women during the mid-1980s, the male-to-female ratio of HIV infection declined from 16:1 in 1979-1982 to 1.0 in 1988-1989. HIV seroprevalence increased significantly (P less than .001) in all age groups, with the greatest increase among teenagers, rising from 0.18% in 1979-1983 to 2.1% in 1987-1989 (P less than .001). Although HIV seroprevalence was higher among whites than blacks during the early 1980s, it increased in blacks subsequently (P less than .001), eventually resulting in a greater rate among black than white clinic patients (P less than .01). These data reflect the evolution of the HIV epidemic in US inner cities. HIV prevalence has increased greater than 20-fold, with recent increases being most marked among women, teenagers, and blacks. Additional resources will undoubtedly be required to support further intensive behavioral and educational programs targeted at adolescents and inner-city minorities.

The association of syphilis with risk of human immunodeficiency virus infection in patients attending sexually transmitted disease clinics.

A serologic survey of 4863 patients attending two inner-city sexually transmitted disease clinics was conducted in 1988 1 year after an initial survey to reassess the prevalence and associated risk factors for human immunodeficiency virus (HIV) infection. The HIV seroprevalence rates had not changed significantly (5.2% in 1987, 4.9% in 1988), and remained higher among men (5.6%) than among women (3.6%). The HIV seroprevalence increased steadily with age, to 34 years in women and to 39 years in men. Of patients with a reactive syphilis serologic test result, 24.3% were HIV infected compared with 3.5% of patients with a nonreactive test for syphilis. In multivariate analysis, a reactive serologic test for syphilis was significantly associated with HIV infection in all major risk behavior categories. Among heterosexuals who denied parenteral drug abuse, HIV infection rates were 6.8 and 8.7 times greater for women and men, respectively, who had a reactive serologic test for syphilis. Evidence of heterosexual transmission of HIV was further suggested by a change in HIV seroprevalence in women from 3.0% in 1987 to 3.6% in 1988, a male to female HIV infection ratio of 1.6, and 3.0% prevalence of infection among patients who denied established risk factors. This was most evident among those younger than 25 years, in whom 72% of infected women and 46.2% of infected men denied high-risk behaviors. These data demonstrate the strong association between syphilis and HIV infection and the importance of heterosexual HIV transmission in patients attending sexually transmitted disease clinics. This study underscores the need for a more comprehensive control program for sexually transmitted diseases, including syphilis and HIV infection.

HIV infection rates in a trauma center treating predominantly rural blunt trauma victims.

Human immunodeficiency virus (HIV) infection rates among 1,497 consecutive adult trauma victims triaged from rural and urban sectors to a statewide trauma center in Baltimore were studied. Those studied were 71.7% men, 77.4% whites, 63.2% vehicular trauma victims, 11.2% assault victims, and 25.7% other trauma victims. Non-Baltimoreans predominated (86.0%) and 32.7% were 25 to 39 years of age. Overall, 1.67% of the victims were HIV antibody positive. Significantly higher infection rates were seen in men (1.96% vs. 0.95%; p less than 0.02), non-whites (4.13% vs. 0.95; p less than 0.005), assault victims compared with vehicular and other trauma victims (5.99% vs. 1.06% vs. 1.30%, respectively; p less than 0.001), and Baltimore City residents (3.81% vs. 1.32%; p less than 0.03). Among those 25 to 39 years of age, 68.0% of the HIV infections were noted. Results suggest that HIV infection rates among trauma center patients are a reflection of the patient population served.