A brief description of the epidemiology of dengue in Dili, Timor-Leste, 2018-2022.

Abstract: Dengue virus (DENV) infection causes 390 million infections per year and 40,000 deaths globally. It is endemic in many countries in Asia, Africa, the Americas, the Caribbean, and Oceania. Dengue is endemic in Timor-Leste year-round, but peak transmission occurs during the rainy season. We briefly describe the epidemiology of DENV in the Municipality of Dili between 2018 and 2022. There were 6,234 cases notified, with a mean annual incidence rate of 330 cases per 100,000 population. There were 55 deaths (case fatality rate 0.9%). The peak annual incidence (3,904 cases) occurred in 2022 after an outbreak was declared in January of that year; this outbreak included 760 cases of dengue haemorrhagic fever and 35 deaths. The number of outbreak cases requiring hospital treatment exceeded the usual capacity, but facilities established for coronavirus disease 2019 (COVID-19) isolation and treatment were repurposed to meet this demand. Existing strategies of vector control, minimising breeding sites and promoting early presentation for treatment should continue, as should the utilisation of surveillance systems and treatment facilities established during the COVID-19 pandemic. However, dengue incidence remains high, and other dengue control strategies-including the deployment of Wolbachia-infected mosquitoes-should be considered in Timor-Leste.

Involvement and readiness of fellows from Papua New Guinea's Field Epidemiology Training Programme in the COVID-19 response, 2020-2021.

Problem: Fellows of the Papua New Guinea Field Epidemiology Training Programme (FETP) were part of the national coronavirus disease (COVID-19) response. However, the specific activities and challenges experienced by fellows in the field were unknown. Context: The advanced FETP cohort commenced just before the COVID-19 pandemic and all fellows were involved in the response. The advanced fellows participating in this review represented a cross-section of the country's public health workforce. Action: A review was conducted to better understand the scope of activities undertaken by FETP fellows, identify the challenges experienced and assess how well the programme prepared fellows for their COVID-19 response roles. A facilitated discussion based on the World Health Organization COVID-19 intra-action review methodology and an online survey was conducted with advanced FETP fellows. Outcome: The fellows made important contributions to the national COVID-19 response by assuming leadership positions at all levels of government, leading training activities and applying core field epidemiology competencies in surveillance and response activities. The programme had prepared them well for the response, giving them the confidence and skills to undertake a diverse range of response roles. Discussion: The FETP review of the COVID-19 response in Papua New Guinea highlighted the role and influence of the fellows during the pandemic response. Fellows were able to apply core field epidemiology competencies across a range of roles. The recommendations derived from this review will be instructive for the FETP specifically and the COVID-19 response generally.

Rosai-Dorfman: Rare Manifestations of a Rare Disease.

Rosai-Dorfman disease (RDD) is an exceedingly rare non-Langerhans cell histiocytosis of uncertain etiology that most commonly presents in children as self-limited, painless, massive cervical lymphadenopathy. However, extranodal disease occurs in 43% of cases and has a wide range of phenotypic presentations. The pathogenesis has not been clearly understood in the literature and coupled with a wide range of clinical manifestations, early diagnosis and initiation of an appropriate treatment modality have been challenging. Herein, we describe a cohort of five cases that occurred at the same institution within a 12-month period. These cases highlight unique and atypical presentations of an already rare disease, outline the varying and tailored diagnostic and therapeutic approaches, and propose a novel environmental predisposing factor given the exceptionally high incidence at our institution over a short period of time. We emphasize the need for further investigation of predisposing factors and to discern targeted therapies that may offer benefits.

Metastatic Endometrioid Carcinoma Mimicking a Subungual Melanoma.

CASE: We report a case of a 76-year-old female with a stage IB, grade I endometrioid endometrial carcinoma who presented with right-hip pain and an enlarging black, exophytic, subungual lesion on her right-small-finger distal phalanx. Clinically, the distal phalanx lesion was suspicious for a subungual melanoma; however, advanced imaging suggested metastatic disease, with lesions in the acetabulum, lungs, brain, vulva, and vagina. CONCLUSION: Partial amputation of the right, small finger and vulvar biopsies confirmed an endometrial carcinoma. To our knowledge, this is the first described case of endometrial adenocarcinoma metastasis to the phalanx of an upper extremity, mimicking a subungual melanoma.

Ready to respond: adapting rapid response team training in Papua New Guinea during the COVID-19 pandemic.

Problem: Rapid response teams (RRTs) are critical for effective responses to acute public health events. While validated training packages and guidance on rolling out training for RRTs are available, they lack country-specific adaptations. Documentation is limited on RRT programming experiences in various contexts. Context: In Papua New Guinea, there remain gaps in implementing standardized, rapid mobilization of multidisciplinary RRTs at the national, provincial and district levels to investigate public health alerts. Action: The human resources needed to respond to the coronavirus disease (COVID-19) pandemic forced a review of the RRT training programme and its delivery. The training model was contextualized and adapted for implementation using a staged approach, with the initiation training phase designed to ensure RRT readiness to deploy immediately in response to COVID-19 and other public health events. Lessons learned: Selecting appropriate trainees and using a phased training approach, incorporating after-training reviews, and between-phase support from the national programme team were found to be important for programme design in Papua New Guinea. Using participatory training methods based on principles of adult learning, in which trainees draw on their own experiences, was integral to building confidence among team members in conducting outbreak investigations. Discussion: The RRT training experience in Papua New Guinea has highlighted the importance of codeveloping and delivering a context-specific training programme to meet a country's unique needs. A staged training approach that builds on knowledge and skills over time, used together with ongoing follow-up and support in the provinces, has been critical in operationalizing ready-to-respond RRTs.

Vitamin D Deficiency in the Military: It's Time to Act!

Vitamin D is critically important to numerous physiologic functions, including bone health. Poor vitamin D status is a common but underrecognized problem that predisposes the military population to stress fracture and completed fracture. This has significant implications for force health protection, warfighter readiness, attrition, and cost. Despite this, vitamin D deficiency is still underdiagnosed and undertreated in the military. This is a major hindrance to military readiness and one that could easily be modified with awareness, prevention, and early treatment. In this commentary, we review the literature on vitamin D deficiency and critically examine the current status of policies and clinical practice related to vitamin D in the military health system. We offer several practical recommendations to increase awareness and readiness while decreasing musculoskeletal injury and the associated costs.

Barriers and enablers experienced by health care workers in swabbing for COVID-19 in Papua New Guinea: A multi-methods cross-sectional study.

OBJECTIVE: We aimed to identify the barriers and enablers that Health Care Workers (HCWs) in Papua New Guinea experienced in swabbing for COVID-19. METHODS: We conducted a cross-sectional multi-methods study: a qualitative scoping exercise and a telephone survey. The target population was COVID-19-trained HCWs from all provinces of Papua New Guinea. A descriptive analysis of survey responses was conducted alongside a rapid qualitative analysis of interviews and open-ended survey questions. RESULTS: Four thematic areas were identified: human resources, logistics, HCW attitudes and community attitudes. The survey response rate was 70.3% (407/579). Commonly reported barriers to COVID-19 swabbing were insufficient staff trained (74.0%, n = 301), inadequate staffing in general (64.9%, n = 264), insufficient supply of personal protective equipment (60.9%, n = 248) and no cold chain to store swabs (57.5%, n = 234). Commonly reported enablers to swabbing were community awareness and risk communication (80.8%, n = 329), consistent and sufficient supplies of personal protective equipment (67.8%, n = 276), increased surge workforce (63.9%, n = 260) and having a fridge to store swabs (59.7%, n = 243). CONCLUSIONS: A comprehensive community and HCW engagement strategy combined with innovations to improve the supply chain are needed to increase COVID-19 swabbing in Papua New Guinea to reach national testing targets. Investments in increasing numbers of frontline workforce, consistent supplies of PPE, swabs, transport medium, cold boxes and ability to make ice packs, in addtion to establishing regular tranport of specimens from the facility to the testing site will strengthen the supply chain. Innovations are needed to address these issues.

Genomic characterisation of Salmonella enterica serovar Wangata isolates obtained from different sources reveals low genomic diversity.

Salmonella enterica serovar Wangata is an important pathogen in New South Wales (NSW), Australia. The incidence of S. Wangata is increasing and transmission is suspected to be via a non-food source. A recent outbreak investigation of sources of S. Wangata recovered isolates from humans, domestic animals, wildlife and the environment. Here, we extend that investigation by characterising and describing the genomic determinates of these isolates. We found that Australian S. Wangata isolates from different sources exhibited similar virulence and antimicrobial resistance gene profiles. There were no major genomic differences between isolates obtained from different geographical regions within Australia or from different host species. In addition, we found evidence (low number of SNPs and identical virulence gene profiles) suggestive of an international transmission event between Australia and the United Kingdom. This study supports the hypothesis that S. Wangata is shared between different hosts in NSW, Australia and provides strong justification for the continued use of genomic surveillance of Salmonella.

Evaluation of the early warning, alert and response system after Cyclone Winston, Fiji, 2016.

OBJECTIVE: To assess the performance of an early warning, alert and response system (EWARS) developed by the World Health Organization (WHO) - EWARS in a Box - that was used to detect and control disease outbreaks after Cyclone Winston caused destruction in Fiji on 20 February 2016. METHODS: Immediately after the cyclone, Fiji's Ministry of Health and Medical Services, supported by WHO, started to implement EWARS in a Box, which is a smartphone-based, automated, early warning surveillance system for rapid deployment during health emergencies. Both indicator-based and event-based surveillance were employed. The performance of the system between 7 March and 29 May 2016 was evaluated. Users' experience with the system was assessed in interviews using a semi-structured questionnaire and by a cross-sectional survey. The system's performance was assessed using data from the EWARS database. FINDINGS: Indicator-based surveillance recorded 34 113 cases of the nine syndromes under surveillance among 326 861 consultations. Three confirmed outbreaks were detected, and no large outbreak was missed. Users were satisfied with the performance of EWARS and judged it useful for timely monitoring of disease trends and outbreak detection. The system was simple, stable and flexible and could be rapidly deployed during a health emergency. The automated collation, analysis and dissemination of data reduced the burden on surveillance teams, saved human resources, minimized human error and ensured teams could focus on public health responses. CONCLUSION: In Fiji, EWARS in a Box was effective in strengthening disease surveillance during a national emergency and was well regarded by users.

Tumor-induced hypophosphatemic osteomalacia caused by a mesenchymal tumor of the mandible managed by a segmental mandibulectomy and microvascular reconstruction with a free fibula flap.

BACKGROUND: Tumor-induced osteomalacia is a rare paraneoplastic syndrome in which patients develop hypophosphatemia and osteomalacia. METHODS AND RESULTS: Here, we report a unique case of a 42-year-old man who presented to our institution with a 1-year history of pain in his ribs, hips, lower back, and feet. Radiologic examination revealed a decrease in bone density and multiple insufficiency fractures. Laboratory evaluation revealed hypophosphatemia, low serum 1,25 dihydroxy vitamin D3 , and elevated fibroblast growth factor 23 (FGF23). A positron emission tomography/CT scan showed increased uptake in the right mandibular third molar region. Panoramic radiography and CT scanning showed a lytic expansile bone lesion. A mandibular bone biopsy revealed a mixed connective tissue tumor. A right segmental mandibulectomy was performed, followed by microvascular reconstruction. The resection was confirmed by normalization of serum phosphate and FGF23. CONCLUSION: Successful management of this condition was achieved, with complete surgical resection of the tumor and reconstructive surgery.

Lessons from the first 6 years of an intervention-based field epidemiology training programme in Papua New Guinea, 2013-2018.

Papua New Guinea (PNG) faces a critical shortage of human resources to address pressing public health challenges arising from an increasing burden of communicable and non-communicable diseases. PNG is an independent State in the Pacific and home to 8.2 million people. Resource and infrastructure constraints due to the country's challenging geography have made it difficult and expensive to deliver health services and implement health programmes. The National Department of Health and its partners developed a field epidemiology training programme of Papua New Guinea (FETPNG) to strengthen the country's public health workforce. The training programme covers field epidemiology competencies and includes the design, implementation and evaluation of evidence-based interventions by Fellows. From 2013 to 2018, FETPNG graduated 81 field epidemiologists. Most FETPNG graduates (84%) were from provincial or district health departments or organisations. Many of their intervention projects resulted in successful public health outcomes with tangible local impacts. Health challenges addressed included reducing the burden of multi-drug resistant-tuberculosis (TB), increasing immunisation coverage, screening and treating HIV/TB patients, and improving reproductive health outcomes. FETPNG Fellows and graduates have also evaluated disease surveillance systems and investigated disease outbreaks. Early and unwavering national ownership of FETPNG created a sustainable programme fitting the needs of this low-resource country. A focus on designing and implementing effective public health interventions not only provides useful skills to Fellows but also contributes to real-time, tangible and meaningful improvements in the health of the population. The graduates of FETPNG now provide a critical mass of public health practitioners across the country. Their skills in responding to outbreaks and public health emergencies, in collecting, analysing and interpreting data, and in designing, implementing and evaluating public health interventions continues to advance public health in PNG.

An outbreak investigation of paediatric severe acute respiratory infections requiring admission to intensive care units - Fiji, May 2016.

INTRODUCTION: Influenza-associated severe acute respiratory infections (SARI) are a major contributor to global morbidity and mortality. In response to a cluster of SARI cases and deaths in pregnant women, with two deceased cases testing positive for influenza A(H1N1)pdm09, an investigation was initiated to determine whether there was an increase of paediatric SARI cases admitted to divisional hospital intensive care units in Fiji in may 2016 compared to May 2013-2015. METHODS: Retrospective case finding was conducted at the paediatric intensive care units (PICUs) in Fiji's three divisional hospitals. Data were collected from 1 January 2013 to 26 May 2016. Cases were identified using a list of clinical diagnoses compatible with SARI. RESULTS: A total of 632 cases of paediatric SARI with complete details were identified. The median age of cases was 6 months (Interquartile range: 2-14 months). Children aged less than 5 years had a higher rate of paediatric SARI requiring admission to a divisional hospital PICU in May 2016 compared to May 2013-2015 (Incidence rate ratio: 1.7 [95% CI: 1.1-2.6]). This increase was not observed in children aged 5-14 years. The case-fatality ratio was not significantly different in 2016 compared to previous years. CONCLUSION: The investigation enabled targeted public health response measures, including enhanced SARI surveillance at divisional hospitals and an emergency influenza vaccination campaign in the Northern Division.

Retrospective use of whole genome sequencing to better understand an outbreak of Salmonella enterica serovar Mbandaka in New South Wales, Australia.

INTRODUCTION: Salmonella enterica serovar Mbandaka is an infrequent cause of salmonellosis in New South Wales (NSW) with an average of 17 cases reported annually. This study examined the added value of whole genome sequencing (WGS) for investigating a non-point source outbreak of Salmonella ser. Mbandaka with limited geographical spread. METHODS: In February 2016, an increase in Salmonella ser. Mbandaka was noted in New South Wales, and an investigation was initiated. A WGS study was conducted three months after the initial investigation, analysing the outbreak Salmonella ser. Mbandaka isolates along with 17 human and non-human reference strains from 2010 to 2015. RESULTS: WGS analysis distinguished the original outbreak cases (n = 29) into two main clusters: Cluster A (n = 11) and Cluster B (n = 6); there were also 12 sporadic cases. Reanalysis of food consumption histories of cases by WGS cluster provided additional specificity when assessing associations. DISCUSSION: WGS has been widely acknowledged as a promising high-resolution typing tool for enteric pathogens. This study was one of the first to apply WGS to a geographically limited cluster of salmonellosis in Australia. WGS clearly distinguished the outbreak cases into distinct clusters, demonstrating its potential value for use in real time to support non-point source foodborne disease outbreaks of limited geographical spread.

Outbreak of Escherichia coli O157:H7 Infections Linked to Aged Raw Milk Gouda Cheese, Canada, 2013.

Between 12 July and 29 September 2013, 29 individuals in five Canadian provinces became ill following infection with the same strain of Escherichia coli O157:H7 as defined by molecular typing results. Five case patients were hospitalized, and one died. Twenty-six case patients (90%) reported eating Gouda cheese originating from a dairy plant in British Columbia. All of the 22 case patients with sufficient product details available reported consuming Gouda cheese made with raw milk; this cheese had been produced between March and July 2013 and was aged for a minimum of 60 days. The outbreak strain was isolated from the implicated Gouda cheese, including one core sample obtained from an intact cheese wheel 83 days after production. The findings indicate that raw milk was the primary source of the E. coli O157:H7, which persisted through production and the minimum 60-day aging period. This outbreak is the third caused by E. coli O157:H7 traced to Gouda cheese made with raw milk in North America. These findings provide further evidence that a 60-day ripening period cannot ensure die-off of pathogens that might be present in raw milk Gouda cheese after production and have triggered an evaluation of processing conditions, physicochemical parameters, and options to mitigate the risk of E. coli O157:H7 infection associated with raw milk Gouda cheese produced in Canada.

Recurrent Shoulder Instability in a Young, Active, Military Population and Its Professional Implications.

BACKGROUND: Shoulder instability is a topic of significant interest within the sports medicine literature, particularly regarding recurrence rates and the ideal treatment indications and techniques. Little has been published specifically addressing the occupational implications of symptomatic recurrent shoulder instability. HYPOTHESIS: Previous arthroscopic repair will continue to be a significant predisposing factor for recurrent instability in a young, active population, and that recurrent instability may have a negative effect on college graduation and postgraduate occupational selection. STUDY DESIGN: Case series. LEVEL OF EVIDENCE: Level 4. METHODS: We conducted a retrospective review of approved medical waivers for surgical treatment of anterior shoulder dislocation or instability prior to matriculation at the US Military Academy or the US Naval Academy for the graduating classes of 2010 to 2013. Statistical analysis was performed to determine the incidence and risk factors for recurrence and to determine the impact on graduation rate and occupation selection. RESULTS: Fifty-nine patients were evaluated; 34% developed recurrent anterior instability. Patients with previous arthroscopic repair had a significantly higher incidence of recurrence (38%, P = 0.044). Recurrent shoulder instability did not significantly affect graduation rates or self-selected occupation ( P ≥ 0.05). CONCLUSION: There is a significant rate of recurrent shoulder instability after primary surgical repair, particularly among young, active individuals. In addition, arthroscopic repair resulted in a significantly higher recurrence rate compared with open repair in our population. Surgical repair for shoulder instability should not necessarily preclude young individuals from pursuing (or being considered for) occupations that may place them at greater risk of recurrence. CLINICAL RELEVANCE: The risk of recurrent instability is greater than the rate typically described, which may suggest that some subpopulations are at greater risk than others. A unique data point regarding instability is the effect on occupation selection.

Lessons learnt from a three-year pilot field epidemiology training programme.

PROBLEM: The Pacific region has widely dispersed populations, limited financial and human resources and a high burden of disease. There is an urgent need to improve the availability, reliability and timeliness of useable health data. CONTEXT: The purpose of this paper is to share lessons learnt from a three-year pilot field epidemiology training programme that was designed to respond to these Pacific health challenges. The pilot programme built on and further developed an existing field epidemiology training programme for Pacific health staff. ACTION: The programme was delivered in country by epidemiologists working for Pacific Public Health Surveillance Network partners. The programme consisted of five courses: four one-week classroom-based courses and one field epidemiology project. Sessions were structured so that theoretical understanding was achieved through interaction and reinforced through practical hands-on group activities, case studies and other interactive practical learning methods. OUTCOME: As of September 2016, 258 students had commenced the programme. Twenty-six course workshops were delivered and one cohort of students had completed the full five-course programme. The programme proved popular and gained a high level of student engagement. DISCUSSION: Face-to-face delivery, a low student-to-facilitator ratio, substantial group work and practical exercises were identified as key factors that contributed to the students developing skills and confidence. Close engagement of leaders and the need to quickly evaluate and adapt the curriculum were important lessons, and the collaboration between external partners was considered important for promoting a harmonized approach to health needs in the Pacific.

Lessons learnt from a measles outbreak in Madang Province, Papua New Guinea, June 2014 - March 2015.

OBJECTIVE: This study examined measles vaccine wastage during an outbreak response in Madang Province of Papua New Guinea from June 2014 to March 2015. METHODS: Vaccine wastage was defined as the number of doses received by a health centre minus the total number of doses administered during and returned following the outbreak vaccination campaign. Vaccine data were collected from the Provincial Health Information Office, the Provincial Vaccine Store register and clinic and health centre immunization registers for calculating the vaccine wastage. Interviews were conducted with all 48 health centres involved in the outbreak response using a structured questionnaire to explore the reasons for vaccine wastage. RESULTS: Of the 154 110 doses issued by Madang Province during the outbreak, a total of 85 236 (55%) doses were wasted. The wastage varied by district from 31% to 90%. The total cost of the vaccine wastage was estimated to be 589 810 Kina (US$ 196 604). None of the health centres maintained vaccine stock registers. Most health centres indicated multiple failures in cold chain logistics. Almost 40% of health centres reported incorrectly diluting vaccines. The same percentage of health centres reported using incorrect injection techniques. DISCUSSION: Regular audits of cold chain logistics, staff training and improved processes for recording vaccine administration and wastage will decrease vaccine wastage during vaccine-preventable disease outbreaks and also benefit routine immunization activities.

Acoustical Direction Finding with Time-Modulated Arrays.

Time-Modulated Linear Arrays (TMLAs) offer useful efficiency savings over conventional phased arrays when applied in parameter estimation applications. The present paper considers the application of TMLAs to acoustic systems and proposes an algorithm for efficiently deriving the arrival angle of a signal. The proposed technique is applied in the frequency domain, where the signal and harmonic content is captured. Using a weighted average method on harmonic amplitudes and their respective main beam angles, it is possible to determine an estimate for the signal's direction of arrival. The method is demonstrated and evaluated using results from both numerical and practical implementations and performance data is provided. The use of Micro-Electromechanical Systems (MEMS) sensors allows time-modulation techniques to be applied at ultrasonic frequencies. Theoretical predictions for an array of five isotropic elements with half-wavelength spacing and 1000 data samples suggest an accuracy of ± 1 ∘ within an angular range of approximately ± 50 ∘ . In experiments of a 40 kHz five-element microphone array, a Direction of Arrival (DoA) estimation within ± 2 . 5 ∘ of the target signal is readily achieved inside a ± 45 ∘ range using a single switched input stage and a simple hardware setup.