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The American Journal of Tropical Medicine and Hygiene - Online First
In order to provide our readers with timely access to new content, papers accepted by the American Journal of Tropical Medicine and Hygiene are posted online ahead of print publication. Papers that have been accepted for publication are peer-reviewed and copy edited but do not incorporate all corrections or constitute the final versions that will appear in the Journal. Final, corrected papers will be published online concurrent with the release of the print issue.
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A Collaborative Multidisciplinary and Without-Walls Research Curriculum in Global Health
Available online: 17 September 2018More LessLongitudinal and collaborative global health research curricula to train a well-versed global health corps through skills building in assessment and evaluation are lacking. A without-walls research curriculum was offered to medical and public health students between 2007 and 2015. Mentored cross-disciplinary research projects were developed and implemented in partnership with communities. A multilevel mixed methods design, including semi-structured interviews, post-curriculum surveys, presentations, publications, postgraduation metrics, and feedback from project sites, evaluated educational outcomes. Students (N = 25; aged 27 ± 1.9 years; 90.5% female) participated in the studies in 12 countries, resulting in 26 national-level presentations and 24 peer-reviewed publications, including per student average and range of Institutional Review Board submission (0.95; 0–3), poster presentation (0.85; 0–3), oral presentation (0.65; 0–2), and peer-reviewed submission (1.05; 0–4). On average, the studies (40% mixed methods) lasted 2 years. Analyses and manuscript writing were the most challenging; data collection and presentations were the most rewarding. Majority of the participants strongly agreed with achieving skills in community engagement, interviewing techniques, research design and implementation, research dissemination, and career development. Interview themes included expectations and learning goals, effective mentorship, impact on career goals, and ethical learning. Mentorship qualities were accessibility, real-time problem solving, research expertise, advocate, and balancing guidance with independence. Project sites’ feedback was overwhelmingly positive regarding the projects’ impact. Postgraduation participants hold positions in humanitarian organizations, research programs serving the underserved, and primary care residencies, fellowships, and faculty. This experience illustrates the feasibility and effectiveness of mentored global health research and underlines the crucial link between community collaboration and scholarship for effective global health practice.
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Predicting Mortality for Adolescent and Adult Patients with Fever in Resource-Limited Settings
Available online: 17 September 2018More LessFebrile illnesses are a major cause of mortality in sub-Saharan Africa. Early identification of patients at increased risk of death may avert adverse outcomes. We aimed to independently evaluate the performance of the Modified Early Warning Score, quick Sequential Organ Failure Assessment (qSOFA) score, and Integrated Management of Adolescent and Adult Illness (IMAI) emergency signs and severity criteria to predict in-hospital mortality among a prospective cohort of febrile patients in Tanzania. We evaluated 419 patients aged ≥ 10 years in the period 2007–2008. Of the 44 patients who died, 31 (70.5%) were human immunodeficiency virus (HIV) infected. On univariate analysis, in-hospital mortality was associated with HIV infection, oxygen saturation < 90%, respiratory distress, Glasgow Coma Scale < 15, neck stiffness, unconsciousness, convulsions, hemoglobin < 9 g/dL, absence of a systemic syndrome, and neurologic syndrome. A qSOFA score ≥ 2, the presence of at least one, two, or three IMAI emergency signs, and IMAI severe respiratory distress syndrome without shock were significantly associated with in-hospital mortality. The criterion “presence of at least one IMAI emergency sign” showed a good diagnostic accuracy, as highlighted by the high sensitivity, low negative likelihood ratio, and wide area under the receiver operating characteristics curve. The remaining scores showed a poor performance in predicting fatal outcomes in our study population. Further studies are needed to validate our findings and to derive early warning scores that have good clinical performance in settings throughout sub-Saharan Africa.
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Highly Accurate Chimeric Proteins for the Serological Diagnosis of Chronic Chagas Disease: A Latent Class Analysis
Available online: 17 September 2018More LessThe existence of an imperfect reference standard presents complications when evaluating the unbiased performance of novel diagnostic techniques. This is especially true in the absence of a gold standard, as is the case in chronic Chagas disease (CD) diagnosis. To circumvent this constraint, we elected to use latent class analysis (LCA). Previously, our group demonstrated the high performance of four Trypanosoma cruzi–chimeric proteins (Molecular Biology Institute of Paraná [IBMP]-8.1, -8.2, -8.3, and -8.4) for CD diagnosis using several distinct immunoassays. Although commercial tests had previously been established as a reference standard, the diagnostic performance of these chimeric antigens could present bias because these tests fail to produce 100% accurate results. Thus, we used LCA to assess the performance of these IBMP chimeric antigens in chronic CD diagnosis. Using the LCA model as a gold standard, sensitivity and specificity values ranged from 93.5% to 99.4% and 99.6% to 100%, respectively. The accuracy values were 96.2% for IBMP-8.2, approximately 98% for IBMP-8.1 and IBMP-8.3, and nearly 100% for IBMP-8.4. For IBMP-8.1 and IBMP-8.2, higher positive predictive values were associated with increases in hypothetical prevalence. Similarly, higher hypothetical prevalence resulted in lower negative predictive values for IBMP-8.1, IBMP-8.2, and IBMP-8.3. In addition, samples with serodiscordant results from commercial serological tests were analyzed using LCA. Molecular Biology Institute of Paraná -8.1 demonstrated potential for use in confirmatory testing with regard to samples with inconsistent results. Moreover, our findings further confirmed the remarkable performance of the IBMP-8.4 antigen to diagnose chronic CD in both endemic and non-endemic areas.
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Management and Follow-up Practices of Children with Unclassified Fever in Rural Ethiopia: Experiences of Health Extension Workers and Caregivers
Available online: 17 September 2018More LessDifferent health-care management guidelines by the World Health Organization exist to help health workers in resource-limited settings treat patients. However, for children with unclassified fever and no danger signs, management guidelines are less clear and follow-up recommendations differ. Both “universal follow-up” for all children, irrespective of health status, and “conditional follow-up” only for children whose fever persists are recommended in different guidelines. It is unclear how feasible and acceptable these two different guidelines are among community health workers and caregivers of the sick child. This qualitative study was conducted in Ethiopia and was nested within a cluster-randomized controlled trial (cRCT). It aimed to determine health extension workers’ (HEWs’) and caregivers’ experience of the management of febrile children and their perceptions of universal versus conditional follow-up recommendations. Seventeen HEWs and 20 caregivers were interviewed. The interviews revealed that HEWs’ understanding of how to handle an unclassified fever diagnosis increased with the implementation of the cRCT in both study arms (universal versus conditional follow-up). This enabled HEWs to withhold medicines from children with this condition and avoid referral to health centers. Both follow-up recommendations had perceived advantages, while the universal follow-up provided an opportunity to see the child’s health progress, the conditional follow-up advice allowed saving time and costs. The findings suggest that improved awareness of the unclassified fever condition can make HEWs feel more comfortable in managing these febrile children themselves and omitting unnecessary medication. Future community-level management guidelines should provide clearer instructions on managing fever where no malaria, pneumonia, diarrhea, or danger signs are present.
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Measles and Rubella Seroprevalence in Mother–Infant Pairs in Rural Nepal and the United States: Pre- and Post-Elimination Populations
Available online: 17 September 2018More LessWe sought to compare seroprevalence of protective measles and rubella-specific antibody in mother–infant pairs across two populations: a pre-disease elimination Nepal population with recently introduced rubella vaccine and post-disease elimination U.S. population. Qualitative measles and rubella IgG was assessed in maternal serum and cord blood from 258 pairs in Nepal, 2012–2013 and 49 pairs in Seattle, WA, 2014–2015. High rates of protective antibody were observed in both populations. Two hundred and forty-four (95%) pregnant women in Nepal had protective measles antibody versus 44 (92%) in Seattle (P = 0.42). Ninety-six percentage of infants in Nepal (N = 246) and Seattle (N = 43) had protective measles antibody (P = 0.75). Ninety-four percentage of pregnant women in Nepal (N = 242) and Seattle (N = 45) had protective rubella antibody (P = 0.23). Two hundred and thirty-eight (93%) infants in Nepal had protective rubella antibody versus 44 (98%) in Seattle (P = 0.12). Continued surveillance will be necessary to ensure protective immunity, inform progress toward disease elimination in Nepal and avoid reemergence in the United States.
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Influenza-Like Illness in Travelers to the Developing World
Available online: 17 September 2018More LessTravelers to developing regions are at risk for development of influenza-like illness (ILI). Little is known of traveler and trip characteristics associated with the development of ILI. TravMil is a prospective observational study, enrolling subjects presenting to six military travel clinics or predeployment-screening sites. We analyzed pre- and post-travel surveys from travelers visiting regions outside of the continental United States, Western or Northern Europe, Canada, Australia, or New Zealand between January 2010 and March 2016. Influenza-like illness was defined as a self-reported fever associated with either sore throat or cough. Trip and traveler characteristics were analyzed to determine risk factors for the development of ILI. Two thousand nine hundred and thirty-two trips were recorded (55% male, median age 45 years, 69% white, 51% on vacation, median travel duration 17 days). The 2,337 trips included the number of self-reported influenza vaccinations in the preceding 5 years (median 5). Eleven percent of the trips were complicated by an ILI lasting a median of 5 days; 70% and 17% of these reported upper and lower respiratory tract infection, respectively, and 12% reported both. On multivariate analysis, increased risk of ILI was associated with female gender (odds ratio [OR]: 1.60 [confidence interval (CI): 1.25–2.05], P < 0.01), age (years) (OR: 1.01 [CI: 1.01–1.02], P < 0.01); and duration of travel (days) (OR: 1.01 [CI: 1.00–1.01], P < 0.01). Influenza-like illness is common in travelers, regardless of traveler characteristics, purpose of travel, destination, or season of year. Female gender, older age, and longer duration of travel were associated with an increased risk of ILI. Additional tools and strategies are needed to prevent ILI in international travelers.
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Development and Evaluation of a Multiplex Quantitative Real-Time PCR for Hookworm Species in Human Stool
Available online: 17 September 2018More LessHookworm disease caused by Necator americanus, Ancylostoma duodenale, and Ancylostoma ceylanicum affects half a billion people worldwide. The prevalence and intensity of infection of individual hookworm species are vital for assessing morbidity and generating targeted intervention programs for their control. The present study aims to evaluate a multiplex real-time quantitative PCR (qPCR) assay to determine the prevalence and egg intensity of all three hookworm species and compare this with standard microscopy and published genus-based conventional and real-time multiplex qPCRs. Performance of the diagnostic assays was evaluated using DNA extracted from 192 fecal samples collected as part of a soil-transmitted helminth (STH) survey in northern Cambodia. The prevalence of hookworms as detected by the multiplex hookworm qPCR of 84/192 (43.8%) was significantly higher than that using microscopy of 49/192 (25.5%). The hookworm multiplex qPCR showed very good agreement for the detection of both N. americanus (Kappa 0.943) and Ancylostoma spp. (Kappa 0.936) with a multiplex STH qPCR. A strong and moderate quantitative correlation between cycle threshold and eggs per gram (EPG) feces was obtained for the hookworm qPCR for seeded DNA egg extracts (R 2 ≥ 0.9004) and naturally egg-infected individuals (R 2 = 0.6848), respectively. The newly developed hookworm quantitative multiplex qPCR has the potential for application in anthelmintic efficacy trials and for monitoring the success of mass deworming programs targeting individual species of anthroponotic and zoonotic hookworms.
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Baseline Characterization of Dengue Epidemiology in Yogyakarta City, Indonesia, before a Randomized Controlled Trial of Wolbachia for Arboviral Disease Control
Available online: 17 September 2018More LessDengue is endemic in Indonesia. Here, we describe the epidemiology of dengue in the city of Yogyakarta, Central Java, as a prelude to implementation of a cluster-randomized trial of Wolbachia for the biocontrol of arboviral transmission. Surveillance records from 2006 to 2016 demonstrate seasonal oscillations of dengue incidence with varying magnitude. Two lines of evidence demonstrate a high force of infection; the hospitalized case burden of patients diagnosed with dengue hemorrhagic fever or dengue shock syndrome over the last decade consisted predominantly of children/adolescents, and a serosurvey of 314 healthy children aged 1–10 years found 68% possessed dengue virus–neutralizing antibodies. Finally, a mobility survey indicated children aged 1–10 years, and particularly 1–5 year-olds, spent most of their daytime hours at home. These findings inform the design of clinical trials to measure the impact of novel vector control methods such as Wolbachia introgression into Aedes aegypti mosquitoes, by providing baseline data on disease incidence and identifying subpopulations for recruitment into prospective studies of dengue virus infection and disease. The mobility survey findings indicate that in cluster trials of interventions applied at the community level, young children can reasonably be expected to spend most of their exposure time, in epidemiological terms, within the treatment arm to which they were randomized.
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Trends in C-Reactive Protein, D-Dimer, and Fibrinogen during Therapy for HIV-Associated Multidrug-Resistant Tuberculosis
Available online: 17 September 2018More LessHIV-positive adults on treatment of multidrug-resistant tuberculosis (MDR-TB) experience high mortality. Biomarkers of HIV/MDR-TB treatment response may enable earlier treatment modifications that improve outcomes. To determine whether changes in C-reactive protein (CRP), D-dimer, and fibrinogen were associated with treatment outcome among those with HIV/MDR-TB coinfection, we studied 20 HIV-positive participants for the first 16 weeks of MDR-TB therapy. Serum CRP, fibrinogen, and D-dimer were measured at baseline and serially while on treatment. At baseline, all biomarkers were elevated above normal levels, with median CRP 86.15 mg/L (interquartile range [IQR] 29.25–149.32), D-dimer 0.85 µg/mL (IQR 0.34–1.80), and fibrinogen 4.11 g/L (IQR 3.75–6.31). C-reactive protein decreased significantly within 10 days of treatment initiation and fibrinogen within 28 days; D-dimer did not change significantly. Five (25%) participants died after a median of 32 days. Older age (median age of 38y among survivors and 54y among deceased, P = 0.008) and higher baseline fibrinogen (3.86 g/L among survivors and 6.37 g/L among deceased, P = 0.02) were significantly associated with death. After adjusting for other measured variables, higher CRP concentrations at the beginning of each measurement interval were significantly associated with a higher risk of death during that interval. Trends in fibrinogen and CRP may be useful for evaluating early response to treatment among individuals with HIV/MDR-TB coinfection.
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Seroepidemiology of Burkholderia pseudomallei, Etiologic Agent of Melioidosis, in the Ouest and Sud-Est Departments of Haiti
Available online: 17 September 2018More LessBurkholderia pseudomallei, the etiological agent of melioidosis, has been hypothesized to be endemic throughout the Caribbean, including the impoverished nation of Haiti. However, because of the protean clinical manifestations, presence of asymptomatic infections, and limited medical diagnostic capacity, the identification of active melioidosis cases remains challenging. A seroepidemiological study was conducted using a novel enzyme-linked immunosorbent assay (ELISA) to detect antibodies toward B. pseudomallei in the native population. The performance of an indirect ELISA with purified lipopolysaccharide (LPS) from B. pseudomallei was evaluated using serum collected from rhesus macaques exposed to aerosolized B. pseudomallei. After optimization, serum collected from asymptomatic population members (n = 756) was screened for polyvalent (IgM/IgG/IgA) and monoclonal (IgG or IgM) immunoglobulins against B. pseudomallei LPS. The population seroprevalence was 11.5% (95% confidence interval [CI]: 9.2, 13.8) for polyvalent immunoglobulins, 9.8% (95% CI: 7.7, 11.9) for IgG, and 1.7% (95% CI: 0.8, 2.6%) for IgM. The seroprevalence was not significantly different by gender (P = 0.16), but increased significantly (P < 0.001) with age, yielding an estimated annual seroconversion rate of 1.05% (95% CI: 0.81, 1.3). The detection of both recent (IgM+) and previous (IgG+) exposure to B. pseudomallei provides serological evidence that melioidosis is endemic in Haiti.
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Socioeconomic Factors Associated with Fasciola hepatica Infection Among Children from 26 Communities of the Cusco Region of Peru
Available online: 17 September 2018More LessFasciola hepatica is the most widely distributed trematode-affecting humans. The Andes Mountains are highly endemic for fascioliasis. We report results of a cross-sectional study evaluating the epidemiology of Fasciola among children in 26 agricultural communities in the Cusco region of Peru. Children 3 to 16 years old were enrolled in preschools and schools. Blood from participants was tested for complete blood counts, transaminases, and Fasciola antibodies. Stool samples were tested for Fasciola and other parasites. A total of 2,515 children were included in the analysis and the mean age was 9.6 years (±3.6). Ten percent (253) of the children had at least one positive test for Fasciola, 6% had chronic infection, and 0.8% acute infection. The rest of the subjects had only antibodies against Fasciola. The prevalence of infection varied from 0% to 20% between communities. Children with evidence of Fasciola exposure were older, lived at higher altitudes, and had a lower socioeconomic status than children without infection. The logistic regression analysis showed that children from Ancahuasi district, older children, and children with higher measures of poverty were more likely to have Fasciola exposure. Fascioliasis is common in the Cusco region and associated with poverty. However, the distribution varies markedly between communities.
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Correlates of Late Presentation to HIV care in a South Indian Cohort
Available online: 17 September 2018More LessLate presentation to HIV care is common in India despite access to free combination antiretroviral therapy (cART). We assessed risk factors for late presentation among patients with a recent HIV diagnosis in an academic university–based antiretroviral treatment center. This retrospective study included 474 recently diagnosed HIV-infected patients registered for cART between 2012 and 2013. Subjects with CD4+ T-lymphocyte (CD4) count ≤ 350 cells/μL or with an AIDS defining event were defined as late presenters (LP) and patients with CD4 count ≤ 200 cells/μL or with an AIDS defining event were defined as LP with advanced HIV disease (LPAD). Multivariable logistic regression analysis was used to investigate factors associated with late presentation. Of the 474 patients, 356 (75.1%) were LP. Of these, 299 (83.99%) were LPAD and 57 (16.01%) LP were AIDS-free. Median CD4 count among LP was 134 cells/μL (IQR 72.25–219). Mean age of LP was 42.50 ± 8.88 years; 256 (71.9%) were males. Increasing age (> 51 years; Adjusted odds ratio [aOR] 4.19; P = 0.014) and rural residence (aOR 3.19; P = < 0.001) were independently associated with late presentation. HIV-positive housewives (aOR 0.34; P = 0.027), HIV-positive individuals with negative partners (aOR 0.48; P = 0.006), and partners with unknown HIV status (aOR 0.43; P = 0.007) were less likely to present late compared with positive partners of people living with HIV/AIDS (PLWHA). Most patients were LP despite free access to cART. Rural population and older PLHIV should be targeted while implementing HIV care. There is a need to strengthen the HIV care cascade by linking PLWHA to cART immediately after diagnosis.
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Case Report: Subcutaneous Ivermectin Pharmacokinetics in Disseminated Strongyloides Infection: Plasma and Postmortem Analysis
Available online: 17 September 2018More LessParenteral ivermectin treatment of disseminated strongyloidiasis and hyperinfection is increasing, although not licensed in humans and with limited pharmacokinetic data available. Plasma and postmortem tissue analysis in an HIV/hepatitis C virus–positive man with disseminated strongyloidiasis suggests loading subcutaneous ivermectin doses are required, from which the central nervous system is protected.
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Case Report: Bothrops lanceolatus Snakebite Surgical Management—Relevance of Fasciotomy
Available online: 17 September 2018More LessBothrops lanceolatus is an endemic Crotalidae species in Martinique, where approximately 30 cases of envenoming are managed yearly. Envenoming characteristics from Bothrops species include local tissue damage, systemic bleeding, and hemodynamic alterations. We hereby report a case of severe envenomation following B. lanceolatus snakebite to the right calf. Severe local manifestations developed progressively up to the lower limb despite adequate antivenom therapy. Systemic manifestations of venom also occurred, resulting in intensive care therapy. Surgery exploration revealed soft tissue necrosis, friability of the deep fascia, and myonecrosis. The patient needed multiple debridement procedures and fasciotomy of all leg compartments and anterior compartment of the thigh. Diagnosis of necrotizing fasciitis was confirmed by positive Aeromonas hydrophila blood cultures. This clinical case illustrates that major soft tissue infection, including necrotizing fasciitis may occur after snakebite. Abnormal coagulation tests should not delay surgical management, as severe envenoming is a life-threatening condition.
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Surveillance for Flaviviruses Near the Mexico–U.S. Border: Co-circulation of Dengue Virus Serotypes 1, 2, and 3 and West Nile Virus in Tamaulipas, Northern Mexico, 2014–2016
S. Viridiana Laredo-Tiscareño, Javier A. Garza-Hernandez, Ma Isabel Salazar, Erick J. De Luna-Santillana, Chandra S. Tangudu, Rosa C. Cetina-Trejo, Gloria L. Doria-Cobos, Santos Daniel Carmona-Aguirre, Julian E. Garcia-Rejon, Carlos Machain-Williams, Bradley J. Blitvich and Mario Alberto Rodríguez PérezAvailable online: 17 September 2018More LessA clinical, serological, and molecular investigation was performed to determine the presence of dengue virus (DENV) and other flaviviruses among residents of the city of Reynosa, Tamaulipas, on the Mexico–U.S. border in 2014–2016. The sample population consisted of 2,355 patients with suspected dengue, in addition to 346 asymptomatic individuals recruited during a household-based epidemiological investigation designed to identify flavivirus seroconversions. Sera were collected from patients with suspected dengue in the acute phase of illness and from asymptomatic individuals at enrollment and every 5–7 months for 19 months. Sera from suspected dengue patients were tested for DENV antigen by enzyme-linked immunosorbent assay (ELISA), and select antigen-positive sera were further tested using a serotype-specific, quantitative reverse transcription–polymerase chain reaction. Sera from the household cohort were tested for flavivirus-reactive antibodies by immunoglobulin (Ig) M and IgG ELISAs using DENV antigen. A total of 418 (17.7%) patients with suspected dengue had laboratory-confirmed DENV infections, including 82 patients who were positive for DENV RNA. The most frequently detected serotype was DENV-1 (61 patients), followed by DENV-2 (16 patients) and DENV-3 (five patients). A total of 217 (62.7%) asymptomatic individuals had flavivirus-reactive antibodies at enrollment, and nine flavivirus-naïve individuals seroconverted. Sera from a subset of dengue patients and household participants, including all those who seroconverted, were further tested by plaque reduction neutralization test, resulting in the detection of antibodies to DENV-1, DENV-2, and West Nile virus. In summary, we provide evidence for the co-circulation of multiple flaviviruses in Reynosa, Tamaulipas, on the Mexico–U.S. border.
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Case Report: Right Hemispheric Neuroimaging Abnormalities in a Patient with Dengue Encephalopathy
Available online: 17 September 2018More LessDengue encephalitis and dengue encephalopathy are frequent neurological complications of systemic dengue virus infection. Neuroimaging is normal in approximately 50% of patients. Common imaging abnormalities involve periventricular structures, including the basal ganglion, thalamus, and periventricular white matter. We describe an unusual case of dengue encephalopathy with unilateral imaging abnormalities involving the right cerebral hemisphere and mimicking the involvement of the right middle cerebral artery.
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Clinical and Epidemiological Characteristics of Patients with Dientamoeba fragilis Infection
Available online: 17 September 2018More LessDientamoeba fragilis is an intestinal protozoan, usually considered nonpathogenic. However, in the last years, there has been an attempt to clarify its possible pathogenic role. We aim to evaluate the clinical and epidemiological characteristics of D. fragilis–infected patients. Adults with D. fragilis detection in feces who attended the Vall d’Hebron University Hospital (Barcelona, Spain) were evaluated retrospectively from April 2009 to March 2014. We classified the patients in asymptomatic, symptomatic without other causes except infection of D. fragilis, and symptomatic with another cause. Among symptomatic patients, treatment response was evaluated. One hundred eight patients were included. Sixty-three percent of the patients were immigrants, 29.6% were autochthonous, and 7.4% were travelers. Forty-nine (45.3%) patients presented symptoms, and eosinophilia was observed in 26 (24.1%) patients. Overall, 59 (54.7%) patients were asymptomatic, 15 (13.8%) presented symptoms which were attributable to other causes, and 34 (31.5%) patients presented symptoms with no other causes. In this last group, 29 patients received specific treatment and 65.5% of them presented a complete resolution of the symptoms. The group of symptomatic patients with no other cause had more proportion of women, more proportion of autochthonous people, and were older compared with the group of asymptomatic patients. Dientamoeba fragilis infection should be considered as pathogenic when other causes are ruled out.
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Seroprevalence and Symptomatic Attack Rate of Chikungunya Virus Infection, United States Virgin Islands, 2014–2015
Available online: 17 September 2018More LessWhen introduced into a naïve population, chikungunya virus generally spreads rapidly, causing large outbreaks of fever and severe polyarthralgia. We randomly selected households in the U.S. Virgin Islands (USVI) to estimate seroprevalence and symptomatic attack rate for chikungunya virus infection at approximately 1 year following the introduction of the virus. Eligible household members were administered a questionnaire and tested for chikungunya virus antibodies. Estimated proportions were calibrated to age and gender of the population. We enrolled 509 participants. The weighted infection rate was 31% (95% confidence interval [CI]: 26–36%). Among those with evidence of chikungunya virus infection, 72% (95% CI: 65–80%) reported symptomatic illness and 31% (95% CI: 23–38%) reported joint pain at least once per week approximately 1 year following the introduction of the virus to USVI. Comparing rates from infected and noninfected study participants, 70% (95% CI: 62–79%) of fever and polyarthralgia and 23% (95% CI: 9–37%) of continuing joint pain in patients infected with chikungunya virus were due to their infection. Overall, an estimated 43% (95% CI: 33–52%) of the febrile illness and polyarthralgia in the USVI population during the outbreak was attributable to chikungunya virus and only 12% (95% CI: 7–17%) of longer term joint pains were attributed to chikungunya virus. Although the rates of infection, symptomatic disease, and longer term joint symptoms identified in USVI are similar to other outbreaks of the disease, a lower proportion of acute fever and joint pain was found to be attributable to chikungunya virus.
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Case Report: Ivermectin and Albendazole Plasma Concentrations in a Patient with Disseminated Strongyloidiasis on Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy
Available online: 17 September 2018More LessDisseminated strongyloidiasis is often fatal, despite treatment with oral albendazole and parenteral ivermectin (IVM). Here, we report elevated plasma IVM and albendazole sulfoxide concentrations in the context of extracorporeal membrane oxygenation and continuous renal replacement therapy in a patient with disseminated strongyloidiasis treated with subcutaneous IVM and nasogastric albenzadole. Despite elevated drug plasma concentrations, live filariform larvae were detected in endotracheal aspirates after 2 weeks of treatment.
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Socially Awkward Abroad: A Call for Social Media Policies in Residencies that Offer Global Health Electives
Available online: 17 September 2018More LessBoth social media use and the popularity of global health electives (GHEs) have increased in recent years. Social media use during GHE is commonplace and has benefits, yet sharers may not consider the ramifications of these posts, including privacy violations. Social media policies—which have become more common in residency programs—may aid in providing clear expectations to trainees abroad. The authors aimed to determine the prevalence of social media policies among pediatric residency programs that offer GHE. The authors used a cross-sectional survey design in which educators at pediatric residency programs that offer GHE were surveyed using REDCap®. For all quantitative data, proportions of responses were calculated and analyzed using Microsoft Excel 2013®. The authors analyzed qualitative data using a conventional content analysis approach. The survey was sent to 74 educators; 39 (53%) responses were received. Most (62%; n = 24) of the pediatric residency programs that offer GHE reported that their institution had a social media policy. About one-third (34%; n = 13) of respondents stated that their programs had social media guidelines that pertained specifically to GHE and fewer indicated that social media guidelines were included in their programs’ GHE predeparture curricula (32%; n = 12). This study found that most of the residency programs surveyed had social media guidelines, but few had guidelines applicable or specific to GHE. Informed by this study and a literature review, the authors propose template language for a social media guideline with considerations for social media use in the context of GHE.
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Gametocyte Carriage, Antimalarial Use, and Drug Resistance in Cambodia, 2008–2014
Available online: 17 September 2018More LessGametocytes are the malaria parasite stages responsible for transmission from humans to mosquitoes. Gametocytemia often follows drug treatment, especially as therapies start to fail. We examined Plasmodium falciparum gametocyte carriage and drug resistance profiles among 824 persons with uncomplicated malaria in Cambodia to determine whether prevalent drug resistance and antimalarial use has led to a concentration of drug-resistant parasites among gametocyte carriers. Although report of prior antimalarial use increased from 2008 to 2014, the prevalence of study participants presenting with microscopic gametocyte carriage declined. Gametocytemia was more common in those reporting antimalarial use within the past year, and prior antimalarial use was correlated with higher IC50s to piperaquine and mefloquine, as well as to increased pfmdr1 copy number. However, there was no association between microscopic gametocyte carriage and parasite drug resistance. Thus, we found no evidence that the infectious reservoir, marked by those carrying gametocytes, is enriched with drug-resistant parasites.
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Onchocerciasis-Associated Epilepsy with Head Nodding Seizures—Nodding Syndrome: A Case Series of 15 Patients from Western Uganda, 1994
Available online: 17 September 2018More LessNodding syndrome (NS) is an encephalopathy characterized by the core symptom of epileptic head nodding seizures, affecting children at the age between 3 and 18 years in distinct areas of tropical Africa. A consistent correlation with onchocerciasis was found, but so far, the causation of NS has not been fully clarified. With a systematic analysis of features of a cohort of epilepsy patients examined in the Itwara onchocerciasis focus of western Uganda in 1994, we provide evidence that NS actually occurred in this area at this time, and we demonstrate a correlation between prevalence of NS and that of onchocerciasis in different villages. Following the elimination of onchocerciasis by community-directed treatment with ivermectin and ground larviciding, our data provide a baseline to examine the question whether NS will disappear once its putative cause has been removed.
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Molecular Detection of Bartonella bacilliformis in Lutzomyia maranonensis in Cajamarca, Peru: A New Potential Vector of Carrion’s Disease in Peru?
Available online: 17 September 2018More LessCarrion’s disease is a neglected, vector-borne illness that affects Colombia, Ecuador, and especially Peru. The phlebotomine sand flies Lutzomyia verrucarum and Lutzomyia peruensis are the main illness vectors described, although other species may be implicated in endemic areas such as some northern Peruvian regions, in which Carrion’s disease vector has not been established. The aim of this study was to evaluate the presence of Bartonella bacilliformis DNA in Lutzomyia maranonensis from Cajamarca, northern Peru. This sand fly has not been defined as a vector yet. CDC light traps were used to collect adult phlebotomine sand flies from 2007 to 2008 in the Cajamarca department. Female specimens were identified using morphological keys and were grouped into pools of five sand flies, taking into account district and sampling site (intradomicile or peridomicile). DNA was extracted, and then conventional and real-time PCR (RT-PCR) were performed to detect B. bacilliformis and subsequently confirmed by sequencing. A total of 383 specimens of L. maranonensis species were analyzed. Two of 76 pools were positive for B. bacilliformis by sequencing; all positives pools were from Querocotillo district. In addition, Mesorhizobium spp. were identified in two pools of sand flies, which is an α-proteobacteria phylogenetically very close to B. bacilliformis. This study presents molecular evidence that suggests L. marononensis is naturally infected by B. bacilliformis in the Cajamarca department. Further research should determine if L. maranonensis is a vector and could transmit B. bacilliformis.
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Impact of Chronic Kidney Disease on Chikungunya Virus Infection Clinical Manifestations and Outcome: Highlights during an Outbreak in Northeast of Brazil
Available online: 17 September 2018More LessThe northeastern region of Brazil has faced in the last 2 years the largest outbreak of chikungunya virus (CHIKV) infection in its history. There are still few studies on kidney involvement in CHIKV. The aim of this study is to describe the impact of chronic kidney disease (CKD) on CHIKV clinical manifestations and outcome. This is a cross-sectional study conducted in the State of Ceara, northeastern Brazil, including all registered cases of CHIKV infection in the period from January 2016 to December 2017. Clinical manifestations were collected from the notification reports from official data bank from the State Secretary of Health of Ceara: National System of Diseases Notification and Laboratory Manager. A total of 182,731 cases were notified. Patients’ mean age was 32.4 ± 14.6 years, and 62.2% were female. The most common clinical manifestations were fever (88.6%), headache (72.9%), intense arthralgia (69.5%), and myalgia (65.6%). Hospital admission was required for 3,080 cases (3.3%), and death occurred in 383 cases (0.2%). Chronic kidney disease was reported in 691 cases (0.3%). Patients with CKD had a higher frequency of almost all clinical manifestations, including fever, myalgia, exanthema, vomiting, nausea, back pain, conjunctivitis, arthritis, severe arthralgia, petechiae, and retro-orbital pain. They also had a significantly higher frequency of diabetes, hematological disorders, liver diseases, hypertension, peptic ulcer disease, and autoimmune diseases. Mortality was significantly higher among CKD patients than patients without CKD (3.0% versus 0.2%, P < 0.0001).
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Praziquantel Resistance in the Zoonotic Cestode Dipylidium caninum
Available online: 17 September 2018More LessDipylidium caninum is a cosmopolitan cestode infecting dogs, cats, and humans. Praziquantel is a highly effective cestocidal drug and resistance in adult cestodes has not been reported. From 2016 to 2018, a population of dogs with cestode infections that could not be eliminated despite multiple treatments with praziquantel or epsiprantel was identified. Cases of D. caninum were clinically resistant to praziquantel and could not be resolved despite increasing the dose, frequency, and duration of treatment. Resistant isolates were identified and characterized by sequencing the 28S, 12S, and voltage-gated calcium channel beta subunit genes. Cases were only resolved following treatment with nitroscanate or a compounded pyrantel/praziquantel/oxantel product. Clinicians should be aware of this alarming development as treatment options for cestodes are limited in both human and veterinary medicine.
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Environmental Determinants of Hemorrhagic Fever with Renal Syndrome in High-Risk Counties in China: A Time Series Analysis (2002–2012)
Available online: 17 September 2018More LessThe transmission pattern of hemorrhagic fever with renal syndrome (HFRS) is associated with environmental conditions, including meteorological factors and land-cover. In the present study, the association between HFRS and environmental factors (including maximum temperature, relative humidity, rainfall, and normalized difference vegetation index) were explored in two typical counties in Northeast and two counties in Northwest China with severe HFRS outbreaks by using seasonal autoregressive integrated moving average model (SARIMAX) with exogenous variables. The results showed that rainfall with 3- to 4-month lag was closely associated with HFRS in the two counties in Northeast China, whereas relative humidity with 1- or 5-month lag significantly impacts HFRS transmission in the two counties in Northwest China. Moreover, the SARIMAX models exhibit accurate forecasting ability of HFRS cases. Our findings provide scientific support for local HFRS monitoring and control, and the development of a HFRS early warning system.
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Case Report: A Common Source Outbreak of Anisakidosis in the United States and Postexposure Prophylaxis of Family Collaterals
Available online: 17 September 2018More LessWe present a case of intussusception with complete small bowel obstruction caused by intestinal anisakidosis requiring surgical resection. A 30-year-old man presented with acute onset of severe abdominal pain 3 days after eating home-cured salmon gravlax. Despite surgery, the patient developed recurrent abdominal pain on two occasions with evidence of continued inflammation proximal to the surgical anastomosis. He was then treated with albendazole and prednisone, and symptoms improved. A decision was made to prophylactically treat two asymptomatic family members who also consumed home-cured gravlax with albendazole, resulting in one individual passing an intact Anisakis worm in her stool. We suggest that albendazole therapy could be considered as a therapy for continued symptoms of anisakidosis and postexposure prophylaxis of Anisakis larvae ingestion from a common source.
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To End TB, First-Ever High-Level Meeting on TB Must Address Stigma
Available online: 17 September 2018More LessWorld leaders gather to consolidate their commitment to ending TB. Vital to the success of renewed efforts is an overdue recognition of the pervasive and pernicious influence of TB stigma. TB stigma is sustained in structures, policies, traditions, and norms. Innovative modifications to infection control, drug dispensing, and surveillance practices are required to increase demand for TB screening and effective therapeutic alliances among those diagnosed. The authors argue that reducing TB stigma requires a scientific and inclusive process, with prominent roles for TB survivors and a willingness to integrate and learn from other stigmatized conditions.
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Antibiotic Resistance Patterns and Molecular Characterization of Methicillin-Resistant Staphylococcus aureus in Clinical Settings Study in Rwanda
Available online: 10 September 2018More LessThe escalating burden of infections attributable to methicillin-resistant Staphylococcus aureus (MRSA) in East African countries is calling for interventional strategies to control the spread of this strain. The present study aimed at determining the prevalence, antimicrobial profiles, and staphylococcal cassette chromosome mec (SCCmec) typing of MRSA strains. This was a cross-sectional laboratory-based study involving 226 non-duplicated S. aureus isolates from different clinical samples of patients attending a referral hospital in Kigali. Kirby–Bauer disk diffusion method was used for drug susceptibility testing. Methicillin-resistant S. aureus were confirmed using PCR assay for the mecA gene and SCCmec type PCR assay was used for genotyping. Of 138 S. aureus, 39 (31.2%) were found to be MRSA strains. The mean age of the patients was 21.9 years. The incidence of MRSA increases with age and was 27.1% in patient age group younger than 18 years, 33.3% in the age group between 19 and 65 years, and 66.7% in patient age group older than 65 years. There was a significant association between geographic regions and incidence of MRSA (P = 0.02) with the high MRSA isolates from Northern (61.5%) and Western (50%) provinces. Methicillin-resistant S. aureus strains were found to be mostly susceptible to linezolid (93.5%). Among the MRSA strains, SCCmec type I and SCCmec type IV were the most prevalent at 56.4% and 17.9%, respectively. A high prevalence of MRSA was found in Rwanda. Staphylococcal cassette chromosome mec type I (52.2%) was the most predominant. A continuous surveillance of MRSA strains, particularly in the hospital settings, should be an enduring exercise in Rwanda.
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Noninvasive Sweat-Based Diagnosis of Visceral Leishmaniasis and Post Kala-Azar Dermal Leishmaniasis
Available online: 10 September 2018More LessThe diagnosis of visceral leishmaniasis (VL) is one of the foremost barriers in the control of this disease, as demonstration of the parasite by splenic/bone marrow aspiration is relatively difficult and requires expertise and laboratory support. The aim of the present study was to find a noninvasive diagnostic approach using the existing recombinant kinesine-39 (rK-39) immunochromatographic nitrocellulose strips test (ICT) with a human sweat specimen for the diagnosis of VL. The investigation was carried out on specimens (blood, sweat, and urine) collected from 58 confirmed VL, 50 confirmed post kala-azar dermal leishmaniasis (PKDL), 36 healthy control, and 35 patients from other diseases. The data obtained from this study reveal that 96.55% clinically confirmed active VL participants were found to be positive when tested against a sweat specimen. Interestingly, the scenario was similar when tested against a blood specimen (96.55% positive by rK-39). Moreover, a test of both sweats and blood specimens from 50 PKDL participants resulted in 100% positivity, whereas no healthy control participants were found to be rK-39 positive. The sensitivity of the rK-39 ICT in sweat specimen was 94.74%, whereas the specificity was 100% in healthy controls from endemic, nonendemic, and other infectious diseases, respectively. No difference was observed in sweat specimen of VL and PKDL cases which signifies its reliability. However, further evaluation of this method on a larger scale could enhance the reliability of the proposed model so that it could be used efficiently in VL management and eradication.
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Case Report: Atypical Cutaneous Leishmaniasis in a Patient with Mixed Leishmania guyanensis and Leishmania amazonensis Infection
Available online: 10 September 2018More LessThe disseminated form of leishmaniasis is a serious and rare disease, being diagnosed in 2% of the cutaneous cases registered per year in Brazil. The main characteristic is the appearance of multiple pleomorphic lesions on the cutaneous surface. A 68-year-old male from the rural area of Tocantins, Brazil, presented atypical disseminated cutaneous leishmaniasis (ACL). The clinical course and histopathological and immunological findings presented a mixed pattern that hindered diagnosis and therapeutic management. Molecular typing revealed a mixed infection with Leishmania (V.) guyanensis and Leishmania (L.) amazonensis. Molecular identification of the agents responsible for ACL is important for adequate therapeutic planning, minimizing the possibility of sequellae that impact the quality of life of the patient.
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Managing Severe Tetanus without Ventilation Support in a Resource-limited Setting in Bangladesh
Available online: 10 September 2018More LessTetanus, a vaccine-preventable and potentially fatal disease, continues to remain prevalent in low- and middle-income countries. Furthermore, physicians are often unfamiliar with management of severe tetanus without ventilator support. Therefore, we proposed a modified treatment protocol that provides a low-cost and effective solution for the management of severe tetanus in resource-constrained settings. This is an observational study of 42 patients with severe tetanus treated during 2015–2016 at Surya Kanta Hospital, Bangladesh. This facility does not have an intensive care unit (ICU), and patients admitted here were provided treatment with the modified protocol. A total number of 42 patients with severe tetanus were treated with the modified protocol. Among them, 24 (57.1%) recovered completely, six (14.3%) recovered with the sequela, and 12 (28.6%) died. Among those who recovered with the sequela, four needed mechanical support during walking and two had a visual impairment. No significant adverse event was recorded during the treatment period. The results gathered during this case series provide a sustainable, low-cost, and effective solution to management of severe tetanus in resource-constrained settings where ICUs are unavailable.
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Plasmodium vivax Infections in Duffy-Negative Individuals in the Democratic Republic of the Congo
Available online: 10 September 2018More LessAlthough Plasmodium vivax has been assumed to be absent from sub-Saharan Africa because of the protective mutation conferring the Duffy-negative phenotype, recent evidence has suggested that P. vivax cases are prevalent in these regions. We selected 292 dried blood spots from children who participated in the 2013–2014 Demographic and Health Survey of the Democratic Republic of the Congo (DRC), to assess for P. vivax infection. Four P. vivax infections were identified by PCR, each in a geographically different survey cluster. Using these as index cases, we tested the remaining 73 samples from the four clusters. With this approach, 10 confirmed cases, three probable cases, and one possible case of P. vivax were identified. Among the 14 P. vivax cases, nine were coinfected with Plasmodium falciparum. All 14 individuals were confirmed to be Duffy-negative by sequencing for the single point mutation in the GATA motif that represses the expression of the Duffy antigen. This finding is consistent with a growing body of literature that suggests that P. vivax can infect Duffy-negative individuals in Africa. Future molecular and sequencing work is needed to understand the relationship of these isolates with other P. vivax samples from Asia and South America and discover variants linked to P. vivax virulence and erythrocyte invasion.
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Case Report: Monoclonal Gammopathy of Undetermined Significance is Associated with Loa loa Infection
Available online: 10 September 2018More LessA 63-year-old woman who migrated from Nigeria to the United States was found to have an elevated total serum protein, anemia, and eosinophilia. Serum protein electrophoresis (SPEP) and serum protein immunofixation electrophoresis (SPIFE) demonstrated monoclonal IgG κ restricted bands (IgG 3,820 mg/dL; κ/λ ratio 4.47), indicative of monoclonal gammopathy of unknown significance (MGUS). A rapid diagnostic test (RDT) for malaria was positive for Plasmodium falciparum (BinaxNOW®). Giemsa-stained blood smears were negative for malarial parasites, however, Loa loa microfilariae were identified. Reverse transcription polymerase chain reaction for P. falciparum, Plasmodium ovale, Plasmodium malariae, and Plasmodium vivax yielded a negative result. She was treated for loiasis with diethylcarbamazine and received no malaria medication. Treatment resulted in a resolution of the microfilaremia and eosinophilia, a negative RDT for malaria, and marked reduction in the monoclonal gammopathy. This is the first reported human case of MGUS associated with loiasis and its resolution after antiparasitic treatment.
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Molecular Detection of Taeniid Eggs in Beetles Collected in an Area Endemic for Taenia solium
Available online: 10 September 2018More LessThe aim of this study was to demonstrate the presence of Taenia solium eggs in beetles collected from sources within the natural environment through molecular techniques. Fifty-four pools of beetles were collected in three villages in Piura, Peru. DNA was extracted using the FastDNA spin kit for soil. Molecular identification of Taenia species was then performed through partial amplification of the mitochondrial cytochrome C oxidase subunit I gene. Finally, positive samples were sequenced to determine the tapeworm species. Seven positive samples were obtained through PCR amplification. Sequencing confirmed that two samples were from T. solium and three samples were from Taenia hydatigena. The other two samples could not be specifically identified. Our findings demonstrate that dung beetles ingest T. solium and T. hydatigena eggs under natural conditions and suggest that beetles may play a role in the dynamics of transmission of these cestodes.
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Altered Systemic Adipokine Levels in Pulmonary Tuberculosis and Changes following Treatment
Available online: 04 September 2018More LessPulmonary tuberculosis (PTB) is associated with modulation of levels of adipokines, specifically adiponectin and leptin, but the effect of standard antituberculosis treatment (ATT) on the systemic levels of adiponectin, resistin, and leptin has not been well explored. To identify the association of adipokines with PTB and their relationship with disease severity and bacterial burden, we measured the levels of adiponectin, resistin, and leptin in PTB individuals and compared them with latent tuberculosis (LTB) and healthy control (HC) individuals. Pulmonary tuberculosis was characterized by diminished circulating levels of adiponectin and leptin and heightened circulating levels of resistin in comparison to that in LTB and HC individuals. However, PTB with bilateral or cavitary disease did not exhibit any increased systemic levels of these adipokines in comparison with those with unilateral or non-cavitary disease, respectively. In addition, none of the adipokines exhibited a positive correlation with bacterial burdens, but adiponectin alone exhibited a negative correlation with body mass index in PTB individuals. Finally, on successful completion of ATT, PTB individuals exhibited significantly increased levels of adiponectin and leptin and significantly decreased levels of resistin. Therefore, our data identify an important association of systemic adipokine levels with PTB disease and its alteration following ATT.
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Epidemiology and Transmission of Respiratory Infections in Thai Army Recruits: A Prospective Cohort Study
Available online: 04 September 2018More LessMilitary recruits are at high risk of respiratory infections. However, limited data exist on military populations in tropical settings, where the epidemiology of respiratory infections differs substantially from temperate settings. We enrolled recruits undertaking a 10-week military training at two Royal Thai Army barracks between May 2014 and July 2015. We used a multiplex respiratory panel to analyze nose and throat swabs collected at the start and end of the training period, and from participants experiencing respiratory symptoms during follow-up. Paired sera were tested for influenza seroconversion using a hemagglutinin inhibition assay. Overall rates of upper respiratory illness and influenza-like illness were 3.1 and 2.0 episodes per 100 person-weeks, respectively. A pathogen was detected in 96% of samples. The most commonly detected microbes were Haemophilus influenzae type B (62.7%) or non–type B (58.2%) and rhinovirus (22.4%). At baseline, bacterial colonization was high and included H. influenzae type B (82.3%), H. influenzae non–type B (31.5%), Klebsiella pneumoniae (14.6%), Staphylococcus aureus (8.5%), and Streptococcus pneumoniae (8.5%). At the end of follow-up, colonization with H. influenzae non–type B had increased to 74.1%, and S. pneumoniae to 33.6%. In the serology subset, the rate of influenza infection was 3.4 per 100 person-months; 58% of influenza infections resulted in clinical disease. Our study provides key data on the epidemiology and transmission of respiratory pathogens in tropical settings. Our results emphasize the need for improved infection prevention and control in military environments, given the high burden of illness and potential for intense transmission of respiratory pathogens.
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Epidemiology of Hepatitis A and Hepatitis E Based on Laboratory Surveillance Data—India, 2014–2017
Available online: 04 September 2018More LessHepatitis A and hepatitis E viruses (HAV and HEV) are the most common etiologies of viral hepatitis in India. To better understand the epidemiology of these infections, laboratory surveillance data generated during 2014–2017, by a network of 51 virology laboratories, were analyzed. Among 24,000 patients tested for both HAV and HEV, 3,017 (12.6%) tested positive for HAV, 3,865 (16.1%) for HEV, and 320 (1.3%) for both HAV and HEV. Most (74.6%) HAV patients were aged ≤ 19 years, whereas 76.9% of HEV patients were aged ≥ 20 years. These laboratories diagnosed 12 HAV and 31 HEV clusters, highlighting the need for provision of safe drinking water and improvements in sanitation. Further expansion of the laboratory network and continued surveillance will provide data necessary for informed decision-making regarding introduction of hepatitis-A vaccine into India’s routine childhood immunization program.
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Factors Associated with the 18-Month Cumulative Incidence of Seroconversion of Active Infection with Taenia solium Cysticercosis: A Cohort Study among Residents of 60 Villages in Burkina Faso
Available online: 04 September 2018More LessTaeniasis/cysticercosis (CC) is an important disease complex with significant burden. This large-scale cohort study aimed at estimating and exploring individual- and village-level factors associated with the cumulative incidences of seroconversion (SC) and seroreversion (SR) of active human CC in three provinces of Burkina Faso. In 60 villages, blood samples were collected and interviews regarding sociodemographic variables and knowledge, attitude, and practices toward the disease complex were conducted at baseline and 18-month follow-up (N = 2,211), with the presence of active CC being determined using the B158/B60 antigen enzyme-linked immunosorbent assay (Ag-ELISA). The 18-month Ag SC and SR were estimated at 3.3% (95% confidence interval [CI]: 2.6; 4.2%) and 35.8% (95% CI: 24.5; 48.5%), respectively. Marked provincial differences were found for the 18-month Ag SC (Boulkiemde: cumulative incidence ratio [CIR]: 2.41 (95% CI: 1.21; 4.78) and Nayala: CIR: 3.28 (95% CI: 1.37; 7.84), compared with Sanguie), while not being significantly associated with other sociodemographic factors. A continued refraining from pork consumption was associated with a lower 18-month Ag SC (CIR: 0.55 [95% CI: 0.28; 1.07]), whereas at the village level, the percentage of households owning pigs was associated with a higher 18-month Ag SC (CIR: 1.03 [95% CI: 1.01; 1.05]). In conclusion, this is one of few cohort studies and the first to have enough power to assess possible causal links between individual- and village-level variables and CC in humans. Variables linked to province, pig raising, and pork consumption behaviors were found to cause Ag SC in humans. The latter results further support the importance of adopting a One Health approach to the control of CC.
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Case Report: Plasmodium knowlesi Infection with Rhabdomyolysis in a Japanese Traveler to Palawan, the Philippines
Available online: 04 September 2018More LessSkeletal muscle is known to be damaged by falciparum malaria via sequestration of infected erythrocytes. We present a case of rhabdomyolysis caused by Plasmodium knowlesi infection. The patient had fever, myalgia, and muscle weakness 5 days after returning to Japan from Palawan, the Philippines. Blood test revealed thrombocytopenia and an elevated creatine kinase level. Although rhabdomyolysis resolved with fluid therapy, fever of 24-hour cycle continued and thrombocytopenia intensified. On day 7 of illness, Giemsa-stained thin blood smear revealed malaria parasites, with a parasite count of 2,380/μL, which were morphologically indistinguishable between P. knowlesi and Plasmodium malariae. Rapid diagnostic test showed a negative result. The pathogen was later confirmed to be P. knowlesi by nested PCR. The patient was successfully treated with artemether/lumefantrine. This case suggests that knowlesi malaria might be able to cause skeletal muscle damage.
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Risk Factors for Malaria Infection in Central Madagascar: Insights from a Cross-Sectional Population Survey
Available online: 04 September 2018More LessCommunity prevalence of infection is a widely used, standardized metric for evaluating malaria endemicity. Conventional methods for measuring prevalence include light microscopy and rapid diagnostic tests (RDTs), but their detection thresholds are inadequate for diagnosing low-density infections. The significance of submicroscopic malaria infections is poorly understood in Madagascar, a country of heterogeneous malaria epidemiology. A cross-sectional community survey in the western foothills of Madagascar during the March 2014 transmission season found malaria infection to be predominantly submicroscopic and asymptomatic. Prevalence of Plasmodium infection diagnosed by microscopy, RDT, and molecular diagnosis was 2.4%, 4.1%, and 13.8%, respectively. This diagnostic discordance was greatest for Plasmodium vivax infection, which was 98.5% submicroscopic. Village location, insecticide-treated bednet ownership, and fever were significantly associated with infection outcomes, as was presence of another infected individual in the household. Duffy-negative individuals were diagnosed with P. vivax, but with reduced odds relative to Duffy-positive hosts. The observation of high proportions of submicroscopic infections calls for a wider assessment of the parasite reservoir in other regions of the island, particularly given the country’s current focus on malaria elimination and the poorly documented distribution of the non–P. falciparum parasite species.
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St. Louis Encephalitis Virus Disease in the United States, 2003–2017
Available online: 04 September 2018More LessSt. Louis encephalitis virus (SLEV), an arthropod-borne flavivirus, can cause disease presentations ranging from mild febrile illness through severe encephalitis. We reviewed U.S. national SLEV surveillance data for 2003 through 2017, including human disease cases and nonhuman infections. Over the 15-year period, 198 counties from 33 states and the District of Columbia reported SLEV activity; 97 (49%) of those counties reported SLEV activity only in nonhuman species. A total of 193 human cases of SLEV disease were reported, including 148 cases of neuroinvasive disease. A median of 10 cases were reported per year. The national average annual incidence of reported neuroinvasive disease cases was 0.03 per million. States with the highest average annual incidence of reported neuroinvasive disease cases were Arkansas, Arizona, and Mississippi. No large outbreaks occurred during the reporting period. The most commonly reported clinical syndromes were encephalitis (N = 116, 60%), febrile illness (N = 35, 18%), and meningitis (N = 25, 13%). Median age of cases was 57 years (range 2–89 years). The case fatality rate was 6% (11/193) and all deaths were among patients aged > 45 years with neuroinvasive disease. Nonhuman surveillance data indicated wider SLEV activity in California, Nevada, and Florida than the human data alone suggested. Prevention depends on community efforts to reduce mosquito populations and personal protective measures to decrease exposure to mosquitoes.
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Mosquito and Virus Surveillance as a Predictor of Human Ross River Virus Infection in South-West Western Australia: How Useful Is It?
Available online: 04 September 2018More LessMosquito and virus surveillance systems are widely used in Western Australia (WA) to support public health efforts to reduce mosquito-borne disease. However, these programs are costly to maintain on a long-term basis. Therefore, we aimed to assess the validity of mosquito numbers and Ross River virus (RRV) isolates from surveillance trap sites as predictors of human RRV cases in south-west WA between 2003 and 2014. Using negative binomial regression modeling, mosquito surveillance was found to be a useful tool for predicting human RRV cases. In eight of the nine traps, when adjusted for season, there was an increased risk of RRV cases associated with elevated mosquito numbers detected 1 month before the onset of human cases for at least one quartile compared with the reference group. The most predictive urban trap sites were located near saltmarsh mosquito habitat, bushland that could sustain macropods and densely populated residential suburbs. This convergence of environments could allow enzootic transmission of RRV to spillover and infect the human population. Close proximity of urban trap sites to each other suggested these sites could be reduced. Ross River virus isolates were infrequent at some trap sites, so ceasing RRV isolation from mosquitoes at these sites or where isolates were not predictive of human cases could be considered. In future, trap sites could be reduced for routine surveillance, allowing other environments to be monitored to broaden the understanding of RRV ecology in the region. A more cost-effective and efficient surveillance program may result from these modifications.
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Migration Medicine: Notes on a Young Science †
Available online: 04 September 2018More LessMigration Medicine: Notes on a Young Science†
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Health-Care Facility Water, Sanitation, and Health-Care Waste Management Basic Service Levels in Bangladesh: Results from a Nation-Wide Survey
Available online: 27 August 2018More LessWe conducted a nationally representative cross-sectional study of 875 health-care facilities (HCFs) to determine water, sanitation, and health-care waste disposal service levels in Bangladesh for doctors, staff, and patients/caregivers in 2013. We calculated proportions and prevalence ratios to compare urban versus rural and government versus other HCFs. We report WHO-defined basic HCF service levels. The most common HCF was nongovernmental private (80%, 698/875), with an average of 25 beds and 12 admissions per day. There was an improved water source inside the HCF for doctors (79%, 95% confidence intervals [CI]: 75, 82), staff (59%, 95% CI: 55, 64), and patients/caregivers (59%, 95% CI: 55, 63). Improved toilets for doctors (81%, 95% CI: 78, 85) and other staff (73%, 95% CI: 70, 77) were more common than for patients/caregivers (54%, 95% CI: 50, 58). Forty-three percentage (434/875) of HCFs had no disposal method for health-care waste. More urban than rural and more government than other HCFs had an improved water source on the premises and improved toilets for staff. WHO-defined basic service levels were detected in > 90% of HCFs for drinking water, among 46–77% for sanitation, and 68% for handwashing at point of care but 26% near toilets. Forty-seven percentage of HCFs attained basic health-care waste management service levels. Patient/caregiver access to water, sanitation, and hygiene facilities is inadequate in many HCFs across Bangladesh. Improving facilities for this group should be an integral part of accreditation.
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Triatoma vitticeps (Stal, 1859) (Hemiptera, Triatominae): A Chagas Disease Vector or a Complex of Vectors?
Available online: 20 August 2018More LessTriatoma vitticeps is a Chagas disease vector that was found infected with Trypanosoma cruzi in homes. As this species is endemic from Brazil (Bahia, Espírito Santo, Minas Gerais, and Rio de Janeiro) and no study comparing the specimens from different Brazilian states was conducted, we analyzed the genetic distance (16S rDNA, Cyt b, and COI mitochondrial genes) and the chromosomal characteristics for T. vitticeps from Minas Gerais, Rio de Janeiro, and Espírito Santo. All specimens showed the same cytogenetic characteristics. On the other hand, the different mitochondrial genes demonstrated high intraspecific variation between the genetic distances of T. vitticeps from different states ranging from 2.3% to 7.2%. Based on this, our results suggest that possibly what is characterized as T. vitticeps is a complex of cryptic species (or subspecies).
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Serial Measurements of Soap Weights and Soap Availability to Describe Handwashing Behavior
Available online: 20 August 2018More LessAvailable measures of handwashing are prone to bias. We tested the feasibility and reliability of weighing soap at repeated visits and subtracting the measured weight from the prior weight to assess daily per capita soap consumption in a low-income community in Dhaka, Bangladesh. Fieldworkers approached 220 households twice weekly over 2 months. They interviewed participants, weighed soap, and assessed hand cleanliness and the presence of a handwashing station. Respondents used bar soap (91% [201]) and laundry detergent cakes (39% [85]) for handwashing as well as for bathing and laundry. Ninety-eight percentage of households had bar soap present on at least one visit, although only 50% had bar soap at every visit during the 2-month period. Fieldworkers observed a soap fragment on the wall near the latrine in 27% (470) of visits. Households consumed a mean 1.5 g of bar soap and 3.2 g detergent cake per person per day. Daily per capita soap consumption was similar in households visited by fieldworkers after different intervals (2, 3, 4, or 5 days). Soap consumption was not associated with household wealth, education of the household head, the presence of a handwashing station, the presence of water or soap at a handwashing station, or palm inspections of the mother or child. Soap weight measurements were an objective, reliable measure of soap consumption that provided different information from other handwashing indicators. The frequent use of a soap product for purposes other than handwashing complicates using soap consumption as a handwashing measure.
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Understanding the Liver-Stage Biology of Malaria Parasites: Insights to Enable and Accelerate the Development of a Highly Efficacious Vaccine
Available online: 20 August 2018More LessIn August 2017, the National Institute of Allergy and Infectious Diseases convened a meeting, entitled “Understanding the Liver-Stage Biology of Malaria Parasites to Enable and Accelerate the Development of a Highly Efficacious Vaccine,” to discuss the needs and strategies to develop a highly efficacious, whole organism–based vaccine targeting the liver stage of malaria parasites. It was concluded that attenuated sporozoite platforms have proven to be promising approaches, and that late-arresting sporozoites could potentially offer greater vaccine performance than early-arresting sporozoites against malaria. New knowledge and emerging technologies have made the development of late-arresting sporozoites feasible. Highly integrated approaches involving liver-stage research, “omics” studies, and cutting-edge genetic editing technologies, combined with in vitro culture systems or unique animal models, are needed to accelerate the discovery of candidates for a late-arresting, genetically attenuated parasite vaccine.
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Usability Testing of a Reusable Pulse Oximeter Probe Developed for Health-Care Workers Caring for Children < 5 Years Old in Low-Resource Settings
Available online: 20 August 2018More LessHypoxemia measured by pulse oximetry predicts child pneumonia mortality in low-resource settings (LRS). Existing pediatric oximeter probes are prohibitively expensive and/or difficult to use, limiting LRS implementation. Using a human-centered design, we developed a low-cost, reusable pediatric oximeter probe for LRS health-care workers (HCWs). Here, we report probe usability testing. Fifty-one HCWs from Malawi, Bangladesh, and the United Kingdom participated, and seven experts provided reference measurements. Health-care workers and experts measured the oxygen saturation (SpO2) independently in < 5 year olds. Health-care worker measurements were classed as successful if recorded in 5 minutes (or shorter) and physiologically appropriate for the child, using expert measurements as the reference. All expert measurements were considered successful if obtained in < 5 minutes. We analyzed the proportion of successful SpO2 measurements obtained in < 1, < 2, and < 5 minutes and used multivariable logistic regression to predict < 1 minute successful measurements. We conducted four testing rounds with probe modifications between rounds, and obtained 1,307 SpO2 readings. Overall, 67% (876) of measurements were successful and achieved in < 1 minute, 81% (1,059) < 2 minutes, and 90% (1,181) < 5 minutes. Versus neonates, increasing age (infant adjusted odds ratio [aOR]; 1.87, 95% confidence interval [CI]: 1.16, 3.02; toddler aOR: 4.33, 95% CI: 2.36, 7.97; child aOR; 3.90, 95% CI: 1.73, 8.81) and being asleep versus being calm (aOR; 3.53, 95% CI: 1.89, 6.58), were associated with < 1 minute successful measurements. In conclusion, we designed a novel, reusable pediatric oximetry probe that was effectively used by LRS HCWs on children. This probe may be suitable for LRS implementation.
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Monitoring and Predicting Net Longevity by Measuring Surface Levels of Insecticide: Implementing a Faster, Cost Effective, Nondestructive, and Field-Ready Alternative to the World Health Organization Cone Test Bioassay
Available online: 20 August 2018More LessAn important component of malaria control programs is the ability to assess the effectiveness of the insecticide in insecticide-treated nets (ITNs) during normal usage. The standard technique to measure insecticidal activity is the World Health Organization (WHO) cone test, which in many circumstances, may be difficult to implement. We have evaluated an alternative technique, the colorimetric field test (CFT) on a group of 24-month-old Permanet® 2.0 nets collected in Colombia. The CFT, which measures surface levels (SL) of deltamethrin is compared with standard high-performance liquid chromatography (HPLC) and the WHO cone test. Effective concentrations of deltamethrin for 80% mortality (EC80) were determined from the CFT and HPLC results. Distribution of insecticide SL after 24 months of use reveal that sampling of the midsection best represents the condition of the entire net. We conclude that the CFT is a practical alternative to the WHO cone test for assessing ITN efficacy.
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A Large Leptospirosis Outbreak following Successive Severe Floods in Fiji, 2012
Available online: 20 August 2018More LessSevere flooding has been linked to outbreaks of leptospirosis. Two sequential extreme flood events in Western Fiji caused the largest outbreak of leptospirosis recorded in the South Pacific, with 1,217 total suspected cases, of which 314 were probable and confirmed. Most (83%) cases occurred within 6 weeks of the flood events, displaying a biphasic epidemic curve associated with the floods. Given the temporal proximity of cases to flooding events, most of the transmission appeared to occur during or immediately after the floods; therefore, prevention of exposure to contaminated environments is a priority in the immediate flood and post-flood period. In addition, genotyping studies suggest that multiple animal reservoirs were implicated in the outbreak, reaffirming the importance of integrated human and animal health strategies for leptospirosis control.
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Ultrasound Evolution of Pediatric Urinary Schistosomiasis after Treatment with Praziquantel in a Highly Endemic Area
Available online: 20 August 2018More LessUrinary schistosomiasis causes damage to the urological system. Ultrasound is a method that detects the burden of secondary disease, individually and in epidemiological studies. In this study, the Schistosoma haematobium–associated urinary tract pathology is analyzed before and after treatment in a short period of time. Seventy children who had previously participated in an epidemiological study on schistosomiasis in the city of Cubal, Angola, and had also performed urinary ultrasound between August 2013 and February 2014 were cited 6–8 months later to assess the possible reinfection and repeat new urinary ultrasound, analyzing changes at the level of urinary pathology. The presence of hematuria and proteinuria was also analyzed. Of the 70 children analyzed, 29 (41.4%) were girls, with an average age of 10.4 years (SD 2.3). Fifty-three (75.7%) had an improvement in their bladder and/or kidney scores, whereas 12 (17.1%) had no change and five (7.1%) had progression of the disease. None of the parameters analyzed completely disappeared. After one single course of treatment with praziquantel, all the analyzed parameters showed regression. Improvement was greater in the urinary bladder than in the upper urinary tract, though these lesions also reversed; the reversion of all parameters was greater among children older than 10 years old than the younger ones. Proteinuria was the parameter with a smaller reduction. Ultrasound should be a usual tool for diagnosis and follow-up in urinary schistosomiasis, particularly in children; more accurate recommendations about follow-up in the case of children whose lesions do not reverse should be established.
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A Retrospective Case–Control Study to Evaluate the Diagnostic Accuracy of Honeycomb Sign in Melioid Liver Abscess
Available online: 20 August 2018More LessAmong pyogenic liver abscesses, melioid etiology is considered in endemic regions in the presence of known health or occupational risk factors. “Honeycomb sign,” used to describe an abscess with multiple internal septations dividing the abscess cavity into multiple loculations of comparable sizes on imaging, is a sensitive sign for melioid liver abscess. This is a retrospective case–control study investigating incidence, sensitivity, and specificity of “honeycomb sign” in melioid liver abscess, in a cohort of patients with culture-proven melioidosis infection. Abscesses ≥ 2 cm were analyzed for the honeycomb sign. P value < 0.05 was taken as statistically significant. Interobserver agreement was calculated between two radiologists for the presence of the sign, sensitivity, and specificity. A total of 40 abscesses were analyzed. Thirty-four abscesses (85%) manifested the honeycomb sign with interobserver agreement (kappa = 0.70 and 0.92). Sensitivity of the sign is 85% (95% CI: 70–94%), specificity is 75% (95% CI: 59–87%), positive predictive value is 77% (95% CI: 62–88%), and negative predictive value is 83% (95% CI: 67–94%). If abscess size is ≥ 3 cm, the sensitivity is 91% (95% CI: 77–98%), specificity is 75% (95% CI: 59–87%), positive predictive value is 76% (95% CI: 61–88%), and negative predictive value is 91% (95% CI: 76–98%). Honeycomb sign is a novel imaging marker for melioid liver abscess. Increased awareness and recognition of this imaging feature has the potential to affect patient management.
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Multiple Novel Mutations in Plasmodium falciparum Chloroquine Resistance Transporter Gene during Implementation of Artemisinin Combination Therapy in Thailand
Available online: 20 August 2018More LessMutations in the chloroquine resistance transporter gene of Plasmodium falciparum (Pfcrt) are associated with drug susceptibility status of chloroquine and other antimalarials that interfere with heme detoxification process including artemisinin. We aim to investigate whether an increase in duration of artemisinin combination therapy (ACT) in Thailand could affect mutations in Pfcrt. The complete coding sequences of Pfcrt and dihydrofolate reductase (Pfdhfr), and size polymorphisms of the merozoite surface proteins-1 and 2 (Pfmsp-1 and Pfmsp-2) of 189 P. falciparum isolates collected during 1991 and 2016 were analyzed. In total, 12 novel amino acid substitutions and 13 novel PfCRT haplotypes were identified. The most prevalent haplotype belonged to the Dd2 sequence and no wild type was found. A significant positive correlation between the frequency of Pfcrt mutants and the year of sample collection was observed during nationwide ACT implementation (r = 0.780; P = 0.038). The number of haplotypes and nucleotide diversity of isolates collected during 3-day ACT (2009–2016) significantly outnumbered those collected before this treatment regimen. Positive Darwinian selection occurred in the transmembrane domains only among isolates collected during 3-day ACT but not among those collected before this period. No remarkable change was observed in the molecular indices for other loci analyzed when similar comparisons were performed. An increase in the duration of artesunate in combination therapy in Thailand could exert selective pressure on the Pfcrt locus, resulting in emergence of novel variants. The impact of these novel haplotypes on antimalarial susceptibilities requires further study.
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Rapid Epidemiological and Entomological Survey for Validation of Reported Indicators and Characterization of Local Malaria Transmission in Guinea, 2017
Available online: 20 August 2018More LessTo confirm and investigate possible explanations for unusual trends in malaria indicators, a protocol for rapid, focal assessment of malaria transmission, and control interventions was piloted in N’Zérékoré and Macenta Prefectures, which each reported surprisingly low incidence of malaria during the peak transmission months during 2017 in holoendemic Forested Guinea. In each prefecture, epidemiological, and entomological cross-sectional surveys were conducted in two sub-prefectures reporting high incidence and one sub-prefecture reporting low incidence. Investigators visited six health facilities and 356 households, tested 476 children, performed 14 larval breeding site transects, and conducted 12 nights of human landing catches during the 2-week investigation. Rapid diagnostic test positivity in the community sample of children under five ranged from 23% to 68% by subprefecture. Only 38% of persons with fever reported seeking care in the public health sector; underutilization was confirmed by verification of health facility and community healthcare worker (CHW) registries. High numbers of Anopheles mosquitoes were collected in human landing collections in N’Zérékoré (38 per night in combined indoor and outdoor collections) and Macenta (87). Most of the detected breeding sites positive for Anopheles larvae (83%) were shallow roadside puddles. In the investigated prefectures, malaria rates remain high and the low reported incidence likely reflects low utilization of the public health-care sector. Strengthening the CHW program to rapidly identify and treat malaria cases and elimination of roadside puddles as part of routine cleanup campaigns should be considered. Systematic joint epidemiological/entomological investigations in areas reporting anomalous signals in routine data can allow control programs to respond with tailored local interventions.
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Case Report: Ocular Gnathostomiasis in Venezuela Most Likely Acquired in Texas
Available online: 20 August 2018More LessA 69-year-old male dentist in Caracas, Venezuela, was referred to our Cornea Clinic with a history of pain, photophobia, and blurred vision on his left eye. Routine biomicroscopic examination with a slit lamp showed a worm in the corneal stroma of his left eye. The worm was surgically removed and was identified morphologically as Gnathostoma binucleatum.
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Editorial
Available online: 20 August 2018More LessAlthough albendazole has been available for human use since 1982 and used for echinococcosis since the mid-1980s, for the most part, it is only approved for the treatment of intestinal helminth diseases as a single dose. Thus, in most countries, the only available presentation is a single 400-mg tablet or two 200-mg tablets. Albendazole is, however, a recommended treatment for several parasitic diseases for which multiple doses are required, and thus, it is often necessary to provide medication in a nonstandard manner. Furthermore, where a multiple dose presentation is available, the approved labeling does not align with the currently recommended long-term regimens. This poses significant challenges for those wishing to treat their patients for echinococcosis.
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Genetic Differentiation of Glossina pallidipes Tsetse Flies in Southern Kenya
Available online: 13 August 2018More LessThe tsetse fly Glossina pallidipes, the major vector of the parasite that causes animal African trypanosomiasis in Kenya, has been subject to intense control measures with only limited success. The G. pallidipes population dynamics and dispersal patterns that underlie limited success in vector control campaigns remain unresolved, and knowledge on genetic connectivity can provide insights, and thereby improve control and monitoring efforts. We therefore investigated the population structure and estimated migration and demographic parameters in G. pallidipes using genotypic data from 11 microsatellite loci scored in 250 tsetse flies collected from eight localities in Kenya. Clustering analysis identified two genetically distinct eastern and western clusters (mean between-cluster F ST = 0.202) separated by the Great Rift Valley. We also found evidence of admixture and migration between the eastern and western clusters, isolation by distance, and a widespread signal of inbreeding. We detected differences in population dynamics and dispersal patterns between the western and eastern clusters. These included lower genetic diversity (allelic richness; 7.48 versus 10.99), higher relatedness (percent related individuals; 21.4% versus 9.1%), and greater genetic differentiation (mean within-cluster F ST; 0.183 versus 0.018) in the western than the eastern cluster. Findings are consistent with the presence of smaller, less well-connected populations in Western relative to eastern Kenya. These data suggest that recent anthropogenic influences such as land use changes and vector control programs have influenced population dynamics in G. pallidipes in Kenya, and that vector control efforts should include some region-specific strategies to effectively control this disease vector.
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Effect of a School-Based Hygiene Behavior Change Campaign on Handwashing with Soap in Bihar, India: Cluster-Randomized Trial
Available online: 13 August 2018More LessChanging hand hygiene behavior at scale in the community remains a challenge. The objective of this study was to estimate the effect of Unilever’s school-based “School of 5” handwashing campaign on handwashing with soap (HWWS) in schoolchildren and their mothers in the Indian state of Bihar. We conducted a cluster-randomized trial in two districts. We randomized a total of 32 villages with at least one eligible school to intervention and control groups (1:1) and recruited 338 households in each group for outcome measurement. We used structured observation in households to measure HWWS at target occasions (after defecation, soap use during bathing, and before each main meal) in schoolchildren and their mothers. Observers were blinded to intervention status. We observed 636 target occasions (297 in the intervention arm and 339 in the control arm) in mothers and school-going children. After the intervention, HWWS prevalence at target occasions was 22.4% in the control arm and 26.6% in the intervention arm (prevalence difference +4.4%, 95% confidence interval: −4.0, 12.8). The difference was similar in children and mothers. Observers appeared to be adequately blinded to intervention status, whereas observed households were successfully kept unaware of the purpose of observations. To conclude, we found no evidence for a health-relevant effect of the School of 5 intervention on HWWS in schoolchildren and their mothers. Qualitative research suggested that reasons for the low impact of the intervention included low campaign intensity, ineffective delivery, and a model possibly not well tailored to these challenging physical and social environments.
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Recurrent Anthrax Outbreaks in Humans, Livestock, and Wildlife in the Same Locality, Kenya, 2014–2017
Available online: 13 August 2018More LessEpidemiologic data indicate a global distribution of anthrax outbreaks associated with certain ecosystems that promote survival and viability of Bacillus anthracis spores. Here, we characterized three anthrax outbreaks involving humans, livestock, and wildlife that occurred in the same locality in Kenya between 2014 and 2017. Clinical and epidemiologic data on the outbreaks were collected using active case finding and review of human, livestock, and wildlife health records. Information on temporal and spatial distribution of prior outbreaks in the area was collected using participatory epidemiology. The 2014–2017 outbreaks in Nakuru West subcounty affected 15 of 71 people who had contact with infected cattle (attack rate = 21.1%), including seven with gastrointestinal, six with cutaneous, and two with oropharyngeal forms of the disease. Two (13.3%) gastrointestinal human anthrax cases died. No human cases were associated with infected wildlife. Of the 54 cattle owned in 11 households affected, 20 died (attack rate = 37%). The 2015 outbreak resulted in death of 10.5% of the affected herbivorous wildlife at Lake Nakuru National Park, including 745 of 4,500 African buffaloes (species-specific mortality rate = 17%) and three of 18 endangered white rhinos (species-specific mortality rate = 16%). The species mortality rate ranged from 1% to 5% for the other affected wildlife species. Participatory epidemiology identified prior outbreaks between 1973 and 2011 in the same area. The frequency and severity of outbreaks in this area suggests that it is an anthrax hotspot ideal for investigating risk factors associated with long-term survival of anthrax spores and outbreak occurrence.
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Molecular Detection of Residual Parasitemia after Pyronaridine–Artesunate or Artemether–Lumefantrine Treatment of Uncomplicated Plasmodium falciparum Malaria in Kenyan Children
Available online: 13 August 2018More LessArtemisinin resistance is rapidly rising in Southeast Asia and may spread to African countries, where efficacy estimates are currently still excellent. Extensive monitoring of parasite clearance dynamics after treatment is needed to determine whether responsiveness to artemisinin-based combination therapies (ACT) is changing in Africa. In this study, Kenyan children with uncomplicated falciparum malaria were randomly assigned to pyronaridine–artesunate (PA) or artemether–lumefantrine (AL) treatment. Parasite clearance was evaluated over 7 days following the start of treatment by qPCR and direct-on-blood PCR nucleic acid lateral flow immunoassay (db-PCR-NALFIA), a simplified molecular malaria diagnostic. Residual parasitemia at day 7 was detected by qPCR in 37.1% (26/70) of AL-treated children and in 46.1% (35/76) of PA-treated participants (P = 0.275). Direct-on-blood PCR nucleic acid lateral flow immunoassay detected residual parasites at day 7 in 33.3% (23/69) and 30.3% (23/76) of AL and PA-treated participants, respectively (P = 0.692). qPCR-determined parasitemia at day 7 was associated with increased prevalence and density of gametocytes at baseline (P = 0.014 and P = 0.003, for prevalence and density, respectively) and during follow-up (P = 0.007 and P = 0.011, respectively, at day 7). A positive db-PCR-NALFIA outcome at day 7 was associated with treatment failure (odds ratio [OR]: 3.410, 95% confidence interval [CI]: 1.513–7.689, P = 0.003), but this association was not found for qPCR (OR: 0.701, 95% CI: 0.312–1.578, P = 0.391). Both qPCR and db-PCR-NALFIA detected substantial residual submicroscopic parasitemia after microscopically successful PA and AL treatment and can be useful tools to monitor parasite clearance. To predict treatment outcome, db-PCR-NALFIA may be more suitable than qPCR.
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Chromobacterium violaceum in Northern Australia: A Sheep in Wolf’s Clothing?
Available online: 13 August 2018More LessIn many parts of the world, the case-fatality rate of Chromobacterium violaceum infection approaches 60%. To evaluate the spectrum of disease associated with C. violaceum in Far North Queensland (FNQ), Australia, we reviewed all culture-confirmed isolates from 1997 to 2017. There were 28 isolates, 15 represented infection, 11 were contaminants, and two charts were destroyed preventing detailed evaluation of these cases. The most common sites of infection were the skin and soft tissue and the urinary tract; there were two cases of bacteremia without focus. There were no deaths attributable to C. violaceum during the study period and only two cases required intensive care unit support, although in both patients this was not for the C. violaceum infection, but for the management of other health issues. Globally, C. violaceum has a reputation as a deadly pathogen, but in FNQ, Australia, infections usually follow a relatively benign course.
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Performance Evaluation of Gravity-Fed Water Treatment Systems in Rural Honduras: Verifying Robust Reduction of Turbidity and Escherichia coli during Wet and Dry Weather
Available online: 06 August 2018More LessThis is the first study to document the reduction of turbidity and Escherichia coli throughout the processes of full-scale gravity-fed drinking water plants (GFWTPs) and their downstream distribution systems in rural Honduras. The GFWTPs, which in these cases were designed by AguaClara, use standard treatment processes: coagulation, sedimentation, filtration, and chlorination. During the dry season, we measured E. coli, turbidity, and chlorine residual at five GFWTPs with < 1,000 connections and at three alternative piped-water systems in neighboring communities. Samples were evaluated from the raw water, settled water, filtered water, post-chlorination in the distribution tank, and at a distant-piped household connection. During the dry season, the treated water and household connections serviced by the GFWTPs met World Health Organization (WHO) recommendations for E. coli (< 1 most probable number [MPN]/100 mL). Alternative plants with the same water sources had comparable or higher E. coli and turbidity measurements posttreatment. We examined performance robustness of two GFWTPs during the transition into the rainy season. The turbidity of the filtered water met WHO recommendations (< 1 nephelometric turbidity units). Escherichia coli was not detected in treated water, indicating that the two GFWTPs can consistently remove particulates and E. coli from source waters containing varying levels of turbidity. During two sampling events during the rainy season, E. coli was detected at the household connection of a GFWTP system with intermittent service and a substandard chlorine residual (geometric mean = 1.0 MPN/100 mL). Strategies to avoid contamination or inactivate E. coli in the distribution system are needed to ensure safe drinking water at the points of delivery, especially for systems with intermittent service.
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Bartonella rochalimae Detection by a Sensitive and Specific PCR Platform
Available online: 06 August 2018More LessBartonella rochalimae is an emerging zoonotic pathogen present in the United States, South America, and Europe. The molecular detection of B. rochalimae frequently relies on PCR assays that target the genus Bartonella coupled with DNA sequencing for species determination. However, the presence of other Bartonella spp. in the sample being tested may result in false-negative results for B. rochalimae, especially when Sanger sequencing is used. We developed a sensitive and specific quantitative PCR platform for B. rochalimae by targeting the intergenic transcribed spacer, gltA, and rpoB genes, which are recommended for subtyping characterization. This PCR platform achieved the limit of detection between five and 10 genomic equivalents per reaction and did not amplify DNA from other Bartonella species or selected hosts. This PCR platform is a fast and cost-effective option to be used in epidemiological evaluations of reservoirs and vectors and in detecting and quantifying B. rochalimae infection in humans.
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Water, Sanitation, and Hygiene Characteristics among HIV-Positive Households Participating in the Global Enterics Multicenter Study in Rural Western Kenya, 2008–2012
Available online: 06 August 2018More LessDiarrheal illness, a common occurrence among people living with HIV (PLHIV), is largely preventable through access to safe drinking water, sanitation, and hygiene (WASH) facilities. We examined WASH characteristics among households with and without HIV-positive residents enrolled in the Global Enteric Multicenter Study (GEMS) in rural Western Kenya. Using univariable logistic regression, we examined differences between HIV-positive and HIV-negative households in regard to WASH practices. Among HIV-positive households, we explored the relationship between the length of time knowing their HIV status and GEMS enrollment. No statistically significant differences were apparent in the WASH characteristics among HIV-positive and HIV-negative households. However, we found differences in the WASH characteristics among HIV-positive households who were aware of their HIV status ≥ 30 days before enrollment compared with HIV-positive households who found out their status < 30 days before enrollment or thereafter. Significantly more households aware of their HIV-positive status before enrollment reported treating their drinking water (odds ratio [OR] confidence interval [CI]: 2.34 [1.12, 4.86]) and using effective water treatment methods (OR [CI]: 9.6 [3.09, 29.86]), and had better drinking water storage practices. This suggests that within this region of Kenya, HIV programs are effective in promoting the importance of practicing positive WASH-related behaviors among PLHIV.
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Antigen Detection in Urine for Noninvasive Diagnosis and Treatment Monitoring of Visceral Leishmaniasis in Human Immunodeficiency Virus Coinfected Patients: An Exploratory Analysis from Ethiopia
Available online: 06 August 2018More LessDiagnosis of visceral leishmaniasis (VL) and assessment of treatment response in human immunodeficiency virus (HIV)–coinfected patients still relies on invasive tissue aspiration. This hampers scale-up and decentralization of care in resource-limited settings. Noninvasive diagnostics are urgently needed. KATEX is a frequently used latex agglutination test for Leishmania antigen in urine that has never been evaluated in HIV-coinfected individuals from Leishmania donovani–endemic areas. This was an exploratory sub-study embedded within the screening phase of a trial in highly endemic northwestern Ethiopia. All patients were HIV-positive and aspirate-confirmed VL cases. We assessed diagnostic accuracy of KATEX for VL diagnosis and as test of cure at end of treatment, using tissue aspirate parasite load as reference methods. We also described the evolution of weekly antigen levels during treatment. Most of the 87 included patients were male (84, 97%), young (median age 31 years), and had poor immune status (median cluster of differentiation type 4 count 56 cells/μL). KATEX had moderate sensitivity (84%) for VL diagnosis. KATEX had moderate sensitivity (82%) and a moderate negative predictive value (87%) but only low specificity (49%) and a low positive predictive value (40%) for the assessment of treatment outcomes. Weekly antigen levels showed characteristic patterns during treatment of patients with different initial parasite loads and treatment outcomes. Antigen detection in urine using KATEX can contribute to improved VL diagnosis in HIV-coinfected patients but has limited use for monitoring of treatment response. Better noninvasive diagnostics are needed to reduce reliance on invasive methods and thus to expand and improve clinical care for VL in resource-limited settings.
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A Serological Survey of Human Onchocerciasis in Yemen
Available online: 06 August 2018More LessYemen is a country that has been treating severe cases of oncho-dermatitis since 1992 and is now moving to a program aimed at the elimination of the transmission of Onchocerca volvulus. It is important to ensure that the currently acceptable tools used in epidemiological assessment of onchocerciasis in Africa and Latin America also apply to Yemen. Five hundred and ten blood samples from three known O. volvulus–endemic areas, locations that have never been under a mass treatment program, were tested for the presence of antibodies against a panel of O. volvulus–specific antigens using enzyme-linked immunosorbent assay (Ov16) and luciferase immunoprecipitation system (OvFAR-1 and Ov-MSA1) assays. Overall, 31.4% of the samples tested were positive, with positivity increasing with age. Positivity was seen in 76.5% of those presenting with clinical onchocerciasis but importantly also in more than 28.5% of those defined as free of oncho-dermatitis; these latter individuals are likely to be serving as a source for persistent reinfection. This study supports the use of the current O. volvulus–specific serologic methodology in Yemen.
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Drinking Water Safety: Role of Hand Hygiene, Sanitation Facility, and Water System in Semi-Urban Areas of India
Available online: 30 July 2018More LessPoor drinking water quality is one of the main causes of acute diarrheal disease in developing countries. The study investigated the relationship between fecal contamination of hands, stored drinking water, and source waters in India. We further evaluated the environmental and behavioral factors associated with recontamination of water between collection and consumption. The bacterial contamination, that is, Escherichia coli (log10 most probable number per two hands), found on mothers’ hands (mean = 1.11, standard deviation [SD] = 1.2, N = 152) was substantially higher than that on their children younger than 5 years (mean = 0.64, SD = 1.0, and N = 152). We found a low level of E. coli (< 1 per 100 mL) in the source water samples; however, E. coli contamination in stored drinking water was above the recommended guidelines of the World Health Organization. The study also found that E. coli on hands was significantly associated with E. coli in the stored drinking water (P < 0.001). Moreover, E. coli was positively associated with gastrointestinal symptoms (odds ratio 1.42, P < 0.05). In the households with elevated levels (> 100 E. coli/100 mL) of fecal contamination, we found that 43.5% had unimproved sanitation facilities, poor water handling practices, and higher diarrheal incidences. The water quality deterioration from the source to the point of consumption is significant. This necessitates effective interventions in collection, transport, storage, and extraction practices when hand–water contact is likely to occur. These findings support the role of hands in the contamination of stored drinking water and suggest that clean source water does not guarantee safe water at the point of consumption.
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Case Report: Imported Case of Lassa Fever—New Jersey, May 2015
Prathit A. Kulkarni, Debra Chew, Manal Youssef-Bessler, Hanaa A. Hamdi, Lindsay A. Montoya, Kimberly B. Cervantes, Nicole L. Mazur, Diana Lucas, Julia W. Wells, David Cennimo, Anne Sutherland, Linda M. Di Domenico, Lincoln P. Miller, Frantz Pierre-Louis, Gregory Rokosz, Atif Nazir, Marie A. de Perio, Luis Lowe, Craig Manning, Kenneth R. Mead, Bryan E. Christensen, César G. Albariño, Ute Ströher, Maleeka Glover, Edward I. Lifshitz, Christina G. Tan, Pierre E. Rollin and Shereen SempleAvailable online: 30 July 2018More LessWe report a fatal case of Lassa fever diagnosed in the United States in a Liberian traveler. We describe infection control protocols and public health response. One contact at high risk became symptomatic, but her samples tested negative for Lassa virus; no secondary cases occurred among health care, family, and community contacts.
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Case Report: Typhoid Fever and Spotted Fever Group Rickettsiosis Presenting Concomitantly in an Indian Immigrant
Available online: 30 July 2018More LessWe present a rare case of an Indian immigrant suffering from concomitant infection of Salmonella typhi and spotted fever group Rickettsia. We discuss the scarce reports of dual infections from the developing world and the related diagnostic challenges.
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Social Influence on Handwashing with Soap: Results from a Cluster Randomized Controlled Trial in Bangladesh
Available online: 30 July 2018More LessWe analyzed data from a cluster-randomized controlled trial conducted among 20 schools in Rajshahi, Bangladesh, to explore the role of social influence on handwashing with soap (HWWS) in a primary school setting. Using data collected through covert video cameras outside of school latrines, we used robust Poisson regression analysis to assess the impact of social influence—defined as the presence of another person near the handwashing location—on HWWS after a toileting event. In adjusted analyses, we found a 30% increase in HWWS when someone was present, as compared with when a child was alone (Prevalence ratio 1.30 CI: 1.14–1.47, P < 0.001). The highest prevalence of HWWS was found when both child(ren) and adult(s) were present or when just children were present (64%). Our study supports the conclusion that the presence of another individual after a toileting event can positively impact HWWS in a primary school setting.
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Outbreak of Hepatitis E Virus Infection in Displaced Persons Camps in Diffa Region, Niger, 2017
Available online: 30 July 2018More LessHepatitis E virus (HEV) infection in developing countries is associated with poor hygiene, lack of clean drinking water, and inadequate sanitation. In this study, we report the first case investigation and describe the present situation of HEV outbreak within displaced persons camps in the Diffa region, Republic of the Niger. The investigation showed the outbreak to be closely linked to unclean water supply, low hygiene, and sanitation facility standards. Between January and September 2017, a total of 1,917 HEV suspect cases were recorded from which 736 (38.4%) have been confirmed positive for HEV by RT-PCR and ELISA. Overall, 38 (1.9%) deaths were recorded, including 17 (44.7%) pregnant women. The ongoing outbreak highlights poor drinking water quality and sanitation conditions in displaced persons camps in the Diffa region. Disease containment and patient care activities, particularly for pregnant women, may have resulted in decreased transmission of infection and deaths.
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Impact of Ivermectin Mass Drug Administration for Lymphatic Filariasis on Scabies in Eight Villages in Kongwa District, Tanzania
Available online: 30 July 2018More LessScabies was recently added to the World Health Organization list of neglected tropical diseases. The ability to treat scabies with oral ivermectin makes a mass drug administration (MDA) campaign a feasible option for scabies control. Ivermectin MDA in communities endemic for lymphatic filariasis (LF) or onchocerciasis may already be having an impact on scabies. We examined the effect of ivermectin MDA for LF on scabies prevalence over 4 years in eight Tanzanian villages. At baseline, 4.4% (95% confidence interval [CI]: 3.7–5.4) of individuals tested positive for scabies, decreasing to 0.84% (95% CI: 0.51–1.4) after one round of ivermectin MDA but increased in Year 3 (2.5% [95% CI: 1.9–3.3]) and Year 4 (2.9% [95% CI: 2.2–3.8]). Most scabies cases were seen in children younger than 15 years. The data suggest that single-dose ivermectin MDA may not be effective in attaining long-term decreases when scabies prevalence is less than 5%.
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Platelet Transfusion Related Panophthalmitis and Endophthalmitis in Patients with Dengue Hemorrhagic Fever
Available online: 30 July 2018More LessDengue is a vector-borne viral illness of major public health importance. It is endemic in many parts of India and also causes frequent epidemics. Platelet transfusions are given in severe cases of dengue fever to treat and prevent hemorrhagic complications. Here, we report three patients in North India with development of panophthalmitis and endophthalmitis shortly after receiving platelet transfusion.
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Evaluation of an OV-16 IgG4 Enzyme-Linked Immunosorbent Assay in Humans and Its Application to Determine the Dynamics of Antibody Responses in a Non-Human Primate Model of Onchocerca volvulus Infection
Available online: 30 July 2018More LessOnchocerciasis is a neglected parasitic disease targeted for elimination. Current World Health Organization guidelines for elimination include monitoring antibody responses to the recombinant Onchocerca volvulus antigen OV-16 in children to demonstrate the absence of transmission. We report the performance characteristics of a modified OV-16 enzyme-linked immunosorbent assay (ELISA) and describe anti–OV-16 responses in serum samples from laboratory-inoculated nonhuman primates (NHPs) in relation to microfilariae (mf) in skin snip biopsies. This OV-16 IgG4 ELISA had sensitivity and specificity of 88.2% and 99.7%, respectively, as determined by receiver operator characteristic analysis using a serum panel of 110 positive and 287 negative samples from people infected with other filariae or other parasitic infections. Anti–OV-16 responses in inoculated NHP (N = 9) were evaluated at quarterly intervals for IgM and the four IgG subclasses. Enzyme-linked immunosorbent assay results showed a well-defined IgG4 reactivity pattern and moderate IgG1 antibody responses. Meanwhile, the reactivity by IgG2, IgG3, or IgM did not show a clear pattern. Temporal evolution of IgG4 reactivity was evaluated through monthly testing, showing that NHPs developed anti–OV-16 IgG4 on average at 15 months postinoculation (range: 10–18 months). The average time to detectable mf was also 15 months (range: 11–25). The OV-16 ELISA used in this study was robust and allowed the detection of IgG4 responses, which were observed only among animals with detectable mf (N = 5), four of which showed declines in antibody responses once mf cleared. These findings also confirmed that the most informative antibody subclass responses to OV-16 are IgG4.
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Imported and Autochthonous Cases of Myiasis Caused by Dermatobia hominis: Taxonomic Identification Using the Internal Transcribed Spacer Region
Available online: 30 July 2018More LessDermatobia hominis is a fly endemic to and widely distributed throughout the Americas; it is found from the southern regions of Mexico to Argentina. However, because of widespread travel, myiasis has become common in countries where neither the disease nor the species that cause this infection are endemic. Central Mexico, for instance, is not a region where myiasis is endemic. We, thus, describe three cases of D. hominis myiasis: two autochthonous cases from the southern part of Mexico and one imported from Costa Rica. In addition, morphological and genetic identification was performed on the maggots extracted from the patients.
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Who Stays and Who Goes: Predictors of Admission among Patients Presenting with Febrile Illness and a Positive Malaria Rapid Diagnostic Test in a Rural Ugandan Health Center
Available online: 30 July 2018More LessNot much is known about clinical decision-making in rural, low-resource settings regarding fever, a common reason for presentation to care. In this prospective cohort study of patients presenting with febrile illness to a rural Ugandan health center, we examined demographic and clinical factors predictive of an initial disposition of inpatient admission after clinical evaluation, but before laboratory testing. We then assessed the association of laboratory results and system factors with a change between initial and final disposition plans. Four thousand nine hundred twenty-four patients with suspected febrile illness were included in the primary analysis. The strongest predictors for an initial disposition of admission after clinical examination were impaired consciousness (adjusted risk ratio [aRR], 3.21; 95% confidence interval [CI]: 2.44–4.21) and fever on examination (aRR, 2.27; 95% CI: 1.79–2.87). Providers initially planned to discharge patients with significant vital sign abnormalities, including tachypnea (3.6%) and hypotension (1.3%). Anemia strongly predicted a final disposition of admission after an initial disposition of discharge (aRR, 48.34; 95% CI: 24.22–96.49); other laboratory abnormalities, including hypoglycemia and acidosis, did not change disposition planning. In those with an initial disposition of admission, living farther than the two neighboring villages was associated with a final disposition of discharge (aRR, 2.12; 95% CI: 1.10–4.12). A concerning number of patients with abnormal vital signs and laboratory results were not admitted for inpatient care. Geographic factors may influence a patient’s final disposition contrary to a provider’s initial disposition plan. Future work should assess longer term outcomes after discharge and a broader study population.
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Quantitative Polymerase Chain Reaction for Diagnosis of Soil-Transmitted Helminth Infections: A Comparison with a Flotation-Based Technique and an Investigation of Variability in DNA Detection
Available online: 30 July 2018More LessAppropriate diagnostic techniques are crucial to global soil-transmitted helminth (STH) control efforts. The recommended Kato–Katz method has low sensitivity in low-transmission settings. Quantitative polymerase chain reaction (qPCR) is a highly sensitive alternative diagnostic option. However, little is known about the variability in qPCR results, and there are few published comparisons between qPCR and other microscopy-based techniques such as sodium nitrate flotation (SNF). Using 865 stool samples collected from 571 individuals, we compared SNF and qPCR in terms of diagnostic sensitivity and infection intensity measurements. In addition, we conducted repeated examinations on a single Necator americanus–positive stool sample over a 6-month period. Results showed good diagnostic agreement between SNF and qPCR for Ascaris spp. (κ = 0.69, P < 0.001), and moderate agreement for hookworm (κ = 0.55, P < 0.001) and Trichuris spp. (κ = 0.50, P < 0.001). Quantitative polymerase chain reaction demonstrated higher sensitivity than SNF for Ascaris spp. (94.1% versus 68.1%) and hookworm (75.7% versus 66.9%) but not for Trichuris spp. (53.1% versus 81.3%), which had very low prevalence. Sodium nitrate flotation and qPCR infection intensity measurements were strongly correlated for Ascaris spp. (ρ = 0.82, P < 0.001) and moderately correlated for hookworm (ρ = 0.58, P < 0.001). Repeated examinations using qPCR showed that N. americanus cycle threshold values decreased significantly at 1 month and remained stable thereafter. Results confirm the high diagnostic sensitivity of qPCR for Ascaris spp. and hookworm, particularly for light-intensity infections, which is ideal for settings approaching transmission elimination. Results support the potential for qPCR to be used as a quantitative assay for STH. Further research is needed in settings where Trichuris trichiura is endemic.
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Predicting Risk of Imported Disease with Demographics: Geospatial Analysis of Imported Malaria in Minnesota, 2010–2014
Available online: 30 July 2018More LessAlthough immigrants who visit friends and relatives (VFRs) account for most of the travel-acquired malaria cases in the United States, there is limited evidence on community-level risk factors and best practices for prevention appropriate for various VFR groups. Using 2010–2014 malaria case reports, sociodemographic census data, and health services data, we explored and mapped community-level characteristics to understand who is at risk and where imported malaria infections occur in Minnesota. We examined associations with malaria incidence using Poisson and negative binomial regression. Overall, mean incidence was 0.4 cases per 1,000 sub-Saharan African (SSA)–born in communities reporting malaria, with cases concentrated in two areas of Minneapolis–St. Paul. We found moderate and positive associations between imported malaria and counts of SSA- and Asian-born populations, respectively. Our findings may inform future studies to understand the knowledge, attitudes, and practices of VFR travelers and facilitate and focus intervention strategies to reduce imported malaria in the United States.
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Quality Assurance and Quality Control in the Global Trachoma Mapping Project
Anthony W. Solomon, Rebecca Willis, Alexandre L. Pavluck, Wondu Alemayehu, Ana Bakhtiari, Sarah Bovill, Brian K. Chu, Paul Courtright, Michael Dejene, Philip Downs, Rebecca M. Flueckiger, Danny Haddad, P. J. Hooper, Khumbo Kalua, Biruck Kebede, Amir Bedri Kello, Colin K. Macleod, Siobhain McCullagh, Tom Millar, Caleb Mpyet, Jeremiah Ngondi, Benjamin Nwobi, Nicholas Olobio, Uwazoeke Onyebuchi, Lisa A. Rotondo, Boubacar Sarr, Oumer Shafi, Oliver Sokana, Sheila K. West, Allen Foster and for the Global Trachoma Mapping ProjectAvailable online: 23 July 2018More LessIn collaboration with the health ministries that we serve and other partners, we set out to complete the multiple-country Global Trachoma Mapping Project. To maximize the accuracy and reliability of its outputs, we needed in-built, practical mechanisms for quality assurance and quality control. This article describes how those mechanisms were created and deployed. Using expert opinion, computer simulation, working groups, field trials, progressively accumulated in-project experience, and external evaluations, we developed 1) criteria for where and where not to undertake population-based prevalence surveys for trachoma; 2) three iterations of a standardized training and certification system for field teams; 3) a customized Android phone–based data collection app; 4) comprehensive support systems; and 5) a secure end-to-end pipeline for data upload, storage, cleaning by objective data managers, analysis, health ministry review and approval, and online display. We are now supporting peer-reviewed publication. Our experience shows that it is possible to quality control and quality assure prevalence surveys in such a way as to maximize comparability of prevalence estimates between countries and permit high-speed, high-fidelity data processing and storage, while protecting the interests of health ministries.
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Shortage of Albendazole and Its Consequences for Patients with Cystic Echinococcosis Treated at a Referral Center in Italy
Available online: 23 July 2018More LessAlbendazole (ABZ) is the best drug available to treat cystic echinococcosis (CE), a neglected tropical disease. Cystic echinococcosis patients often receive a continuous course of the drug for 6–12 months. In Italy, ABZ shortages occur almost on a yearly basis. We searched clinical records at the World Health Organization Collaborating Center for the Clinical Management of CE in Pavia, Italy, to estimate the amount of ABZ prescribed to patients between January 2012 and February 2017. The cost of ABZ was estimated at €2.25 per tablet based on the current market price in Italy. Patients to whom ABZ had been prescribed were contacted to determine if they had experienced difficulties in purchasing the drug and to assess how such problems affected their treatment. Of 348 identified CE patients, 127 (36.5%) were treated with ABZ for a total of 20,576 days. This led to an estimated cost of €92,592. Seventy-five patients were available for follow-up, 42 (56%) reported difficulties in obtaining ABZ. Of these patients, four (9.5%) had to search out of their region and 10 (23.8%) had to go out of the country. A total of 27 patients (64%) had to visit more than five pharmacies to locate the drug and 10 patients (23.8%) interrupted treatment because of ABZ nonavailability. Shortages in ABZ distribution can disrupt CE treatment schedules and jeopardize patient health.
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Genomic Investigation of a Mycobacterium tuberculosis Outbreak Involving Prison and Community Cases in Florida, United States
Available online: 09 July 2018More LessWe used whole-genome sequencing to investigate a tuberculosis outbreak involving U.S.-born persons in the prison system and both U.S.- and foreign-born persons in the community in Florida over a 7-year period (2009–2015). Genotyping by spacer oligonucleotide typing and 24-locus mycobacterial interspersed repetitive unit-variable number tandem repeat suggested that the outbreak might be clonal in origin. However, contact tracing could not link the two populations. Through a multidisciplinary approach, we showed that the cluster involved distinct bacterial transmission networks segregated by country of birth. The source strain is of foreign origin and circulated in the local Florida community for more than 20 years before introduction into the prison system. We also identified novel transmission links involving foreign and U.S.-born cases not discovered during contact investigation. Our data highlight the potential for spread of strains originating from outside the United States into U.S. “high-risk” populations (such as prisoners), with subsequent movement back to the general community.
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Molecular Identification of Onchocerca spp. Larvae in Simulium damnosum sensu lato Collected in Northern Uganda
Available online: 02 October 2017More LessPrevious studies have demonstrated that the presence of larvae of other filarial species in Simulium damnosum sensu lato can distort estimates of transmission potential for Onchocerca volvulus in West Africa. However, studies conducted in foci of onchocerciasis in West Central Uganda indicated that larvae other than O. volvulus were not common in vectors collected there. Recent data collected in Northern Uganda revealed a striking discordance between estimates of the prevalence of flies carrying O. volvulus infective larvae obtained from molecular pool screening and dissection methods. To resolve this discrepancy, sequences from three mitochondrially encoded genes were analyzed from the larvae collected by dissection. All larvae analyzed were Onchocerca ochengi v. Siisa, a parasite of cattle, or Onchocerca ramachandrini, a parasite of warthogs. These results suggest that nonhuman parasite larvae are common in vectors in Northern Uganda, underscoring the necessity for molecular identification methods to accurately estimate O. volvulus transmission.
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