Field challenges to measles elimination in the Democratic Republic of the Congo.

BACKGROUND: During a measles epidemic, the Ministry of Public Health (MOH) of the Democratic Republic of the Congo conducted supplementary immunization activities (2016-SIA) from August 28-September 3, 2016 throughout Maniema Province. From October 29-November 4, 2016, Médecins Sans Frontières and the MOH conducted a reactive measles vaccination campaign (2016-RVC) targeting children six months to 14 years old in seven health areas with heavy ongoing transmission despite inclusion in the 2016-SIA, and a post-vaccination survey. We report the measles vaccine coverage (VC) and effectiveness (VE) of the 2016-SIA and VC of the 2016-RVC. METHODS: A cross-sectional VC cluster survey stratified by semi-urban/rural health area and age was conducted. A retrospective cohort analysis of measles reported by the parent/guardian allowed calculation of the cumulative measles incidence according to vaccination status after the 2016-SIA for an estimation of crude and adjusted VE. RESULTS: In November 2016, 1145 children (6-59 months old) in the semi-urban and 1158 in the rural areas were surveyed. Post-2016-SIA VC (documentation/declaration) was 81.6% (95%CI: 76.5-85.7) in the semi-urban and 91.0% (95%CI: 84.9-94.7) in the rural areas. The reported measles incidence in October among children less than 5 years old was 5.0% for 2016-SIA-vaccinated and 11.2% for 2016-SIA-non-vaccinated in the semi-urban area, and 0.7% for 2016-SIA-vaccinated and 4.0% for 2016-SIA-non-vaccinated in the rural area. Post-2016-SIA VE (adjusted for age, sex) was 53.9% (95%CI: 2.9-78.8) in the semi-urban and 78.7% (95%CI: 0-97.1) in the rural areas. Post 2016-RVC VC (documentation/declaration) was 99.1% (95%CI: 98.2-99.6) in the semi-urban and 98.8% (95%CI: 96.5-99.6) in the rural areas. CONCLUSIONS: Although our VE estimates could be underestimated due to misclassification of measles status, the VC and VE point estimates of the 2016-SIA in the semi-urban area appear suboptimal, and in combination, could not limit the epidemic. Further research is needed on vaccination strategies adapted to urban contexts.

Diphtheria outbreak with high mortality in northeastern Nigeria.

SUMMARY A diphtheria outbreak occurred from February to November 2011 in the village of Kimba and its surrounding settlements, in Borno State, northeastern Nigeria. We conducted a retrospective outbreak investigation in Kimba village and the surrounding settlements to better describe the extent and clinical characteristics of this outbreak. Ninety-eight cases met the criteria of the case definition of diphtheria, 63 (64.3%) of whom were children aged <10 years; 98% of cases had never been immunized against diphtheria. None of the 98 cases received diphtheria antitoxin, penicillin, or erythromycin during their illness. The overall case-fatality ratio was 21.4%, and was highest in children aged 0-4 years (42.9%). Low rates of immunization, delayed clinical recognition of diphtheria and absence of treatment with antitoxin and appropriate antibiotics contributed to this epidemic and its severity.

Risk factors for cholera transmission in Haiti during inter-peak periods: insights to improve current control strategies from two case-control studies.

Two community-based density case-control studies were performed to assess risk factors for cholera transmission during inter-peak periods of the ongoing epidemic in two Haitian urban settings, Gonaives and Carrefour. The strongest associations were: close contact with cholera patients (sharing latrines, visiting cholera patients, helping someone with diarrhoea), eating food from street vendors and washing dishes with untreated water. Protective factors were: drinking chlorinated water, receiving prevention messages via television, church or training sessions, and high household socioeconomic level. These findings suggest that, in addition to contaminated water, factors related to direct and indirect inter-human contact play an important role in cholera transmission during inter-peak periods. In order to reduce cholera transmission in Haiti intensive preventive measures such as hygiene promotion and awareness campaigns should be implemented during inter-peak lulls, when prevention activities are typically scaled back.

[The prevalence of yaws among the Aka in the Congo]. / La prévalence du pian parmi les Aka du Congo.

This study, conducted in 2012 in two districts of the Congo (Bétou and Enyellé), screened for yaws (endemic treponemiasis) that could be treated by a single dose of azithromycin. The screening involved a clinical history, followed by a clinical examination of the children reporting dermatological problems. A rapid diagnostic test for treponema was performed on the children with suspicious lesions. Of 6215 children screened, 485 (7.8%) had such lesions; 480 (99.0%) of them had a rapid diagnostic test, and it was positive for 183 (38.1%). This so-called Morges strategy is aimed at eradicating yaws in endemic areas.

Unacceptably high mortality related to measles epidemics in Niger, Nigeria, and Chad.

BACKGROUND: Despite the comprehensive World Health Organization (WHO)/United Nations Children's Fund (UNICEF) measles mortality-reduction strategy and the Measles Initiative, a partnership of international organizations supporting measles mortality reduction in Africa, certain high-burden countries continue to face recurrent epidemics. To our knowledge, few recent studies have documented measles mortality in sub-Saharan Africa. The objective of our study was to investigate measles mortality in three recent epidemics in Niamey (Niger), N'Djamena (Chad), and Adamawa State (Nigeria). METHODS AND FINDINGS: We conducted three exhaustive household retrospective mortality surveys in one neighbourhood of each of the three affected areas: Boukoki, Niamey, Niger (April 2004, n = 26,795); Moursal, N'Djamena, Chad (June 2005, n = 21,812); and Dong District, Adamawa State, Nigeria (April 2005, n = 16,249), where n is the total surveyed population in each of the respective areas. Study populations included all persons resident for at least 2 wk prior to the study, a duration encompassing the measles incubation period. Heads of households provided information on measles cases, clinical outcomes up to 30 d after rash onset, and health-seeking behaviour during the epidemic. Measles cases and deaths were ascertained using standard WHO surveillance-case definitions. Our main outcome measures were measles attack rates (ARs) and case fatality ratios (CFRs) by age group, and descriptions of measles complications and health-seeking behaviour. Measles ARs were the highest in children under 5 y old (under 5 y): 17.1% in Boukoki, 17.2% in Moursal, and 24.3% in Dong District. CFRs in under 5-y-olds were 4.6%, 4.0%, and 10.8% in Boukoki, Moursal, and Dong District, respectively. In all sites, more than half of measles cases in children aged under 5 y experienced acute respiratory infection and/or diarrhoea in the 30 d following rash onset. Of measles cases, it was reported that 85.7% (979/1,142) of patients visited a health-care facility within 30 d after rash onset in Boukoki, 73.5% (519/706) in Moursal, and 52.8% (603/1,142) in Dong District. CONCLUSIONS: Children in these countries still face unacceptably high mortality from a completely preventable disease. While the successes of measles mortality-reduction strategies and progress observed in measles control in other countries of the region are laudable and evident, they should not overshadow the need for intensive efforts in countries that have just begun implementation of the WHO/UNICEF comprehensive strategy.

[Are we testing the right people? Results of a patient questionnaire in the STD and HIV counselling office of the local health authority in the city of Cologne]. / Testen wir die Richtigen? Ergebnisse einer Klientenbefragung in der Beratungsstelle zu STD einschliesslich Aids des Gesundheitsamtes der Stadt Köln.

BACKGROUND: HIV testing and counselling is offered free of charge in most local health offices in Germany. During 2003, a survey was performed among German-speaking clients of the Cologne local health office to look at socio-demographic background, reasons for testing and sexual risk behaviour. METHODS: All German-speaking clients attending the HIV counselling office from March to July 2003 were asked to fill in an anonymous standardised questionnaire. Questions included demographic characteristics, social status, STI history, reasons for HIV testing, sexual orientation and number of sexual partners. Data were compared to the general Cologne population regarding demographic characteristics. Female respondents were compared to heterosexual men and men who have sex with men (MSM); German respondents were compared to migrants using SPSS 14.0. RESULTS: A total of 457 female and 488 male clients participated (response rate 93.9 %). Average age was 28.4 years. Of all participants, 17.7 % were of non-German origin. The respondents had a high school degree in 80.8 % of the cases compared to 33.5 % in the general Köln population (p < 0.001). Among men, 30.2 % were MSM. Having a "new partner" or "unprotected sex with a person with unknown HIV status" were reported by 483 (39.8 %) and 373 (30.8 %) as reasons for testing. 38.7 % of the respondents reported choosing the local health office for HIV testing because it was free of charge and 24.5 % because it was anonymous. Women and heterosexual men had a median of 1, MSM a median of 3 sexual partners within the past 6 months (p < 0.001). Vaccination against hepatitis B was reported by 34.4 % of the clients, the proportion was higher among MSM (46.9 % p < 0.001) and lower among migrants. 112 (11.9 %) persons reported having had a previous STI. CONCLUSIONS: With the exception of MSM, the offer of free and anonymous HIV testing and counselling does not reach persons who carry a higher risk for HIV. As the risk for STI is higher than for HIV in Germany and there is a low public awareness, HIV counselling should be used for comprehensive sexual health counselling and include the offer for STI testing, Further outreaching efforts and other settings are necessary to reach persons with a low education level and highly vulnerable persons.

[SARS surveillance--did it meet the demands made on the surveillance of new infectious diseases?]. / SARS-Surveillance--Wurde sie den Anforderungen an die Surveillance neu auftretender Infektionskrankheiten gerecht?

INTRODUCTION: The world-wide outbreak of severe acute respiratory syndrome (SARS) in the spring of 2003 highlighted the importance of reliable surveillance for infectious diseases. The aim of this investigation is to identify possibilities for the improvement of the German surveillance system based on the experiences made during the SARS epidemic 2003. METHODS: The RKI has established two linked databases for the surveillance of SARS, to store case-based data on SARS and to keep a record of inquiries by the public health system. Based on these data we evaluated the information flow for the surveillance of SARS mainly qualitatively. RESULTS AND DISCUSSION: With occurrence of the first SARS case in Germany a nationwide surveillance system for SARS was established. Since Germany was exclusively confronted with imported SARS cases, the surveillance system could fulfil the requirements. It is unclear, however, whether the current procedures are sufficient to manage larger epidemics of emerging diseases. For this task the public health system needs a uniform electronic information management system which allows rapid adaptation to the epidemic situation and is able to deal with a large amount of data.

Sensitivity and specificity for dementia of population-based criteria for cognitive impairment: the MoVIES project.

BACKGROUND: Few norms exist for the elderly on the cognitive tests commonly used to screen for dementia; conventional cutpoints used in clinical settings may be of limited value in population screening. A particular problem is posed by elderly populations with low educational levels, as performance on most cognitive tests is affected by education. Thus, a healthy but poorly educated population may obtain test scores in the range considered impaired in the clinical setting. METHODS: A random sample of 1,367 subjects aged 65+ years was screened for dementia in a rural community in Southwestern Pennsylvania. Two sets of cognitive measures were used: a global cognitive scale (the MMSE) and a brief battery of tests tapping a variety of cognitive domains. Rather than using a priori cutoff scores, we examined the specificity and sensitivity for dementia of two operationally defined levels of cognitive impairment, at the 5th and 10th percentiles of the study sample on each set of measures. RESULTS: Results suggest that the screening of multiple cognitive domains at the 10th percentile had significantly greater sensitivity but not lower specificity for definite dementia than did the use of the single global scale. CONCLUSION: Our data support the use of population-based cutpoints over standard cutoff scores, in that the global scale at the conventional cutoff was less sensitive than the battery at the same percentile, and because adequate norms do not exist for tests such as those in the battery.

Swimming in Aplysia brasiliana: analysis of behavior and neuronal pathways.

Swimming of Aplysia brasiliana was analyzed using time-lapse video and computer graphics techniques to quantify the cyclical movements of different regions of the parapodia. Both the speed of swimming and the period of oscillation are temperature dependent, whereas the metachronal offset is not. The parapodial arterial supply is described; ligation of parapodial arteries does not affect the parapodial motions. Peripheral and central lesions indicated that (1) the anterior parapodial nerve plays the major role in parapodial flapping, (2) a separate neuronal oscillator resides in each pedal ganglion, (3) bilateral coordination is mediated via the pedal commissure, and (4) the swimming "command" pathway is the cerebro-pedal connective. During regular parapodial flapping the speed of level midwater swimming is constant throughout the cycle, suggesting that swimming is not produced by jet propulsion. An alternative propulsion model is advanced.

Neuroethological studies of freely swimming Aplysia brasiliana.

Recently developed neurophysiological and behavioural techniques were used to study swimming in the marine gastropod Aplysia brasiliana. Aplysia swim by bilateral parapodial flapping with an anterior to posterior metachronal wave. Parapodial oscillations are measured from video records. Population recordings from nerves innervating the parapodia during normal swimming in intact Aplysia reveal synchronous phasic activity in large efferent units associated with parapodial opening. Isolated brain studies and stimulation of central pathways in intact animals suggest a central pattern generator. We conclude that the output of the neuronal oscillator that controls parapodial flapping radiates synchronously from each pedal ganglion. The putative command to swim originates within the cerebral ganglia.

Weight loss following LH lesions independent of changes in motor activity or metabolic rate.

Lesions in the lateral hypothalamus (LH) which resulted in aphagia and a significant loss in body weight, did not reduce either the running wheel activity or the stabilimeter activity of the animals. Following recovery, the animals failed to regain the lost weight. They had normal food and water intakes under ad lib conditions, and ate food when water deprived. They did not drink when deprived of food. Both control and LH animals also had higher than normal oxygen consumption rates. However, the LH group was not higher than the controls postoperatively. These data argue against their being a unitary LH lesion syndrome and suggest that the chronic weight loss seen in animals with LH lesions is not a secondary consequence either of having disrupted the pituitary-thyroid axis, or of having changed the animals' spontaneous activity levels.