Communicable Disease Surveillance Systems in Disasters: Application of the Input, Process, Product, and Outcome Framework for Performance Assessment.

OBJECTIVE: One of the most important measures following disasters is setting up a communicable disease surveillance system (CDSS). This study aimed to develop indicators to assess the performance of CDSSs in disasters. METHOD: In this 3-phase study, firstly a qualitative study was conducted through in-depth, semistructured interviews with experts on health in disasters and emergencies, health services managers, and communicable diseases center specialists. The interviews were analyzed, and CDSS performance assessment (PA) indicators were extracted. The appropriateness of these indicators was examined through a questionnaire administered to experts and heads of communicable diseases departments of medical sciences universities. Finally, the designed indicators were weighted using the analytic hierarchy process approach and Expert Choice software. RESULTS: In this study, 51 indicators were designed, of which 10 were related to the input (19.61%), 17 to the process (33.33%), 13 to the product (25.49%), and 11 to the outcome (21.57%). In weighting, the maximum score was that of input (49.1), and the scores of the process, product, and outcome were 31.4, 12.7, and 6.8, respectively. CONCLUSION: Through 3 different phases, PA indicators for 4 phases of a chain of results were developed. The authors believe that these PA indicators can assess the system's performance and its achievements in response to disasters. (Disaster Med Public Health Preparedness. 2019;13:158-164).

Diversity of Sand Flies (Diptera: Psychodidae) in Endemic Focus of Visceral Leishmaniasis in Azar Shahr District, East Azarbaijan Province, North West of Iran.

BACKGROUND: There are nearly 1000 species of Phlebotomine sand flies in 6 genera, of which only two, Phlebotomus in the old world and Lutzomyia in the new world are medically important. Globally, leishmaniasis prevalent in 98 countries and affects estimated 12 million people with almost two million new cases per year. Some rural areas of Azarshahr District in East Azarbaijan Province have been reported to be endemic for visceral leishmaniasis. This study is the first attempt to determine the species diversity and density in a new focus of visceral leishmaniasis in Azarshahr District, East Azarbaijan Province, Iran. METHODS: Sand flies were collected form indoor and outdoor biweekly using sticky traps. Diversity index of the collected sand flies within different villages were estimated by the Shannon-Weaver. RESULTS: The activity of the sand flies extended from April to October with one peak in August. Diversity of sand flies within study area were estimated as 0.917, 1.867, 1.339, 1.673, and 1.562 in Almalodash, Jaragil, Segaiesh, Amirdizaj, and Germezgol Vvillages, respectively. CONCLUSION: Identifying the diversity and seasonal abundance of the collected species is of importance for prediction of the period of maximum risk for leishmaniasis transmission and for the successful implementation of a control program. Species diversity is one of the most important factors in ecological studies.

Wolbachia Endobacteria in Natural Populations of Culex pipiens of Iran and Its Phylogenetic Congruence.

BACKGROUND: Wolbachia are common intracellular bacteria that infect different groups of arthropods including mosquitoes. These bacteria modify host biology and may induce feminization, parthenogenesis, male killing and cytoplasmic incompatibility (CI). Recently Wolbachia is being nominated as a bio-agent and paratransgenic candidate to control mosquito borne diseases. METHODS: Here we report the results of a survey for presence, frequency, and phylogenetic congruence of these endosymbiont bacteria in Culex pipiens populations in Northern, Central, and Southern parts of Iran using nested-PCR amplification of wsp gene. RESULTS: Wolbachia DNA were found in 227 (87.3%) out of 260 wild-caught mosquitoes. The rate of infection in adult females ranged from 61.5% to 100%, while in males were from 80% to 100%. The Blast search and phylogenetic analysis of the wsp gene sequence revealed that the Wolbachia strain from Iranian Cx. pipiens was identical to the Wolbachia strains of supergroup B previously reported in members of the Cx. pipiens complex. They had also identical sequence homology with the Wolbachia strains from a group of distinct arthropods including lepidopteran, wasps, flies, damselfly, thrips, and mites from remote geographical areas of the world. CONCLUSION: It is suggested that Wolbachia strains horizontally transfer between unrelated host organisms over evolutionary time. Also results of this study indicates that Wolbachia infections were highly prevalent infecting all Cx. pipiens populations throughout the country, however further study needs to define Wolbachia inter-population reproductive incompatibility pattern and its usefulness as a bio-agent control measure.

Developing a Performance Assessment Framework and Indicators for Communicable Disease Management in Natural Disasters.

INTRODUCTION: Communicable disease management (CDM) is an important component of disaster public health response operations. However, there is a lack of any performance assessment (PA) framework and related indicators for the PA. This study aimed to develop a PA framework and indicators in CDM in disasters. METHODS: In this study, a series of methods were used. First, a systematic literature review (SLR) was performed in order to extract the existing PA frameworks and indicators. Then, using a qualitative approach, some interviews with purposively selected experts were conducted and used in developing the PA framework and indicators. Finally, the analytical hierarchy process (AHP) was used for weighting of the developed indicators. RESULTS: The input, process, products, and outcomes (IPPO) framework was found to be an appropriate framework for CDM PA. Seven main functions were revealed to CDM during disasters. Forty PA indicators were developed for the four categories. CONCLUSION: There is a lack of any existing PA framework in CDM in disasters. Thus, in this study, a PA framework (IPPO framework) was developed for the PA of CDM in disasters through a series of methods. It can be an appropriate framework and its indicators could measure the performance of CDM in disasters.

Performance Assessment of a Communicable Disease Surveillance System in Response to the Twin Earthquakes of East Azerbaijan.

OBJECTIVE: Following the twin earthquakes on August 11, 2012, in the East Azerbaijan province of Iran, the provincial health center set up a surveillance system to monitor communicable diseases. This study aimed to assess the performance of this surveillance system. METHODS: In this quantitative-qualitative study, performance of the communicable diseases surveillance system was assessed by using the updated guidelines of the Centers for Disease Control and Prevention (CDC). Qualitative data were collected through interviews with the surveillance system participants, and quantitative data were obtained from the surveillance system. RESULTS: The surveillance system was useful, simple, representative, timely, and flexible. The data quality, acceptability, and stability of the surveillance system were 65.6%, 10.63%, and 100%, respectively. The sensitivity and positive predictive value were not calculated owing to the absence of a gold standard. CONCLUSIONS: The surveillance system satisfactorily met the goals expected for its setup. The data obtained led to the control of communicable diseases in the affected areas. Required interventions based on the incidence of communicable disease were designed and implemented. The results also reassured health authorities and the public. However, data quality and acceptability should be taken into consideration and reviewed for implementation in future disasters.

Performance assessment of communicable disease surveillance in disasters: a systematic review.

BACKGROUND: This study aimed to identify the indices and frameworks that have been used to assess the performance of communicable disease surveillance (CDS) in response to disasters and other emergencies, including infectious disease outbreaks. METHOD: In this systematic review, PubMed, Google Scholar, Scopus, ScienceDirect, ProQuest databases and grey literature were searched until the end of 2013. All retrieved titles were examined in accordance with inclusion criteria. Abstracts of the relevant titles were reviewed and eligible abstracts were included in a list for data abstraction. Finally, the study variables were extracted. RESULTS: Sixteen articles and one book were found relevant to our study objectives. In these articles, 31 criteria and 35 indicators were used or suggested for the assessment/evaluation of the performance of surveillance systems in disasters. The Centers for Disease Control (CDC) updated guidelines for the evaluation of public health surveillance systems were the most widely used. CONCLUSION: Despite the importance of performance assessment in improving CDS in response to disasters, there is a lack of clear and accepted frameworks. There is also no agreement on the use of existing criteria and indices. The only relevant framework is the CDC guideline, which is a common framework for assessing public health surveillance systems as a whole. There is an urgent need to develop appropriate frameworks, criteria, and indices for specifically assessing the performance of CDS in response to disasters and other emergencies, including infectious diseases outbreaks. Key words: Disasters, Emergencies, Communicable Diseases, Surveillance System, Performance Assessment.

Malpighian tubules are important determinants of Pseudomonas transstadial transmission and longtime persistence in Anopheles stephensi.

BACKGROUND: Pseudomonas is a genus of bacteria commonly found in investigations of gut microbes in malaria mosquitoes. Among those mosquitoes is the dominating malaria vector in Asia, Anopheles stephensi, where Pseudomonas is a prevailing bacterium and natural inhabitant of its breeding places. In order to explore the reason for finding Pseudomonas so frequently, an investigation of its localization and transstadial properties was undertaken. METHODS: A Pseudomonas isolate from An. stephensi was transformed successfully with an endogenous plasmid modified to express green fluorescent protein (GFP). Subsequently, the Pseudomonas-GFP was added to the laboratory larval breeding place of An. stephensi and taken up by the larvae. After 24 hours, the larvae were cleaned and moved to a bath with double-distilled water. Also, female adults were fed sugar solution containing Pseudomonas-GFP. The Pseudomonas-GFP was traced in the alimentary canal of larvae, pupae and adults. RESULTS: Fluorescent microscopy and PCR assays showed that the Pseudomonas bacteria underwent transstadial transmission from larvae to pupae and then to adults. In blood-fed female mosquitoes, the bacteria increased in numbers and remained in the mosquito body for at least three weeks after eclosion. In addition to the midgut, the Malpighian tubules of both larvae and adult mosquitoes were colonized by the bacteria. Also Pseudomonas-GFP that was distributed through sugar solution was able to colonize the Malpighian tubules of adult females. CONCLUSIONS: Colonization of the Malpighian tubules by Pseudomonas bacteria seems to be important for the transstadial passage from larvae to adult and presumably for the longevity of the bacteria in the adult mosquito. The existence of an entry point in the larval stage, and the long duration in the female gut, opens up for a possible use of Pseudomonas in mosquito paratransgenesis.

Phylogenetic analysis of the oriental-Palearctic-Afrotropical members of Anopheles (Culicidae: Diptera) based on nuclear rDNA and mitochondrial DNA characteristics.

The phylogenetic relationships of Anopheles spp. at the junction of Oriental, Palearctic, and Afrotropical regions in the Iranian plateau were investigated using molecular markers. A 711-bp mitochondrial DNA cytochrome oxidase C subunit I (COI) fragment and the entire second internal transcribed spacer (ITS2) region (286-576 bp) of the nuclear ribosomal DNA (rDNA-ITS2) were sequenced from 14 and 28 taxa, respectively. The analyses included 12 species within Anopheles and 4 within the Myzorhynchus Series of the subgenus Anopheles, 8 within Neocellia, 6 within Myzomyia, 3 within Paramyzomyia, and 1 within the Pyretophorus Series of the subgenus Cellia. The congruent tree topologies of both molecular markers strongly supported monophyly of subgenera Anopheles and Cellia. Phylogenetic trees constructed on the basis of ITS2 sequences could accurately categorize all of the series according to the classical taxonomy but could not distinguish Pyretophorus (Anopheles subpictus) from Paramyzomyia Series. Although sequence data of the COI region were available for only 14 species, the inferred trees revealed good classification among the series but could not show the monophyletic relationship of Cellia spp. Except for a few cases, the tree inferred from ITS2 sequences revealed the best classification for the species studied. The molecular data could significantly improve our understanding of the phylogenetic position of the taxa.

Isolation and identification of culturable bacteria from wild Anopheles culicifacies, a first step in a paratransgenesis approach.

BACKGROUND: Due to the effect of midgut bacteria on proliferation of parasites and their potential as paratransgenesis tools, their identification in malaria vector mosquitoes is important. Anopheles culicifacies s.l. is one of the main malaria vectors in Asia; however, its midgut microbiota remains un-studied. This work was primarily designed to isolate potential candidates for use in a paratransgenesis approach, but also to give a picture of the midgut microbiota of wild-caught An. culicifacies larvae and adults from the southeast corner of Iran, which has the highest malaria endemicity in the country. METHODS: A total of 68 larvae and 34 adult females (newly eclosed and older) from three different biotopes in Iran were analyzed for their midgut microflora. The mosquitoes had their midgut bacterial contents plated on three different culture media (brain heart agar, nutrient agar and blood agar) yielding 57 bacterial isolates. The 16S rRNA genes of the isolates were sequence analyzed for species designation, which then was confirmed by biochemical analysis. RESULTS: A total of twelve bacterial genera were identified: Acinetobacter, Aeromonas, Bacillus, Chryseobacterium, Delftia, Exiguobacterium, Kurthia, Microbacterium, Pseudomonas, Staphylococcus, Thorsellia and Variovorax. In older females, only Gram-negative bacteria were found, whereas larvae and newly-eclosed adults also harbored Gram-positive bacteria. The diversity of isolates also varied between sampling sites and mosquito stages, with the largest number of genera found in the Anguri district and in larvae, respectively. Pseudomonas was the most common genus retrieved from all sampling sites, and in both larvae and adults, suggesting a potential transstadial passage of these bacteria. Interestingly, identical 16S sequences of Pseudomonas were found in mosquitoes originating from different habitats at least 45 km apart, which could suggest that these bacteria have been adapted to the mosquitoes. CONCLUSIONS: The study of vector mosquito microbiota has recently gathered increased interest because of the potential influence on vector competence. By adding data from a hitherto uncharacterized malaria mosquito, a better picture of gut flora in vector mosquitoes was obtained. Furthermore, some species of the predominant genus Pseudomonas will be evaluated for the selection of a paratransgenesis candidate.

Molecular characterization, biological forms and sporozoite rate of Anopheles stephensi in southern Iran.

OBJECTIVE: To identify the biological forms, sporozoite rate and molecular characterization of the Anopheles stephensi (An. stephensi) in Hormozgan and Sistan-Baluchistan provinces, the most important malarious areas in Iran. METHODS: Wild live An. stephensi samples were collected from different malarious areas in southern Iran. The biological forms were identified based on number of egg-ridges. Molecular characterization of biological forms was verified by analysis of the mitochondrial cytochrome oxidase subunit I and II (mtDNA-COI/COII). The Plasmodium infection was examined in the wild female specimens by species-specific nested-PCR method. RESULTS: Results showed that all three biological forms including mysorensis, intermediate and type are present in the study areas. Molecular investigations revealed no genetic variation between mtDNA COI/COII sequences of the biological forms and no Plasmodium parasites was detected in the collected mosquito samples. CONCLUSIONS: Presence of three biological forms with identical sequences showed that the known biological forms belong to a single taxon and the various vectorial capacities reported for these forms are more likely corresponded to other epidemiological factors than to the morphotype of the populations. Lack of malaria parasite infection in An. stephensi, the most important vector of malaria, may be partly due to the success and achievement of ongoing active malaria control program in the region.

Molecular characterization, biological forms and sporozoite rate of Anopheles stephensi in southern Iran

Objective: To identify the biological forms, sporozoite rate and molecular characterization of the Anopheles stephensi (An. stephensi) in Hormozgan and Sistan-Baluchistan provinces, the most important malarious areas in Iran. Methods: Wild live An. stephensi samples were collected from different malarious areas in southern Iran. The biological forms were identified based on number of egg-ridges. Molecular characterization of biological forms was verified by analysis of the mitochondrial cytochrome oxidase subunit I and II (mtDNA-COI/COII). The Plasmodium infection was examined in the wild female specimens by species-specific nested–PCR method. Results: Results showed that all three biological forms including mysorensis, intermediate and type are present in the study areas. Molecular investigations revealed no genetic variation between mtDNA COI/COII sequences of the biological forms and no Plasmodium parasites was detected in the collected mosquito samples. Conclusions:Presence of three biological forms with identical sequences showed that the known biological forms belong to a single taxon and the various vectorial capacities reported for these forms are more likely corresponded to other epidemiological factors than to the morphotype of the populations. Lack of malaria parasite infection in An. stephensi, the most important vector of malaria, may be partly due to the success and achievement of ongoing active malaria control program in the region.

Some ecological attributes of malarial vector Anopheles superpictus Grassi in endemic foci in southeastern Iran.

OBJECTIVE: To determine the bionomics and susceptibility status of the malarial vector Anopheles superpictus (An. superpictus) to different insecticides in the Sistan-Baluchestan province which has the highest malarial prevalence in Iran. METHODS: Different sampling methods, in addition to scoring abdominal conditions, were used to define the seasonal activity and endo/exophilic behavior of this species. In addition, the standard WHO susceptibility tests were applied on adult field strains. RESULTS: Most adult mosquitoes were collected from outdoor shelters. The peak of seasonal activity of An. superpictus occurred at the end of autumn. Most larvae were collected from natural and permanent breeding places with full sunlight and no vegetation. Blood feeding activities occurred around midnight. Compared with the abdominal conditions of adult mosquitoes collected indoors, the abdominal conditions of adult mosquitoes collected outdoors were gravid and semigravid. This species was suspected to be resistant to DDT, but was susceptible to other insecticides. CONCLUSIONS: An. superpictus was present in almost all outdoor shelters, and the ratios of gravid, semigravid/unfed, and freshly fed confirmed that this species had a higher tendency to rest outdoors than indoors. This behavior can protect An. superpictus from indoor residual spraying in this malarious area. To the best of our knowledge, this is the first report on the susceptibility status of An. superpictus in Southeastern Iran. We do not suggest the use of DDT for indoor residual spraying in southeast Iran.

The Black Flies (Diptera: Simuliidae) of Iran.

Although Iran has a large geographic area encompassing 13 ecoregions, its simuliid fauna remains largely unexplored. To begin redressing this faunal gap, we reviewed literature records and coupled morphological and chromosomal identifications of material newly collected from 16 sites in Iran. Twenty-three nominal species are now recognized, including new country records for Simulium crassicaulum (Rubtsov) and Simulium alajense Rubtsov, and the southernmost world record for Simulium transcaspicum Enderlein. Multiple cytoforms of the Simulium aureum group, Simulium bezzii complex, and Simulium ornatum group were found.

Some ecological attributes of malarial vector Anopheles superpictus Grassi in endemic foci in southeastern Iran

Objective:To determine the bionomics and susceptibility status of the malarial vector Anopheles superpictus (An. superpictus) to different insecticides in the Sistan-Baluchestan province which has the highest malarial prevalence in Iran. Methods:Different sampling methods, in addition to scoring abdominal conditions, were used to define the seasonal activity and endo/exophilic behavior of this species. In addition, the standard WHO susceptibility tests were applied on adult field strains. Results: Most adult mosquitoes were collected from outdoor shelters. The peak of seasonal activity of An. superpictus occurred at the end of autumn. Most larvae were collected from natural and permanent breeding places with full sunlight and no vegetation. Blood feeding activities occurred around midnight. Compared with the abdominal conditions of adult mosquitoes collected indoors, the abdominal conditions of adult mosquitoes collected outdoors were gravid and semigravid. This species was suspected to be resistant to DDT, but was susceptible to other insecticides. Conclusions:An. superpictus was present in almost all outdoor shelters, and the ratios of gravid, semigravid/unfed, and freshly fed confirmed that this species had a higher tendency to rest outdoors than indoors. This behavior can protect An. superpictus from indoor residual spraying in this malarious area. To the best of our knowledge, this is the first report on the susceptibility status of An. superpictus in Southeastern Iran. We do not suggest the use of DDT for indoor residual spraying in southeast Iran.

Identification of bacterial microflora in the midgut of the larvae and adult of wild caught Anopheles stephensi: a step toward finding suitable paratransgenesis candidates.

To describe the midgut microbial diversity and to find the candidate bacteria for the genetic manipulation for the generation of paratransgenic Anopheline mosquitoes refractory to transmission of malaria, the microbiota of wild larvae and adult Anopheles stephensi mosquito midgut from southern Iran was studied using a conventional cell-free culture technique and analysis of a 16S ribosomal RNA (rRNA) gene sequence library. Forty species in 12 genera including seven Gram-negative Myroides, Chryseobacterium, Aeromonas, Pseudomonas, Klebsiella, Enterobacter and Shewanella and five Gram-positive Exiguobacterium, Enterococcus, Kocuria, Microbacterium and Rhodococcus bacteria were identified in the microbiota of the larvae midgut. Analysis of the adult midgut microbiota revealed presence of 25 Gram-negative species in five genera including Pseudomonas, Alcaligenes, Bordetella, Myroides and Aeromonas. Pseudomonas and Exiguobacterium with a frequency of 51% and 14% at the larval stage and Pseudomonas and Aeromonas with a frequency of 54% and 20% at the adult stage were the most common midgut symbionts. Pseudomonas, Aeromonas and Myroides genera have been isolated from both larvae and adult stages indicating possible trans-stadial transmission from larva to adult stage. Fast growth in cheap media, Gram negative, and being dominantly found in both larvae and adult stages, and presence in other malaria vectors makes Pseudomonas as a proper candidate for paratransgenesis of An. stephensi and other malaria vectors.

A survey of Crimean-Congo haemorrhagic fever in livestock and ticks in Ardabil Province, Iran during 2004-2005.

Crimean-Congo haemorrhagic fever (CCHF) is a viral haemorrhagic fever caused by the CCHF virus. It is mainly transmitted to humans and animals by ticks. In recent y, large numbers of livestock have been transported across the border areas of Ardabil Province resulting in an outbreak of CCHF in the adjacent districts. A comprehensive study was carried out to assess the epidemiological aspects of the disease in this province. In the study area, 130 ticks were collected from randomly selected villages and classified into 9 species of hard tick and 2 species of soft tick. All ticks were analyzed for the presence of CCHF virus genome using gel-based and real-time reverse transcriptase polymerase chain reactions (RT-PCR). The results showed CCHF infection in almost 28% of ticks collectively. Also, of 56 livestock sera, around 39% were IgG-positive. The presence of anti-CCHF virus IgG antibodies and the CCHF virus genome in ticks points to a great hidden threat of an outbreak in these districts. Those in high-risk professions in this province should be informed and trained on the risk of CCHF with urgency.