Hospital-based surveillance for acute febrile illness in Egypt: a focus on community-acquired bloodstream infections.

Acute febrile illness (AFI) is a common syndrome in Egypt. However its etiologies are not well characterized. To determine the relative frequency of pathogen etiologies and possibly improve diagnostic, clinical management and public health measures, we implemented laboratory-based surveillance in a network of infectious disease hospitals throughout Egypt. Admitted patients with AFI provided background details and a blood sample for bacterial culture and serologic analysis. Case definitions were based on laboratory results. Of 10,130 patients evaluated between 1999 and 2003, 5% were culture positive for Salmonella enterica serogroup Typhi, 3% for Brucella, and 2% for other pathogens. An additional 18% of patients had positive serologic results for typhoid and 11% for brucellosis. Risk factor analysis identified availability of municipal water to be significantly (P < 0.05) associated with protection against typhoid. Animal contact and consumption of raw dairy products were significantly associated with brucellosis. The surveillance network identified typhoid fever and brucellosis as the most common bacterial causes of AFI in Egypt, allowed better description of their epidemiology, and may lead to the development of targeted prevention strategies.

The changing epidemiology of meningococcal meningitis after introduction of bivalent A/C polysaccharide vaccine into school-based vaccination programs in Egypt.

BACKGROUND: The strategy recommended by the World Health Organization (WHO) to curtail outbreaks of meningococcus in Africa is enhanced surveillance with administration of oily chloramphenicol as well as vaccination when incidence thresholds are exceeded. The role of capsular polysaccharide meningococcal vaccine in outbreak prevention has been the subject of considerable debate. The Egyptian Ministry of Health and Population initiated a school-based vaccination program with bivalent A/C capsular polysaccharide vaccine in 1992. This investigation reviews data on meningococcal meningitis in Egypt comparing years before and after introduction of the vaccine. METHODS: This is a retrospective review of several sources to examine the rates and serogroups of meningococcal meningitis before and after the introduction of the meningococcal A/C vaccine in Egypt. FINDINGS: Between 1967 and 1991, outbreaks of meningococcal disease were documented with a periodicity of 8 years in Egypt. However, there has not been an outbreak since 1991 and over the same period, there has also been a progressive decline in the baseline incidence of meningococcus. Also, a shift from a serogroup A to serogroup B predominance in meningococcal disease was noted during the study period. These data suggest that there has been an alteration in the epidemiology of meningococcal disease in Egypt that coincided with the implementation of the school-based vaccination program. INTERPRETATION: Routine use of the bivalent A/C meningococcal vaccine may be an alternative for the control and prevention of meningococcal disease in high-risk areas including the "meningitis belt".

Occupational exposure to needlestick injuries and hepatitis B vaccination coverage among health care workers in Egypt.

BACKGROUND: The health care worker (HCW) is at substantial risk of acquiring bloodborne pathogen infections through exposure to blood or infectious body fluids. Hepatitis B vaccination of HCWs and optimal HCW practices regarding management of sharps can minimize these risks. This study explores the frequency of exposure to needlestick injuries and the hepatitis B vaccination coverage among HCWs in Egypt. METHODS: All HCWs available in a 25% random sample of different types of health care facilities from 2 governorates in Egypt (Nile Delta and Upper Egypt) were included in the study. A total of 1485 HCWs were interviewed. History of exposure to needlestick injuries, vaccination status, and socioeconomic data were collected. RESULTS: Of the 1485 HCWs interviewed, 529 (35.6%) were exposed to at least 1 needlestick injury during the past 3 months with an estimated annual number of 4.9 needlesticks per worker. The most common behavior associated with needlestick injuries was 2-handed recapping. Overall, 64% of HCWs disposed of needles unsafely in nonpuncture-proof containers. Overall 15.8% of HCWs reported receiving 3 doses of hepatitis B vaccine. Vaccination coverage was highest among professional staff (38%) and lowest among housekeeping staff (3.5%). Using Kane's model to predict infections after needlestick exposures, we estimate 24,004 hepatitis C virus and 8617 hepatitis B virus infections occur each year in Egypt as a result of occupational exposure in the health care environment. CONCLUSION: High rates of needlestick injuries and low vaccination coverage contribute highly to the rates of viral hepatitis infections among HCWs. Prevention of occupational infection with bloodborne pathogens should be a priority to the national program for promotion of infection control. Training of HCWs on safe handling and collection of needles and sharps, and hepatitis B vaccination of all HCWs is required to reduce transmission.

Estimating the incidence of typhoid fever and other febrile illnesses in developing countries.

To measure the incidence of typhoid fever and other febrile illnesses in Bilbeis District, Egypt, we conducted a household survey to determine patterns of health seeking among persons with fever. Then we established surveillance for 4 months among a representative sample of health providers who saw febrile patients. Health providers collected epidemiologic information and blood (for culture and serologic testing) from eligible patients. After adjusting for the provider sampling scheme, test sensitivity, and seasonality, we estimated that the incidence of typhoid fever was 13/100,000 persons per year, and the incidence of brucellosis was 18/100,000 persons per year in the district. This surveillance tool could have wide applications for surveillance for febrile illness in developing countries.

Overview of injection practices in two governorates in Egypt.

OBJECTIVE: To describe the extent and characteristics of injection use and injection providers in Egypt, given that unsafe injections are associated with blood-borne pathogen transmission. METHODS: Household surveys of a population-based sample of residents in the Nile Delta and in Upper Egypt; focus group discussions and in-depth interviews with community target groups, formal and informal medical providers. RESULTS: Of 4197 persons interviewed, 26.2% reported receiving an injection in the past 3 months. Of these, 77% reported it was for therapeutic indications. The age-sex specific prevalence of injections was highest among children 0-2 years of age and among older adults. Women were more likely to report having an injection than men, particularly at the age above 20 years. Overall, respondents reported receiving on average 4.2 injections per year, indicating that up to 281 million injections are provided per year in Egypt. Injection administrators were public and private sector physicians, pharmacists, barbers, doctor assistants, housekeepers, relatives and friends. Injection prescribers were mostly private and public sector physicians. Of the 1101 respondents who received an injection in the past 3 months, 92 (8.4%) reported that the provider did not use a syringe taken from a closed sealed packet. CONCLUSION: The frequency of therapeutic injection use is high in Egypt and may contribute to blood-borne pathogen transmission. The Ministry of Health and Population (MOHP) is developing interventions targeted towards promotion of injection safety and reduction of injection overuse on community basis as part of a comprehensive strategy to prevent blood-borne pathogen transmission in Egypt.