Mitigation policies, community mobility, and COVID-19 case counts in Australia, Japan, Hong Kong, and Singapore.

OBJECTIVES: The objective of the study was to characterize the timing and trends of select mitigation policies, changes in community mobility, and coronavirus disease 2019 (COVID-19) epidemiology in Australia, Japan, Hong Kong, and Singapore. STUDY DESIGN: Prospective abstraction of publicly available mitigation policies obtained from media reports and government websites. METHODS: Data analyzed include seven kinds of mitigation policies (mass gathering restrictions, international travel restrictions, passenger screening, traveler isolation/quarantine, school closures, business closures, and domestic movement restrictions) implemented between January 1 and April 26, 2020, changes in selected measures of community mobility assessed by Google Community Mobility Reports data, and COVID-19 epidemiology in Australia, Japan, Hong Kong, and Singapore. RESULTS: During the study period, community mobility decreased in Australia, Japan, and Singapore; there was little change in Hong Kong. The largest declines in mobility were seen in places that enforced mitigation policies. Across settings, transit-associated mobility declined the most and workplace-associated mobility the least. Singapore experienced an increase in cases despite the presence of stay-at-home orders, as migrant workers living in dormitories faced challenges to safely quarantine. CONCLUSIONS: Public policies may have different impacts on mobility and transmission of severe acute respiratory coronavirus-2 transmission. When enacting mitigation policies, decision makers should consider the possible impact of enforcement measures, the influence on transmission of factors other than movement restrictions, and the differential impact of mitigation policies on subpopulations.

Evaluation of the national tuberculosis surveillance program in Haiti.

OBJECTIVE: To assess the quality of tuberculosis (TB) surveillance in Haiti, including whether underreporting from facilities to the national level contributes to low national case registration. METHODS: We collected 2010 and 2012 TB case totals, reviewed laboratory registries, and abstracted individual TB case reports from 32 of 263 anti-tuberculosis treatment facilities randomly selected after stratification/weighting toward higher-volume facilities. We compared site results to national databases maintained by a non-governmental organization partner (International Child Care [ICC]) for 2010 and 2012, and the National TB Program (Programme National de Lutte contre la Tuberculose, PNLT) for 2012 only. RESULTS: Case registries were available at 30/32 facilities for 2010 and all 32 for 2012. Totals of 3711 (2010) and 4143 (2012) cases were reported at the facilities. Case totals per site were higher in site registries than in the national databases by 361 (9.7%) (ICC 2010), 28 (0.8%) (ICC 2012), and 31 (0.8%) cases (PNLT 2012). Of abstracted individual cases, respectively 11.8% and 6.8% were not recorded in national databases for 2010 (n = 323) and 2012 (n = 351). CONCLUSIONS: The evaluation demonstrated an improvement in reporting registered TB cases to the PNLT in Haiti between 2010 and 2012. Further improvement in case notification will require enhanced case detection and diagnosis.

Improving rates of cotrimoxazole prophylaxis in resource-limited settings: implementation of a quality improvement approach.

OBJECTIVE: To demonstrate the effectiveness of quality improvement methods to monitor and improve administration of cotrimoxazole (CTX) prophylaxis to improve health outcomes among adults living with HIV/AIDS in low resource countries. DESIGN: Program evaluation. SETTING: HIV/AIDS health care facilities in Uganda, Mozambique, Namibia and Haiti. INTERVENTION: Performance measures based on national guidelines are developed in each country. These may include CD4 monitoring, ART adherence and uptake of CTX prophylaxis. CTX prophylaxis is routinely selected, because it has been shown to reduce HIV-related morbidity and mortality. Patient records are sampled using a standard statistical table to achieve a minimum confidence interval of 90% with a spread of ±8% in participating clinics. If an electronic medical record is available, all patients are reviewed. Routine review of performance measures, usually every 6 months, is conducted to identify gaps in care. Improvement interventions are developed and implemented at health facilities, informed by performance results, and local/national public health priorities. MAIN OUTCOME MEASURE: Median clinic rates of CTX prophylaxis. RESULTS: Median performance rates of CTX prophylaxis generally improved for adult HIV+ patients between 2006 and 2013 across countries, with median clinic rates higher than baseline at follow-up in 16 of 18 groups of clinics implementing CTX -focused improvement projects. CONCLUSIONS: Quality management offers a data-driven method to improve the quality of HIV care in low resource countries. Application of improvement principles has been shown to be effective to increase the rates of CTX prophylaxis in national HIV programs in multiple countries.

Piloting the use of personal digital assistants for tuberculosis and human immunodeficiency virus surveillance, Kenya, 2007.

SETTING: Improved documentation of human immunodeficiency virus (HIV) testing and care among tuberculosis (TB) patients is needed to strengthen TB-HIV programs. In 2007, Kenya piloted the use of personal digital assistants (PDAs) instead of paper registers to collect TB-HIV surveillance data from TB clinics. OBJECTIVE: To evaluate the acceptability, data quality and usefulness of PDAs. DESIGN: We interviewed four of 31 district coordinators who collected data in PDAs for patients initiating TB treatment from April to June 2007. In 10 of 93 clinics, we randomly selected patient records for comparison with corresponding records in paper registers or PDAs. Using Cochran-Mantel-Haenszel tests, we compared missing data proportions in paper registers with PDAs. We evaluated PDA usefulness by analyzing PDA data from all 93 clinics. RESULTS: PDAs were well accepted. Patient records were more frequently missing (28/97 vs. 1/112, P < 0.001) and data fields more frequently incomplete (148/1449 vs. 167/2331, P = 0.03) in PDAs compared with paper registers. PDAs, however, facilitated clinic-level analyses: 48/93 (52%) clinics were not reaching the targets of testing >or=80% of TB patients for HIV, and 8 (9%) clinics were providing <80% of TB-HIV co-infected patients with cotrimoxazole (CTX). CONCLUSION: PDAs had high rates of missing data but helped identify clinics that were undertesting for HIV or underprescribing CTX.

Developing WHO guidelines with pragmatic, structured, evidence-based processes: A case study.

Many guidelines, including those produced by the World Health Organisation (WHO), have failed to adhere to rigorous methodological standards. Operational examples of guideline development processes may provide important lessons learned to improve the rigour and quality of future guidelines. To this end, this paper describes the process of developing WHO guidelines on prevention and care interventions for adults and adolescents living with HIV. Using a pragmatic, structured, evidence-based approach, we created an organising committee, identified topics, conducted systematic reviews, identified experts and distributed evidence summaries. Subsequently, 55 global HIV experts drafted and anonymously submitted guideline statements at the beginning of a conference. During the conference, participants voted on statements using scales evaluating appropriateness of the statements, strength of recommendation and level of evidence. After review of voting results, open discussion, re-voting and refinement of statements, a draft version of the guidelines was completed. A post-conference writing team refined the guidelines based on pre-determined guideline writing principles and incorporated external comments into a final document. Successes and challenges of the guideline development process were identified and are used to highlight current issues and debates in developing guidelines with a focus on implications for future guideline development at WHO.

Modelling local and global effects on the risk of contracting Tuberculosis using stochastic Markov-chain models.

For some diseases, the transmission of infection can cause spatial clustering of disease cases. This clustering has an impact on how one estimates the rate of the spread of the disease and on the design of control strategies. It is, however, difficult to assess such clustering, (local effects on transmission), using traditional statistical methods. A stochastic Markov-chain model that takes into account possible local or more dispersed global effects on the risk of contracting disease is introduced in the context of the transmission dynamics of tuberculosis. The model is used to analyse TB notifications collected in the Asembo and Gem Divisions of Nyanza Province in western Kenya by the Kenya Ministry of Health/National Leprosy and Tuberculosis Program and the Centers for Disease Control and Prevention. The model shows evidence of a pronounced local effect that is significantly greater than the global effect. We discuss a number of variations of the model which identify how this local effect depends on factors such as age and gender. Zoning/clustering of villages is used to identify the influence that zone size has on the model's ability to distinguish local and global effects. An important possible use of the model is in the design of a community randomised trial where geographical clusters of people are divided into two groups and the effectiveness of an intervention policy is assessed by applying it to one group but not the other. Here the model can be used to take the effect of case clustering into consideration in calculating the minimum difference in an outcome variable (e.g. disease prevalence) that can be detected with statistical significance. It thereby gauges the potential effectiveness of such a trial. Such a possible application is illustrated with the given time/spatial TB data set.

Evaluation of TB and HIV services prior to introducing TB-HIV activities in two rural districts in western Kenya.

SETTING: Health facilities providing tuberculosis (TB) treatment in two districts in rural western Kenya with a high TB and human immunodeficiency virus (HIV) burden. OBJECTIVE: To evaluate TB and HIV/acquired immune-deficiency syndrome (AIDS) services at the facilities and identify barriers to providing quality diagnostic HIV testing and counseling (DTC) and HIV treatment for TB patients in anticipation of the introduction of TB-HIV collaborative services. METHODS: We performed a standard interview with health workers responsible for TB care, inspected the facilities and collected service delivery data. A self-administered questionnaire on training attended was given to all health workers. Results were shared with stakeholders and plans for implementation were developed. RESULTS: Of the 59 facilities, 58 (98%) provided TB treatment, 19 (32%) offered sputum microscopy and 24 (41%) HIV testing. Most facilities (72%) advised HIV testing only if TB patients were suspected of having AIDS. Barriers identified included unaccommodating TB clinic schedules and lack of space, which was an obstacle to holding confidential discussions. The need to refer for HIV testing and/or HIV care was a perceived barrier to recommending these services. Activities implemented following the assessment aimed 1) to provide HIV testing and cotrimoxazole prophylaxis at all TB treatment clinics, 2) to increase availability of HIV treatment services, and 3) to address structural needs at each facility. CONCLUSION: This evaluation identified barriers to the implementation of HIV testing and care services within facilities providing TB treatment.

Serotonin syndrome in HIV-infected individuals receiving antiretroviral therapy and fluoxetine.

OBJECTIVE: To describe HIV-infected individuals taking antidepressants who developed the serotonin syndrome due to drug--drug or drug--food interactions. DESIGN AND SETTING: Case studies carried out at the HIV Outpatient Clinic, Atlanta Veterans Affairs Medical Center. PARTICIPANTS AND INTERVENTIONS: HIV-positive patients who were receiving antiretroviral and antidepressant therapies and presented with symptoms consistent with the serotonin syndrome. Their antidepressants were discontinued or the doses reduced in order to resolve the symptoms. RESULTS: Five cases of serotonin syndrome developed after patients who were taking antidepressants ingested P450 inhibitors. CONCLUSIONS: Serotonin syndrome should be suspected in patients on serotonergic medications who present with mental status change, autonomic dysfunction, and neuromuscular abnormalities. Suspicion should be heightened in those who are ingesting substances known to inhibit P450 enzymes, such as protease inhibitors, non-nucleoside reverse transcriptase inhibitors, and grapefruit juice.

Serologic response to culture filtrate antigens of Mycobacterium ulcerans during Buruli ulcer disease.

Buruli ulcer (BU) is an emerging necrotic skin disease caused by Mycobacterium ulcerans. To assess the potential for a serodiagnostic test, we measured the humoral immune response of BU patients to M. ulcerans antigens and compared this response with delayed-type hypersensitivity responses to both Burulin and PPD. The delayed-type hypersensitivity response generally supported the diagnosis of BU, with overall reactivity to Burulin in 28 (71.8%) of 39 patients tested, compared with 3 (14%) of 21 healthy controls. However, this positive skin test response was observed primarily in patients with healed or active disease, and rarely in patients with early disease (p=0.009). When tested for a serologic response to M. ulcerans culture filtrate, 43 (70.5%) of 61 BU patients had antibodies to these antigens, compared with 10 (37.0%) of 27 controls and 4 (30. 8%) of 13 tuberculosis patients. There was no correlation between disease stage and the onset of this serum antibody response. Our findings suggest that serologic testing may be useful in the diagnosis and surveillance of BU.

Parainfluenza virus infection among adults hospitalized for lower respiratory tract infection.

To better define the contribution of human parainfluenza viruses (HPIVs) to lower respiratory tract infection in adults, we tested acute- and convalescent-phase serum specimens from hospitalized adults participating in a population-based prospective study of lower respiratory tract infection during 1991-1992. We tested all available specimens from the epidemic seasons for each virus and approximately 300 randomly selected specimens from the corresponding off-seasons for antibodies to HPIV-1, HPIV-2, or HPIV-3. During the respective epidemic season, HPIV-1 infection was detected in 18 (2.5%) of 721 and HPIV-3 infection in 22 (3.1%) of 705 patients with lower respiratory tract infection. Only 2 (0.2%) of 1,057 patients tested positive for HPIV-2 infection. No HPIV-1 infections and only 2 (0.7% of 281 patients tested) HPIV-3 infections were detected during the off-seasons. HPIV-1 and HPIV-3 were among the four most frequently identified infections associated with lower respiratory tract infection during their respective outbreak seasons.

Resistance to a residential AIDS home: an empirical test of NIMBY.

OBJECTIVE: This study is designed to evaluate the NIMBY (not-in-my-back-yard) syndrome regarding a proposed residential home for HIV-positive individuals. Hypotheses attempted to explain support of the home and fear of loss in real estate values. These variables were analyzed in terms of value of homes, distance to site, fear of AIDS and homophobia. METHOD: A survey of New Hope, Pennsylvania employed a 10% probability cluster sample. This resulted in 106 responses and a response rate of 70.7%. Correlational and multiple regression analyses were used to test hypotheses. FINDINGS: Support of the home and fear of loss in real estate values were not found to be related to distance from one's home to the site or to value of one's home. Bath were related to fear of AIDS and homophobia. CONCLUSIONS: NIMBY opposition in the case of an AIDS residence was found to be primarily related to fear of AIDS and homophobia. This situation, an AIDS residence, appears to be different from other instances of NIMBY.

The prevalence of colonization with vancomycin-resistant Enterococcus at a Veterans' Affairs institution.

OBJECTIVE: To study vancomycin-resistant Enterococcus (VRE) prevalence, risk factors, and clustering among hospital inpatients. DESIGN: Rectal-swab prevalence culture survey conducted from February 5 to March 22, 1996. SETTING: The Veterans' Affairs Medical Center, Atlanta, Georgia. PATIENTS: Hospital (medical and surgical) inpatients. RESULTS: The overall VRE prevalence was 29% (42/147 patients). The VRE prevalence was 52% (38/73 patients) among patients who had received at least one of six specific antimicrobials during the preceding 120 days, compared with only 5% (4/74) among those who had not received the antimicrobials (relative risk, 9.6; P<.001). The longer the period (up to 120 days) during which antimicrobial use was studied, the more closely VRE status was predicted. Among 67 hospital patients in 28 multibed rooms, clustering of VRE among current roommates was not found. CONCLUSIONS: At this hospital with relatively high VRE prevalence, VRE colonization was related to antibiotic use but not to roommate VRE status. In hospitals with a similar VRE epidemiology, obtaining cultures from roommates of VRE-positive patients may not be as efficient a strategy for identifying VRE-colonized patients as obtaining screening cultures from patients who have received antimicrobials.

Accuracy of ICD-9-CM codes in detecting community-acquired pneumococcal pneumonia for incidence and vaccine efficacy studies.

Studies have used medical record discharge data as coded by the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to estimate pneumococcal pneumonia incidence and vaccine efficacy. However, the accuracy of coding data to identify laboratory-confirmed pneumococcal pneumonia is not known. With the use of information collected in Ohio for a community-based pneumonia incidence study, the authors calculated the sensitivities, specificities, positive predictive values (PPV), and negative predictive values (NPV) of specific codes for pneumococcal pneumonia among hospitalized patients with community-acquired pneumonia. Sensitivities of the most common ICD-9-CM codes listed in the first five positions for patients with laboratory-confirmed pneumococcal pneumonia were 58.3% (code 481.0, pneumococcal pneumonia), 20.4% (38.0, streptococcal septicemia), 19.2% (38.2, pneumococcal septicemia), 15.0% (518.81, respiratory failure), 14.2% (486.0, pneumonia, organism unspecified), and 11.3% (482.3, streptococcal pneumonia). Using the first five listed ICD-9-CM codes rather than just the first listed code increased sensitivity without causing substantial change in specificity, PPV, and NPV. Sensitivity, PPV, and NPV of individual and groups of codes varied with different case definitions of pneumococcal pneumonia. Incidence and vaccine efficacy studies with the ability to validate diagnoses by medical chart review can use a combination of many ICD-9-CM codes to maximize sensitivity. However, without the ability to review medical charts, researchers must carefully decide which codes would best suit their studies.

Incidence of community-acquired pneumonia requiring hospitalization. Results of a population-based active surveillance Study in Ohio. The Community-Based Pneumonia Incidence Study Group.

BACKGROUND: Pneumonia is the leading cause of death due to infectious diseases in the United States; however, the incidence of most infections causing community-acquired pneumonia in adults is not well defined. METHODS: We evaluated all adults, residing in 2 counties in Ohio, who were hospitalized in 1991 because of community-acquired pneumonia. Information about risk factors, symptoms, and outcome was collected through interview and medical chart review. Serum samples were collected from consenting individuals during the acute and convalescent phases, and specific etiologic diagnoses were assigned based on results of bacteriologic and immunologic tests. RESULTS: The incidence of community-acquired pneumonia requiring hospitalization in the study counties in 1991 was 266.8 per 100,000 population; the overall case-fatality rate was 8.8%. Pneumonia incidence was higher among blacks than whites (337.7/100,000 vs 253.9/ 100,000; P < .001), was higher among males than females (291.4 vs 244.8; P < .001), and increased with age (91.6/100,000 for persons aged < 45 years, 277.2/ 100,000 for persons aged 45-64 years, and 1012.3/ 100,000 for persons aged > or = 65 years; P < .001). Extrapolation from study incidence data showed the projected annual number of cases of community-acquired pneumonia requiring hospitalization in the United States to be 485,000. These data provide previously unavailable estimates of the annual number of cases that are due to Legionella species (8000-18,000), Mycoplasma pneumoniae (18,700-108,000), and Chlamydia pneumoniae (5890-49,700). CONCLUSIONS: These data provide information about the importance of community-acquired pneumonia and the relative and overall impact of specific causes of pneumonia. The study provides a basis for choosing optimal empiric pneumonia therapy, and allows interventions for prevention of pneumonia to be targeted at groups at greatest risk for serious illness and death.

DNA fingerprinting by infrequent-restriction-site amplification.

Identification of bacterial strains by DNA fingerprinting facilitates epidemiologic studies and improves disease control. For some species of organisms, no typing method is available; for others, typing methods are tedious. We developed a method of amplifying DNA sequences flanking infrequent restriction sites by PCR and used the method to produce strain-specific electrophoretic patterns from crude bacterial lysates. This method of fingerprinting is rapid, sensitive, and widely applicable. Identical enzymes, adaptors, primers, and PCR conditions were used to characterize 32 Mycobacterium avium-M. intracellulare isolates, 4 Pseudomonas aeruginosa isolates, and 4 Staphylococcus aureus isolates.

Respiratory syncytial virus is an important cause of community-acquired lower respiratory infection among hospitalized adults.

Respiratory syncytial virus (RSV), the most important cause of lower respiratory disease in infants and young children, is rarely considered among the causes for community-acquired lower respiratory infection in adults. All noninstitutionalized adults hospitalized with community-acquired pneumonia in two Ohio counties were evaluated between December 1990 and May 1992. Fifty-three (4.4%) of 1195 adults admitted during the RSV seasons and 4 (1.0%) of 390 in the off-season had serologic evidence of RSV infection, making RSV one of the four most common pathogens identified. RSV-infected patients had clinical features (e.g., wheezing and rhonchi) that distinguished them from all non-RSV-infected patients and other features (e.g., nonelevated white blood cell counts) that distinguished them from those infected with bacterial or atypical agents. However, RSV infection was not diagnosed during hospitalization for any of the 57 RSV-infected patients. RSV should be considered in the differential diagnosis for adults hospitalized between November and April with community-acquired lower respiratory infection.

Reevaluation of the definition of Legionnaires' disease: use of the urinary antigen assay. Community Based Pneumonia Incidence Study Group.

Cases of Legionnaires' disease have been categorized as definitive and presumptive. The sensitivity and specificity of antibody titers of > or = 256 and of urinary antigen ratios of > or = 3 were evaluated in 68 patients with "definitive" Legionnaires' disease and in 636 patients with pneumonia who had negative cultures and did not have fourfold rises in titers of antibody to Legionella pneumophila. An acute-phase antibody titer of > or = 256 did not discriminate between cases and noncases (10% vs. 6%; P = .29). The urinary antigen assay gave a positive result in fewer than 1% of noncases but was positive in 55.9% of all cases. This assay was most sensitive (80%) in cases in which L. pneumophila serogroup 1 was isolated. We propose that the case definition for definitive Legionnaires' disease be expanded to include positive urinary antigen assays and that the category of presumptive Legionnaires' disease--based on acute-phase or standing antibody titers of > or = 256 in the nonoutbreak setting--be discarded. The urinary antigen assay will be a valuable tool in the prompt diagnosis of Legionnaires' disease.

Emergence of Buruli ulcer disease in the Daloa region of Cote d'Ivoire.

Recent reports have suggested increases in Buruli ulcer (BU), an infection caused by Mycobacterium ulcerans in west Africa. In 1991, we conducted surveillance for BU in a rural area of Cote d'Ivoire and identified 312 cases of active or healed ulceration. A case-control study was then performed to investigate risk factors for this infection. The rate of illness did not appear to differ between males and females (5.2% versus 7.5%; P = 0.11). The highest rate of illness was seen in the 10-14-year-old age group (143 cases per 1,000 population). New cases increased more than three-fold between 1987 and 1991, and local prevalence of BU was as high as 16.3%. Twenty-six percent of persons with healed ulcers had chronic functional disability. Participation in farming activities near the main river in the region was identified in the case-control study as a risk factor for infection (odds ratio [OR] for each 10-min decrease in walking distance between the fields and the river = 1.52, 95% confidence interval [CI] 1.01, 2.28, P = 0.046). Wearing long pants was protective (OR 0.20, 95% CI 0.06, 0.62, P < 0.005). We conclude that the incidence of BU is increasing rapidly in Cote d'Ivoire. Specific causes of this increase were not identified, but wearing protective clothing appeared to decrease the risk of disease.