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PRESENTACIÓN, VIA DE ADMINISTRACIÓN Y DOSIS
Background: Dengue is the most rapidly spreading mosquito borne viral disease in the world. The disease is caused by infection with one of four related viral subtype (DEN 1-4). The vector-borne disease is primarily transmitted by Aedes aegypti mosquitoes. It was estimated that there are 390 million persons infected by dengue per year. Dengue has been a public health problem in the Lao People’s Democratic Republic and the magnitude of the disease burden and Epidemiological trends remain poorly understood. Methods: We did the descriptive analysis on Epidemiology and Laboratory data reported within the
indicator-based National Surveillance System for Notifiable Selected Diseases that consists of passive weekly reports of clinically suspected cases, on admission, from all health care facilities across the countries. Specimens are transfer to NCLE on wet ice by bus or air for further laboratory diagnosis. Results: During 2006 to 2012, the annual dengue notification rate ranged between 62 and 367 cases per 100 000 population. The case fatality rate was 0.2% for all year except for 2008 when it was significantly higher at 0.5% (P < 0.01). The largest number of cases occurred among 10 to 20 year old (34%) with significantly more male (12 000 cases) than female (9119 cases, P < 0.01). Case report was highest from May/June to October/November with peak in late August or September. There was a lower proportion of laboratory confirmed dengue in 40 year old age group (33.9%, P < 0.01) compare to young age groups (43.4-51.6%). The number of provinces with notification rate ≥ 200 per 100 000 increased from one in 2006-2008 to five in 2009 and to 10 in 2010 (the first year that all provinces in the country reported dengue cases). All four serotypes were detected. Conclusions: There are many challenges to effective Dengue surveillance and response in Lao PDR. The dengue case reported indicate a gradually
expansion of geographic areas. Effort need to be focus on using available data to prompt more effective outbreak response to guide the design and implementation of intervention strategy
Board 238. NoroSTAT: Enhanced Norovirus Outbreak Surveillance Network
M. E. Wikswo1, L. Barclay1, T. DeSalvo2, T. Davis3, E. Salehi4, E. Brandt4, A. M. Saupe5, E. Cebelinski5,
K. Garman6, A. Woron6, K. Williamson7, C. Biggs7, J. Vinje1, A. J. Hall1; 1CDC, Atlanta, GA, USA, 2Wisconsin Dept. of Hlth. Services, Madison, WI, USA, 3Wisconsin State Lab. of Hygiene, Madison, WI,
USA, 4Ohio Dept. of Hlth., Columbus, OH, USA, 5Minnesota Dept. of Hlth., St. Paul, MN, USA, 6Tennessee Dept. of Hlth., Nashville, TN, USA, 7Oregon Publ. Hlth. Div., Portland, OR, USA
Background: The Norovirus Sentinel Testing and Tracking (NoroSTAT) network, launched August 2012, is a network of five state health departments and CDC working to establish and maintain standards for norovirus outbreak reporting to national surveillance systems. These standards aim to improve timeliness, completeness, and consistency of norovirus outbreak reporting and provide near real-time assessment of norovirus activity in the US. Methods: Participating health departments report specific epidemiologic and laboratory data on suspected or confirmed norovirus outbreaks to CDC within seven business days of notification. We summarized data from the first two years of NoroSTAT, August 1, 2012 through July 31, 2014. We evaluated the performance of NoroSTAT by comparing timeliness and completeness of reports from participating sites after and in the three years before the creation of the network. Results: During the first two years of NoroSTAT, 1391 norovirus outbreaks were reported. The most common primary mode of transmission was direct person-to-person contact, reported in 1022 (73%) outbreaks, followed by foodborne (n=190, 14%). The most common exposure setting was long-term care facilities (n=836, 60%). Other common settings included restaurants (n= 152, 11%) and schools (n=109, 8%). Median reporting lag decreased from 18 days in the three years before NoroSTAT to 2 days during NoroSTAT. A total of 1388 (99.8%) outbreak reports contained all required data elements, but only 945 (71%) of the 1322 outbreaks in the three years preceding NoroSTAT contain these data. Of the 751 (54%) outbreaks for
which genotype was reported, the most frequent were GII.4 Sydney (n=428, 57%) and GII.6 (n=48, 6%). The median time required for testing and genotype reporting decreased from 22 days to 3 days.
Conclusions: These data reaffirm that most norovirus outbreaks occur in long-term care facilities and are spread through direct person-to-person transmission. Norovirus outbreak reporting through NoroSTAT has improved both the completeness and timeliness of reports. This information can be used to quickly evaluate current norovirus outbreak activity, make comparisons to previous years, and assess strain- specific characteristics of norovirus outbreaks, including the impact of new strains on outbreak frequency and severity.
Board 239. Evaluation of Enhanced Surveillance Strategies for World Pride Celebration in Toronto, Canada
E. Gournis1,2, A. Arthur1, C. Fung3; 1Toronto Publ. Hlth., Toronto, ON, Canada, 2Dalla Lana Sch. of Publ.
Hlth., Univ. of Toronto, Toronto, ON, Canada, 3Publ. Hlth. Ontario, Toronto, ON, Canada
Background: In June 2014, Toronto, Canada hosted World Pride (WP), an international event that celebrates lesbian, gay, bisexual, and transgender communities through parades, festivals, and cultural events. WP involved a large number of international travelers and 2 million expected participants, increasing the likelihood of public health threats related to mass gatherings. Given the number of visitors and the increased attention to invasive meningococcal disease (IMD) among MSM weeks before the event, Toronto Public Health (TPH) developed and implemented an enhanced surveillance plan. The focus was on communicable diseases assessed to have a high probability of occurrence and/or high potential impact. This summarizes the evaluation of the enhanced surveillance plan for communicable disease threats during WP. Methods: The evaluation questions captured both outcomes and process: 1) How effective was the surveillance plan in early outbreak identification, and 2) Was the plan easy to implement and acceptable? The questions examined relevant attributes of a surveillance system as outlined in the CDC Guidelines for Evaluating a Public Health Surveillance System. A mix of qualitative and quantitative methods was used. Results/Outcomes: Potential events of interest were detected during the surveillance period, including 2 IMD cases, 3 reports of food poisoning linked to restaurants in the core area for WP events, and a cluster of shigellosis among MSM. None of these cases or clusters could be directly linked to WP or of any measureable consequence to WP participants. As such,
sensitivity and positive predictive value could not be assessed. Process: Users of the system deemed it useful, simple and flexible. The system however did not meet expectations for stability, as the emergency department syndromic data system experienced power issues and was down for the main WP weekend. Conclusions: The enhanced plan for this mass gathering in Toronto demonstrated current surveillance tools are useful and easy to adapt for special events. Areas to be strengthened included contingency planning for power outages or other obstacles to accessing key data sources. The information gained through this evaluation will be used to strengthen preparedness for the Pan/ParaPan American Games, to be hosted by Toronto in the summer of 2015.
Board 240. Hantavirus Fever Without Pulmonary Syndrome in Panama
B. Armien1, J. M. Pascale1, C. Muñoz2, J. Mariñas2, H. Nuñez3, M. Herrera3, J. Trujillo4, D. Sanchez2, B.
Hjelle5, F. Koster6; 1Inst. Conmemorativo Gorgas de Estudios de Salud, Panama, Panama, 2Ministerio de
Salud, Panama, Panama, 3Caja de Seguro Social, Panama, Panama, 4Hosp. Santo Tomas, Panama,
Panama, 5Univ. of New Mexico, Albuquerque, NM, USA, 6Lovelace Respiratory Res. Inst., Albuquerque,
NM, USA
Background: In Panama, hantavirus pulmonary syndrome (HPS) is caused by Choclo virus, a species phylogenetically related to Andes and Maporal viruses. Up to 60% of the population has been positive for specific serum antibody in community-based surveys, but mortality is very uncommon. Methods: In four western Panama clinics, we tested individuals presenting with a severe febrile prodrome for acute hantavirus (HV) infection by immunoglobulin M enzyme-linked immunosorbent assay and reverse transcription polymerase chain reaction as well as clinically similar infections, such as dengue and leptospirosis. Results: From 2006 to 2009, at least 21%of 117 patients diagnosed with HV infection had HV Fever (HF) with no evidence of pulmonary edema (no respiratory distress or radiographic lung infiltrates), and 44%of patients had very mild HPS (radiographic pulmonary edema but no respiratory insufficiency). Conclusions: Hantavirus infection caused by Choclo virus in Panama presents often as HF, which contrasts with HV in the Americas but is consistent with the high seroprevalence in endemic regions.
Board 241. An Evaluation of the Pacific Outbreak Early Warning Detection System—The Pacific Syndromic Surveillance System
A. T. Craig1, E. J. Nilles2, V. Biaukula2, D. Durrheim3, B. Paterson4; 1Univ. of Newcastle (Aust.),
Newcastle, Australia, 2World Hlth.Organization, Suva, Fiji, 3Univ. of Newcastle (Aust.) / Hunter New
England Publ. Hlth., Wallsend, Australia, 4Univ. of Newcastle (Aust.), Hunter Med. Res. Inst., Newcastle,
Australia
Background: The Pacific Syndromic Surveillance System (PSSS), launched in 2010, provides a simple mechanism by which 121 sentinel surveillance sites in 21 limited-resource Pacific island countries and areas (PICs) undertake routine indicator based surveillance for the detection of infectious disease outbreaks. Four years on, this evaluation aims to assess whether the PSSS is meeting its objectives; measure progress since a formative evaluation conducted in 2011; and provide recommendations to enhance the PSSS’s performance in the future. Method: Data were collected between July and
December 2014. Eighteen key informant interviews were conducted with users of the system. Resulting data were thematically analysed. Historic quantitative system data were collected and analysed to assess timeliness and completeness of reporting. It was not possible to analyse sensitivity of the PSSS as a gold standard was not available. Results: The evaluation found that the PSSS has enhanced PICs’ ability to undertake early warning surveillance and, in doing so, has contributed to efforts to comply with
performing well in terms of its simplicity, acceptability and usefulness for public health decision makers. Despite this, issues with timeliness and completeness of reporting, data quality and system stability remain challenging. Conclusion: The evaluation found that in four years the PSSS has made a significant contribution to improving public health security in the Pacific. Further, the system has supported PICs’ to develop and maintain infectious disease surveillance, a core public health capacity required to implement the IHR effectively. This evaluation’s findings highlight the utility of simple
syndrome-based early warning surveillance methods to detect disease outbreaks in settings with limited capacity and limited access to confirmatory diagnostic services, as is the case in the Pacific. As the PSSS evolves, a balance between simplicity (and hence implementability, flexibility and adaptability) and
technological advances to improve timeliness and data quality performance will need to be found to ensure long-term sustainability.
Board 242. Use of Surveillance Data to Estimate Seasonal Influenza Thresholds in Canada L. Lee, M. Saboui, D. Schanzer, T. Mersereau; Publ. Hlth. Agency of Canada, Ottawa, ON, Canada Background: In Canada, FluWatch is the national surveillance system that monitors the spread of influenza and influenza-like illness (ILI). A primary objective of FluWatch is to detect influenza activity across Canada as early as possible. Influenza thresholds have been developed and used by many countries to indicate influenza activity levels that would signal the start or end of a season, as well as to detect periods of increased or severe activity. Canada has not yet established validated thresholds for use in its surveillance system. The World Health Organization (WHO) has developed a novel method to establish seasonal and alert thresholds for influenza. The objective of this study was to use the WHO’s method to calculate thresholds for select surveillance indicators and determine the feasibility of use in Canada. Methods: Data from three indicators were used in this study: national ILI consultation rates per 1,000 patient visits, percent positive influenza laboratory specimens, and number of hospitalizations due to influenza. Data were analyzed from influenza seasons 1994-1995 to 2013-2014 from September through August. The 2008-2009 and 2009-2010 seasons were excluded due to the H1N1 pandemic. Using the WHO methodology, alert and seasonal thresholds were determined for each indicator. Results: The seasonal thresholds for each indicator were determined to be 20.3 ILI consultations per 1,000 patient visits, 3.1% positive influenza detections and 27.6 hospitalizations due to influenza. Seasonal thresholds of each indicator defined the start and end of influenza season in different weeks and the duration of the influenza season also varied. The weekly alert thresholds calculated using the upper 95th percentile
ranged from 7.7 to 80.6 consultations per 1,000 patient visits for the ILI, 0.1% to 3.0% positive for
laboratory detections and 0 to 716 hospitalizations. Conclusions: This study demonstrated that the WHO seasonal influenza threshold protocol may be used to calculate seasonal and alerts thresholds within a Canadian context. Further analysis with internal and external data is required to validate the results and determine the applicability of these thresholds. Refinements to this method may be needed to provide an accurate picture for seasonal influenza in Canada.
Board 243. Ebola Response in the District of Columbia: Early Warning Surveillance in the United States Capital
A. K. Hennenfent, K. Li, K. Dassie, M. Grant, K. Zamore, J. Davies-Cole; District of Columbia Dept. of Hlth., Washington, DC, USA
Background: The Centers for Disease Control and Prevention (CDC) announced in October 2014 the start of enhanced monitoring for travelers arriving in the USA from countries undergoing widespread transmission of Ebola virus disease (EVD). With this enhanced effort, six District of Columbia (DC) Department of Health (DOH) epidemiologists were tasked with rapidly establishing contact with all domestic and international travelers arriving in DC. The following describes their approach in
implementing an infectious disease early warning surveillance system. Methods: Returning DC residents (or visitors) were actively monitored with the goal of completing the initial risk assessment phone interview within 24 hours of receiving arrival notifications from the CDC or another jurisdiction. To help achieve this goal, a contact and monitoring protocol was created establishing standardized timelines and methods for first contact and failed contact, which remained consistent for all team members once in place, including on weekends and holidays. Results: From 10/17/2014 through 3/15/2015, over 92% (286/309) of PUM who completed all or a portion of their monitoring period under DC DOH supervision were successfully contacted. The highest successful contact rate was achieved in March 2015 (31/31, 100%), with the lowest in December 2014 (73/86, 84.9%). Average time from the initial arrival notification to first contact attempt was approximately 15.3 hours with 57.9% (179/309) of PUM interviewed within 24 hours of notification. DOH was consulted on 22 persons seeking medical care at a DC healthcare facility.
Collaboration between the treating hospital, DC DOH, and CDC determined EVD testing was necessary for six of these individuals with none ultimately testing positive. Conclusion: The small size of the DC Ebola response team created a situation where six epidemiologists closely collaborated in implementing an early warning surveillance system, developing contact and monitoring protocols, as well as
interviewing PUM. This allowed for a timely completion of interviews and an overall high successful contact rate that improved over time as protocols evolved from gained experience. This unified small team approach to surveillance and individual case management can serve as a model for future outbreak scenarios within the District and other urban settings.
Board 244. Sporadic Norovirus Surveillance and Outbreak Trends, Tennessee, 2012–2014
A. M. Coatsworth1, N. Halasa2, A. Hall3, K. Garman1, L. Constantine-Renna1, J. Chappell2, M. Wikswo3,
D. Payne3, J. Dunn1; 1Tennessee Dept. of Hlth., Nashville, TN, USA, 2Vanderbilt Univ. Med. Ctr.,
Nashville, TN, USA, 3CDC, Atlanta, GA, USA
Background: In Tennessee (TN), sporadic cases of norovirus are not reportable; however, norovirus outbreaks are reportable and are monitored through the Norovirus Sentinel Testing and Tracking Network (NoroSTAT). Sporadic norovirus incidence data from a CDC-sponsored New Vaccine Surveillance Network (NVSN) in Davidson County, TN and NoroSTAT data were used to compare the temporal trends
of sporadic norovirus incidence and reported outbreaks. Methods: Sporadic norovirus cases were identified through acute gastroenteritis (AGE) surveillance among children ≥15 days and ≤17 years enrolled from Vanderbilt Emergency Department and outpatient clinics during 2012-2014. AGE cases positive for norovirus and the total number of outbreaks from selected middle TN counties documented in NoroSTAT were compared by year. All norovirus positive specimens were sequenced. Sporadic and outbreak genogroups were compared. A moving average of 4 weeks was implemented to identify peaks in trends. Results: Of the 2330 children with AGE enrolled in the NVSN surveillance system, 346 (15%) were positive for norovirus during August 2012-July 2014. During the same time period, 33 confirmed norovirus outbreaks occurred within middle TN counties, with 52% occurring in long-term care facilities. No outbreaks of Genogroup I were reported during Year 1 (August 2012-July 2013), but 15 outbreaks were characterized as Genogroup II. In Year 2 (August 2013-July 2014), 5 outbreaks were characterized as Genogroup I and 13 outbreaks were Genogroup II. During both years, sporadic cases increased precipitously prior to the reported outbreaks. The number of weeks from the peak of sporadic norovirus cases identified in NVSN surveillance to the peak in outbreaks reported was 10 weeks for Genogroup II during Year 1. In Year 2, the interval was 12 weeks for Genogroup II and 13 weeks for Genogroup I. Conclusions: Increases in pediatric norovirus infections appear to precede outbreaks in the community, which provides key insights into community transmission dynamics and potential opportunities for prevention. Surveillance for sporadic norovirus can provide an early signal for increasing norovirus outbreaks. Early indications of norovirus activity can allow for timely warnings to intensify infection control measures among vulnerable populations.
Board 245. Rabies Surveillance Evaluation in an Area Without Human Cases in Brazil
C. Martins1, L. H. Gomes2, A. M. Vieira2, F. Ferreira1; 1Univ. of São Paulo, São Paulo, Brazil, 2Pasteur
Inst., São Paulo, Brazil
Background: Rabies has been kept under control in São Paulo State, Brazil with no human, only three canine and seven feline cases in 2003-2013 (all AgV-3). Methods: Accordingly, a rabies surveillance system in this area was evaluated following the CDC (Centers of Diseases Control, Atlanta, USA) methodology. Results: The system was based on investigation of pet bites in human beings, aggressor pet monitoring and brain testing of suspected animals, which was dependent of post-mortem diagnosis in dogs and cats (low simplicity). Despite new technologies on data processing and diagnosis were
introduced, the system has been poorly adapted to disease dynamics overtime, with no increment on animal case registration (low flexibility). Although local services have highly demonstrated system perception (high acceptability), private clinics have shown low participation and awareness (low acceptability). Total geographic area without data of surveillance actions increased 30% from 2003 to 2013 (low representativeness). No standardize database between cities and laboratories and no data archiving of animals under surveillance were found (low data quality). The system was unable to define the real population under surveillance, even when receiving dogs with suspicious symptoms (potentially suspect cases); in overall, 39.2% of local services and 72.8% of private clinics have not suspect rabies in
these cases (low sensitivity). In 2012, the positive predictive value was 0.03% for dogs (2/5,566) and 0.06% for cats (1/1,797). The average time elapsed between clinical signs and laboratorial result in 2012/2013 was 25 days for suspicious dogs and cats (low opportunity). Evaluation of local services facility to accomplish actions showed that only 25% had available pet housing and 16% had temporary disposal of carcasses (low stability). Conclusions: Under these indicators, the current rabies surveillance system of São Paulo has shown incapacity for early disease detection once based in dog and cat
population.