A growing global network's role in outbreak response: AFHSC-GEIS 2008-2009.

A cornerstone of effective disease surveillance programs comprises the early identification of infectious threats and the subsequent rapid response to prevent further spread. Effectively identifying, tracking and responding to these threats is often difficult and requires international cooperation due to the rapidity with which diseases cross national borders and spread throughout the global community as a result of travel and migration by humans and animals. From Oct.1, 2008 to Sept. 30, 2009, the United States Department of Defense's (DoD) Armed Forces Health Surveillance Center Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) identified 76 outbreaks in 53 countries. Emerging infectious disease outbreaks were identified by the global network and included a wide spectrum of support activities in collaboration with host country partners, several of which were in direct support of the World Health Organization's (WHO) International Health Regulations (IHR) (2005). The network also supported military forces around the world affected by the novel influenza A/H1N1 pandemic of 2009. With IHR (2005) as the guiding framework for action, the AFHSC-GEIS network of international partners and overseas research laboratories continues to develop into a far-reaching system for identifying, analyzing and responding to emerging disease threats.

Capacity-building efforts by the AFHSC-GEIS program.

Capacity-building initiatives related to public health are defined as developing laboratory infrastructure, strengthening host-country disease surveillance initiatives, transferring technical expertise and training personnel. These initiatives represented a major piece of the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) contributions to worldwide emerging infectious disease (EID) surveillance and response. Capacity-building initiatives were undertaken with over 80 local and regional Ministries of Health, Agriculture and Defense, as well as other government entities and institutions worldwide. The efforts supported at least 52 national influenza centers and other country-specific influenza, regional and U.S.-based EID reference laboratories (44 civilian, eight military) in 46 countries worldwide. Equally important, reference testing, laboratory infrastructure and equipment support was provided to over 500 field sites in 74 countries worldwide from October 2008 to September 2009. These activities allowed countries to better meet the milestones of implementation of the 2005 International Health Regulations and complemented many initiatives undertaken by other U.S. government agencies, such as the U.S. Department of Health and Human Services, the U.S. Agency for International Development and the U.S. Department of State.

Department of Defense influenza and other respiratory disease surveillance during the 2009 pandemic.

The Armed Forces Health Surveillance Center's Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) supports and oversees surveillance for emerging infectious diseases, including respiratory diseases, of importance to the U.S. Department of Defense (DoD). AFHSC-GEIS accomplishes this mission by providing funding and oversight to a global network of partners for respiratory disease surveillance. This report details the system's surveillance activities during 2009, with a focus on efforts in responding to the novel H1N1 Influenza A (A/H1N1) pandemic and contributions to global public health. Active surveillance networks established by AFHSC-GEIS partners resulted in the initial detection of novel A/H1N1 influenza in the U.S. and several other countries, and viruses isolated from these activities were used as seed strains for the 2009 pandemic influenza vaccine. Partners also provided diagnostic laboratory training and capacity building to host nations to assist with the novel A/H1N1 pandemic global response, adapted a Food and Drug Administration-approved assay for use on a ruggedized polymerase chain reaction platform for diagnosing novel A/H1N1 in remote settings, and provided estimates of seasonal vaccine effectiveness against novel A/H1N1 illness. Regular reporting of the system's worldwide surveillance findings to the global public health community enabled leaders to make informed decisions on disease mitigation measures and controls for the 2009 A/H1N1 influenza pandemic. AFHSC-GEIS's support of a global network contributes to DoD's force health protection, while supporting global public health.

HIV awareness and condom use among female sex workers in Afghanistan: implications for intervention.

There is little information about HIV awareness or condom use among female sex workers (FSWs) in Afghanistan. The purpose of this cross-sectional study was to assess HIV awareness, knowledge, and condom use among FSWs in three Afghan cities. FSWs residing in Jalalabad, Kabul, and Mazar-i-Sharif were recruited through outreach programs and completed an interviewer-administered questionnaire and rapid tests for hepatitis B surface antigen, HIV, syphilis, and hepatitis C virus. Logistic regression identified factors associated with HIV awareness, comprehensive HIV knowledge (knowledge that HIV cannot be detected by sight, that condoms prevent HIV, and rejection of local misconceptions about HIV transmission), and consistent condom use (use with every sex act) with clients in the last six months. Of 520 participants, 76.9% had no formal education and 37.7% lived outside Afghanistan in the last five years. Nearly half (44.2%) were aware of HIV but, of these, only 17.4% (N = 40) had comprehensive HIV knowledge. There were significant differences by site; FSWs in Jalalabad were more likely to be aware of HIV but FSWs in Kabul were more likely to have correct HIV knowledge and use condoms consistently with clients. Consistent client condom use was reported by 11.5% (N = 60) and was independently associated with having more clients per month (AOR = 1.99, 95% CI: 1.04-3.81). In conclusion, comprehensive HIV knowledge and consistent condom use with clients are low among Afghan FSWs in these cities. Efforts to reach this population should focus on relaying accurate information and expanding condom use with clients.

Implications of hepatitis C viremia vs. antibody alone on transmission among male injecting drug users in three Afghan cities.

OBJECTIVES: To assess differences between injecting drug users (IDUs) with hepatitis C virus (HCV) viremia and IDUs with HCV antibody (Ab) or no evidence of prior infection in three Afghan cities. METHODS: IDUs in Hirat, Jalalabad, and Mazar-i-Sharif completed questionnaires and rapid testing for blood-borne infections including HCV Ab. HCV Ab was confirmed with a recombinant immunoblot assay (RIBA); RIBA-positive specimens underwent reverse transcriptase polymerase chain reaction (RT-PCR) for HCV. Risk behaviors associated with viremia were assessed with site-controlled ordinal regression analysis. RESULTS: Of 609 participants, 223 (36.6%) had confirmed HCV Ab. Of 221 with serum available for PCR evaluation, 127 (57.5%) were viremic. HCV viremia prevalence did not differ by site (range 41.7-59.1%; p=0.52). Among all IDUs, in age and site-controlled ordinal regression analysis, HCV was independently associated with HIV co-infection (adjusted odds ratio (AOR) 7.16, 95% confidence interval (CI) 4.41-11.64), prior addiction treatment (AOR 1.95, 95% CI 1.57-2.42), ever aspirating and re-injecting blood (AOR 1.62, 95% CI 1.18-2.23), prior incarceration (AOR 1.60, 95% CI 1.04-2.45), and sharing injecting equipment in the last 6 months (AOR 1.35, 95% CI 1.02-1.80). CONCLUSION: HCV viremia was present in many participants with prior HCV infection and was associated with some injecting risk behaviors, indicating a substantial risk for transmission. Current harm reduction programs should aim to improve HCV awareness and prevention among IDUs in Afghanistan as a matter of urgency.

Prevalence of HIV, hepatitis B and hepatitis C and associated risk behaviours amongst injecting drug users in three Afghan cities.

BACKGROUND: HIV amongst injecting drug users (IDUs) has been described in Kabul but little data exists for other Afghan cities. We assessed HIV, hepatitis B virus (HBV), and C virus (HCV) prevalence and associated risk behaviours amongst IDUs in Hirat, Jalalabad, and Mazar-i-Sharif, Afghanistan. METHODS: Consented participants reporting injecting drugs within the previous 6 months completed interviewer-administered questionnaires and testing for HIV, hepatitis C antibody (HCV Ab), and hepatitis B surface antigen (HBsAg). Logistic regression was used to determine characteristics associated with each infection. RESULTS: Of 623 participants, most (98.7%) were male. Prevalence of HIV, HCV, and HBV was 1.8% (95% CI: 0.88-3.2), 36.0% (95% CI: 33-41), and 5.8% (95% CI: 3.9-7.6), respectively. All HIV cases and highest HCV prevalence were detected in Hirat; HBV prevalence was highest in Jalalabad. Amongst male IDUs, 62.9% had been imprisoned, of whom 17.2% (n=66) injected in prison. High risk behaviours were common; 30.2% reported needle sharing in the last 6 months, 23.1% reported sex with another male, and 50.4% reported paying females for sex. Behaviours varied significantly by site; generally, Hirat participants reported fewer sexual risk behaviours. Sex with other males was negatively associated with both HBV and HCV in multivariate logistic regression analysis; no injecting behaviours were associated with both HBV and HCV. CONCLUSIONS: Whilst HIV prevalence is low, HCV prevalence and high risk behaviours were common in these populations. Regional variations should be considered in programming to prevent transmission of HIV and viral hepatitis amongst IDUs in Afghanistan.

Evaluation of a prototype dengue-1 DNA vaccine in a Phase 1 clinical trial.

Candidate dengue DNA vaccine constructs for each dengue serotype were developed by incorporating pre-membrane and envelope genes into a plasmid vector. A Phase 1 clinical trial was performed using the dengue virus serotype-1 (DENV-1) vaccine construct (D1ME(100)). The study was an open-label, dose-escalation, safety and immunogenicity trial involving 22 healthy flavivirus-naïve adults assigned to one of two groups. Each group received three intramuscular injections (0, 1, and 5 months) of either a high dose (5.0mg, n=12) or a low dose (1.0mg, n=10) DNA vaccine using the needle-free Biojector(®) 2000. The most commonly reported solicited signs and symptoms were local mild pain or tenderness (10/22, 45%), local mild swelling (6/22, 27%), muscle pain (6/22, 27%) and fatigue (6/22, 27%). Five subjects (41.6%) in the high dose group and none in the low dose group developed detectable anti-dengue neutralizing antibodies. T-cell IFN gamma responses were detected in 50% (4/8) and 83.3% (10/12) of subjects in the low and high dose groups, respectively. The safety profile of the DENV-1 DNA vaccine is acceptable at both doses administered in the study. These results demonstrate a favorable reactogenicity and safety profile of the first in human evaluation of a DENV-1 DNA vaccine.

Contraceptive utilization and pregnancy termination among female sex workers in Afghanistan.

BACKGROUND: To determine the prevalence and correlates of prior pregnancy termination and unmet need for contraception among female sex workers (FSWs) in Afghanistan. METHODS: FSWs in Jalalabad, Kabul, and Mazar-i-Sharif were recruited between June 2006 and December 2007 through outreach programs. Participants completed an interviewer-administered survey describing demographics, behaviors associated with risk of sexually transmitted infections (STIs) and unplanned pregnancy, and medical history. Correlates of prior pregnancy termination and current unmet need for contraception were assessed with logistic regression analysis, controlling for site. RESULTS: Of 520 FSWs, most (82.3%) had been pregnant at least once (mean 4.9 ± 2.7, range 1-17), among whom unplanned pregnancy (36.9%) and termination (33.2%) were common. Jalalabad participants were more likely to report both prior unplanned pregnancy (60.6% vs. 48.3% in Kabul or 20.7% in Mazar, p < 0.001) and prior termination (54.9% vs. 31.8% in Kabul or 26.8% in Mazar, p < 0.001). Most FSWs (90.0%) stated pregnancy was not currently desirable, and 85.2% were using contraception. Unmet need for contraception (14.7% of participants) was positively associated with having sold sex outside their city of residence (adjusted odds ratio [AOR] 1.88, 95% confidence interval [CI] 1.28-2.77) and inversely associated with illicit drug use (AOR 0.41, 95% CI 0.31-0.53). CONCLUSIONS: Although FSWs in Afghanistan report high rates of contraceptive use, unplanned pregnancy is common. Reproductive health services should be included in programming for FSWs to reduce unplanned pregnancies and to reduce HIV/STI risks.

Studies on West Nile virus infection in Egypt.

We conducted a prospective cohort study to determine prevalence and incidence of West Nile virus (WNV) in Egypt. Cohorts were established in Upper (UE), Middle (ME), and Lower (LE) Egypt. Additionally, a cross-sectional serosurvey was performed in the North (NS) and South (SS) Sinai. Cohorts were bled initially and 1 year later. Sera were tested for WNV-IgG by ELISA and positive sera were confirmed by plaque reduction neutralization test (PRNT). Sentinel chicken flocks placed in the above sites were bled monthly for virus isolation and serology. Mosquitoes were collected monthly from the above sites and tested for WNV. Human seroprevalence rates were 35%, 27%, 14%, 1% and 7% in UE, ME, LE, NS and SS, respectively. Seroconversion rates were 18%, 17% and 7% in UE, ME and LE, respectively; 49% of the seroconverters reported undiagnosed febrile illness. Sentinel chickens showed seroconversion in all study sites. WNV was isolated from both sentinel chickens and mosquitoes in cohort sites. This study demonstrates that WNV was actively circulating during the study period in different areas in Egypt and causing febrile illness in a considerable proportion of individuals in the study sites.

Zoonotic transmission of avian influenza virus (H5N1), Egypt, 2006-2009.

During March 2006-March 2009, a total of 6,355 suspected cases of avian influenza (H5N1) were reported to the Ministry of Health in Egypt. Sixty-three (1%) patients had confirmed infections; 24 (38%) died. Risk factors for death included female sex, age > or = 15 years, and receiving the first dose of oseltamivir >2 days after illness onset. All but 2 case-patients reported exposure to domestic poultry probably infected with avian influenza virus (H5N1). No cases of human-to-human transmission were found. Greatest risks for infection and death were reported among women > or = 15 years of age, who accounted for 38% of infections and 83% of deaths. The lower case-fatality rate in Egypt could be caused by a less virulent virus clade. However, the lower mortality rate seems to be caused by the large number of infected children who were identified early, received prompt treatment, and had less severe clinical disease.

HIV, hepatitis B, and hepatitis C prevalence and associated risk behaviors among female sex workers in three Afghan cities.

OBJECTIVE: To assess prevalence of HIV, syphilis, and hepatitis B (HBV) and C virus (HCV) and associated risk behaviors among female sex workers (FSWs) in three Afghan cities. DESIGN: Cross-sectional prevalence assessment. METHODS: Consented FSWs from Jalalabad, Kabul, and Mazar-i-Sharif completed an interviewer-administered questionnaire, pretest and posttest counseling, and rapid and confirmatory testing for HIV, HCV, HBV, and syphilis. Logistic regression was used to detect correlates associated with HBV infection. RESULTS: Of 520 participants, median age and age of initiating sex work were 29 and 23 years, respectively, and the median number of monthly clients was 12. Few FSWs reported ever having used illicit drugs (6.9%) or alcohol (4.7%). Demographic and risk behaviors varied significantly by enrollment site, with Kabul FSWs more likely to report sexually transmitted infection symptoms, longer sex work duration, and sex work in other cities. Prevalence of HIV was 0.19%, HCV was 1.92%, and HBV was 6.54%, with no cases of syphilis detected. HBV was independently associated with at least 12 clients monthly [adjusted odds ratio (AOR) = 3.15, 95% confidence interval (CI) 1.38-7.17], ever using alcohol (AOR = 2.61, 95%CI 1.45-4.69), anal sex (AOR = 2.42, 95%CI 1.15-5.08), and having children (AOR = 2.12, 95%CI 1.72-2.63) in site-controlled multivariable analysis. CONCLUSION: Although prevalence of HIV, HCV, and syphilis is currently low in these three Afghan cities, risky sexual practices were common and associated with HBV. Programming inclusive of voluntary testing for HIV, viral hepatitis, and sexually transmitted infections, hepatitis vaccination, substance abuse prevention, and condom promotion for both FSWs and clients should be pursued in Afghanistan.

Prevalence and correlates of syphilis and condom use among male injection drug users in four Afghan cities.

BACKGROUND: : Injecting drug use is increasing in Afghanistan but little is known about sexual risk behaviors and sexually transmitted infection (STI) prevalence among injection drug users (IDU). The purpose of this study is to assess prevalence and correlates of syphilis and condom use with female sex workers (FSWs) among male IDUs in Hirat, Jalalabad, Kabul, and Mazar-i-Sharif, Afghanistan. METHODS: : Participants in this cross-sectional study completed an interviewer-administered questionnaire and serologic testing for syphilis between June 2005 and January 2008. Factors associated with syphilis condom use with FSWs were assessed with site-controlled logistic regression analysis. RESULTS: : Of 1078 male IDUs, most (90.3%) reported prior sexual experience, of whom 27.6% reported any condom use. Sexual experiences with FSWs (58.1%) and men or boys (25.7%) were common, although prior condom use with FSWs (32.6%) or male partners (10.8%) was relatively rare. Few reported having a lifetime STI diagnosis (6.3%, n = 68) or symptoms (10.4%, n = 110) in the last 6 months. Prevalence of syphilis was 3.72% (95% CI: 2.66%-5.06%) and varied significantly between sites ranging from 0% (Jalalabad) to 13.9% (Mazar-i-Sharif) (P < 0.001)). Syphilis was significantly associated with STI diagnosis (adjusted odds ratio [AOR] = 3.84) or sex with FSWs (AOR = 3.82) in the last 6 months, and with lower (≤6 years) educational level (AOR = 2.20). Prior condom use with FSWs was independently associated with living outside Afghanistan in the last decade (AOR = 5.52, 95% CI: 1.83-16.71), higher income (AOR = 2.03, 95% CI: 1.17-3.51), greater number of lifetime partners (AOR = 1.80, 95% CI: 1.32-2.45), and younger age (AOR = 0.985, 95% CI: 0.973-0.998). CONCLUSIONS: : Although prevalence of syphilis and condom use varied significantly by site, high levels of risky sexual behavior were common, and consistent condom use was rare among IDUs in Afghanistan. Harm reduction programming should incorporate sexual risk reduction and condom promotion and distribution in Afghan cities.

Antigenic and genetic diversity of highly pathogenic avian influenza A (H5N1) viruses isolated in Egypt.

Highly pathogenic avian influenza A virus (H5N1) has diverged antigenically and genetically since its initial detection in Asia in 1997. Viruses belonging to clade 2.2 in particular have been reported in numerous countries with the majority occurring in Egypt. Previous reports identified antigenic similarities between viruses belonging to clade 2.2. However, poultry and human viruses isolated in northern Egypt during 2007 and 2008 were found to be antigenically distinct from other clade 2.2 viruses from this country. Genetic analysis of the hemagglutinin revealed a high degree of nucleotide and amino acid divergence. The antigenic changes in Egyptian viruses isolated during 2007-08 necessitated that two of these strains be considered as potential H5N1 pre-pandemic vaccine candidates.

Distinct circulating recombinant HIV-1 strains among injecting drug users and sex workers in Afghanistan.

Little information is available regarding a circulating HIV genotype among high-risk groups in Afghanistan; we describe HIV genotypes among injecting drug users (IDUs) and sex workers (SWs) in four Afghan cities. Participants completed behavioral questionnaires and HIV testing. Western blot-confirmed specimens had peripheral mononuclear blood cells isolated for genotyping. Analysis of recombinants was done by bootscanning and manual sequence alignment. The single SW sample harbored a CRF01_AE strain. Of 10 IDUs available for analysis, all were CRF35_AD and from Hirat. Analyzed subregions (gag p17 and env C1-C5) revealed close homology between the Hirat specimens. Three distinct subclusters comprising two or three strains were identified, whereas two other strains were generally equidistant from previously identified Kabul strains. Results suggest that the nascent HIV epidemic among IDUs in Hirat is largely, if not entirely, subtype CRF35_AD, and the close homology suggests recent infection; harm reduction should be supported to avert further transmission.

Influenza and respiratory disease surveillance: the US military's global laboratory-based network.

The US Department of Defense influenza surveillance system now spans nearly 500 sites in 75 countries, including active duty US military and dependent populations as well as host-country civilian and military personnel. This system represents a major part of the US Government's contributions to the World Health Organization's Global Influenza Surveillance Network and addresses Presidential Directive NSTC-7 to expand global surveillance, training, research and response to emerging infectious disease threats. Since 2006, the system has expanded significantly in response to rising pandemic influenza concerns. The expanded system has played a critical role in the detection and monitoring of ongoing H5N1 outbreaks worldwide as well as in the initial detection of, and response to, the current (H1N1) 2009 influenza pandemic. This article describes the system, details its contributions and the critical gaps that it is filling, and discusses future plans.

Risk factors for brucellosis in Samarqand Oblast, Uzbekistan.

OBJECTIVES: This study was conducted to identify the potential risk factors for human brucellosis infection in Samarqand, Uzbekistan. METHODS: Clinically identified cases admitted to different hospitals during 2004-2006 (N=144), and age-, sex- and residence-matched control patients (N=288) with other unrelated conditions, were included in this study. Structured questionnaires were completed and consent forms signed. Patients and controls were tested on site for Brucella infection by standard tube agglutination test and culture. Statistical analyses were performed with Stata software for univariate and multivariate analysis. RESULTS: Among the 144 patients with confirmed brucellosis, 137 (95.1%) owned farm animals, 135 (93.8%) were from rural areas, and 119 (82.6%) were enrolled during the animal breeding season. Multivariate analysis indicated that brucellosis was highly associated with contact with aborted animals (adjusted matched odds ratio (AMOR) 87.19, 95% confidence interval (CI) 9.36-911.85; p<0.001), slaughtering/butchering animals (AMOR 35.35, 95% CI 6.25-199.77; p<0.001) in the household, consumption of raw milk (AMOR 54.13, 95% CI 1.98-1476.13; p=0.018), and being in a family that had brucellosis sharing the same exposure (AMOR 15.93, 95% CI 1.37-184.97; p=0.027). CONCLUSIONS: To reduce the burden of brucellosis in Samarqand Oblast, veterinary services should be improved. Also public health education programs should be increased. Implementing these measures will minimize exposure to infected farm animals and reduce the risk of infection.

Oseltamivir resistance mutation N294S in human influenza A(H5N1) virus in Egypt.

In December 2006, three human specimens were received that were suspected positive for influenza A(H5N1). The specimens were tested using real time PCR. And the presence of A(H5N1) virus was confirmed in 2 patients (16F and 26M), The NA sequence from A(H5N1) positive specimens collected before and after antiviral therapy revealed a mutation (N294S) (N295S according to N1 numbering), previously associated with resistance to oseltamivir. When tested with NA inhibition assays, the two N294S viruses from Egypt exhibited from 57 to 138-fold reduction in susceptibility to oseltamivir, depending on the assay. To our knowledge, this is the first time oseltamivir resistance has been detected in A(H5N1) infecting a human prior to treatment.

An immunocytometric assay based on dengue infection via DC-SIGN permits rapid measurement of anti-dengue neutralizing antibodies.

Dengue remains a global public health threat and development of a safe and effective vaccine is a principal public health goal. The primary correlate of immunity is thought to be neutralizing antibodies. Currently, the plaque reduction neutralization test (PRNT) is the gold standard measure of dengue neutralizing antibody responses, but this test is limited by time-consuming performance. In addition, some feel that use of viral strains adapted to grow in Vero or BHK cells may not accurately reflect protective responses. A human cell line transfected to express a putative natural dengue receptor, DC-SIGN (CD209), was used to measure antibody-mediated dengue neutralization. Using neutralizing monoclonal antibodies, immune sera, and laboratory adapted dengue viruses, serotype-specific neutralizing activity was demonstrated similar to that seen in the Vero PRNT. Importantly, serotype-specific neutralizing activity against recently isolated dengue strains with less heterotypic cross-neutralization than laboratory adapted viruses was also demonstrated.

Bacteria as agents of biowarfare. How to proceed when the worst is suspected.

Recognition of an increasing incidence of uncommon pneumonias with a high mortality rate, clusters of cases, or a high incidence of pet illnesses or death should alert medical personnel to the possibility of terrorism with bacteriologic agents. Prompt reporting of such unusual occurrences to the local health department is of paramount importance for early identification of cases, treatment initiation, and institution of preventive measures.