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Purpose During the 2014–2016 Ebola outbreak in West Africa, the Sierra Leone Ministry of Health and Sanitation (MoHS), the US Centers for Disease Control and Prevention, and responding partners under the coordination of the National Ebola Response Center (NERC) and the MoHS's Emergency Operation Center (EOC) systematically recorded information from the 117 Call Center system and district alert phone lines, case investigations, laboratory sample testing, clinical management, and safe and dignified burial records. Since 2017, CDC assisted MoHS in building and managing the Sierra Leone Ebola Database (SLED) to consolidate these major data sources. The primary objectives of the project were helping families to identify the location of graves of their loved ones who died at the time of the Ebola epidemic through the SLED Family Reunification Program and creating a data source for epidemiological research. The objective of this paper is to describe the process of consolidating epidemic records into a useful and accessible data collection and to summarize data characteristics, strength, and limitations of this unique information source for public health research. Methods Because of the unprecedented conditions during the epidemic, most of the records collected from responding organizations required extensive processing before they could be used as a data source for research or the humanitarian purpose of locating burial sites. This process required understanding how the data were collected and used during the outbreak. To manage the complexity of processing the data obtained from various sources, the Sierra Leone Ebola Database (SLED) Team used an organizational strategy that allowed tracking of the data provenance and lifecycle. Results The SLED project brought raw data into one consolidated data collection. It provides researchers with secure and ethical access to the SLED data and serves as a basis for the research capacity building in Sierra Leone. The SLED Family Reunification Program allowed Sierra Leonean families to identify location of the graves of loved ones who died during the Ebola epidemic. Conclusions The SLED project consolidated and utilized epidemic data recorded during the Sierra Leone Ebola Virus Disease outbreak that were collected and contributed to SLED by national and international organizations. This project has provided a foundation for developing a method of ethical and secure SLED data access while preserving the host nation's data ownership. SLED serves as a data source for the SLED Family Reunification Program and for epidemiological research. It presents an opportunity for building research capacity in Sierra Leone and provides a foundation for developing a relational database. Large outbreak data systems such as SLED provide a unique opportunity for researchers to improve responses to epidemics and indicate the need to include data management preparedness in the plans for emergency response.

As COVID-19 was declared a health emergency in March 2020, there was immense demand for information about the novel pathogen. This paper examines the clinician-reported impact of Project ECHO COVID-19 Clinical Rounds on clinician learning. Primary sources of study data were Continuing Medical Education (CME) Surveys for each session from the dates of March 24, 2020 to July 30, 2020 and impact surveys conducted in November 2020, which sought to understand participants’ overall assessment of sessions. Quantitative analyses included descriptive statistics and Mann-Whitney testing. Qualitative data were analyzed through inductive thematic analysis. Clinicians rated their knowledge after each session as significantly higher than before that session. 75.8% of clinicians reported they would ‘definitely’ or ‘probably’ use content gleaned from each attended session and clinicians reported specific clinical and operational changes made as a direct result of sessions. 94.6% of respondents reported that COVID-19 Clinical Rounds helped them provide better care to patients. 89% of respondents indicated they ‘strongly agree’ that they would join ECHO calls again.COVID-19 Clinical Rounds offers a promising model for the establishment of dynamic peer-to-peer tele-mentoring communities for low or no-notice response where scientifically tested or clinically verified practice evidence is limited.

Purpose Organizations responding to the 2014–2016 Ebola epidemic in Sierra Leone collected information from multiple sources and kept it in separate databases, including distinct data systems for Ebola hot line calls, patient information collected by field surveillance officers, laboratory testing results, clinical information from Ebola treatment and isolation facilities, and burial team records. Methods After the conclusion of the epidemic, the Sierra Leone Ministry of Health and Sanitation and the U.S. Centers for Disease Control and Prevention partnered to collect these disparate records and consolidate them in the Sierra Leone Ebola Database. Results The Sierra Leone Ebola Database data are providing a lasting resource for postepidemic data analysis and epidemiologic research, including identifying best strategies in outbreak response, and are used to help families locate the graves of family members who died during the epidemic. Conclusion This report describes the Ministry of Health and Sanitation and Centers for Disease Control and Prevention processes to safeguard Ebola records while making the data available for public health research.

Monoclonal antibody therapeutics to treat coronavirus disease (COVID-19) have been authorized by the US Food and Drug Administration under Emergency Use Authorization (EUA). Many barriers exist when deploying a novel therapeutic during an ongoing pandemic, and it is critical to assess the needs of incorporating monoclonal antibody infusions into pandemic response activities. We examined the monoclonal antibody infusion site process during the COVID-19 pandemic and conducted a descriptive analysis using data from 3 sites at medical centers in the United States supported by the National Disaster Medical System. Monoclonal antibody implementation success factors included engagement with local medical providers, therapy batch preparation, placing the infusion center in proximity to emergency services, and creating procedures resilient to EUA changes. Infusion process challenges included confirming patient severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positivity, strained staff, scheduling, and pharmacy coordination. Infusion sites are effective when integrated into pre-existing pandemic response ecosystems and can be implemented with limited staff and physical resources.

Although the economic consequences of epidemic outbreaks to affected areas are often well documented, little is known about how these might carry over into the economies of unaffected regions. In the absence of direct pathogen transmission, global trade is one mechanism through which geographically distant epidemics could reverberate to unaffected countries. This study explores the link between global public health events and U.S. economic outcomes by evaluating the role of the 2014 West Africa Ebola outbreak in U.S. exports and exports‐supported U.S. jobs, 2005–2016. Estimates were obtained using difference‐in‐differences models where sub‐Saharan Africa countries were assigned to treatment and comparison groups based on their Ebola transmission status, with controls for observed and unobserved time‐variant factors that may independently influence trends in trade. Multiple model specification checks were performed to ensure analytic robustness. The year of peak transmission, 2014, was estimated to result in $1.08 billion relative reduction in U.S. merchandise exports to Ebola‐affected countries, whereas estimated losses in exports‐supported U.S. jobs exceeded 1,200 in 2014 and 11,000 in 2015. These findings suggest that remote disruptions in health security might play a role in U.S. economic indicators, demonstrating the interconnectedness between global health and aspects of the global economy and informing the relevance of health security efforts.

ObjectiveThe COVID-19 pandemic has significantly stressed healthcare systems. The addition of monoclonal antibody (mAb) infusions, which prevent severe disease and reduce hospitalizations, to the repertoire of COVID-19 countermeasures offers the opportunity to reduce system stress but requires strategic planning and use of novel approaches. Our objective was to develop a web-based decision-support tool to help existing and future mAb infusion facilities make better and more informed staffing and capacity decisions.Materials and MethodsUsing real-world observations from three medical centers operating with federal field team support, we developed a discrete-event simulation model and performed simulation experiments to assess performance of mAb infusion sites under different conditions.Results162,000 scenarios were evaluated by simulations. Our analyses revealed that it was more effective to add check-in staff than to add additional nurses for middle-to-large size sites with ≥ 2 infusion nurses; that scheduled appointments performed better than walk-ins when patient load was not high; and that reducing infusion time was particularly impactful when load on resources was only slightly above manageable levels.DiscussionPhysical capacity, check-in staff, and infusion time were as important as nurses for mAb sites. Health systems can effectively operate an infusion center under different conditions to provide mAb therapeutics even with relatively low investments in physical resources and staff.ConclusionSimulations of mAb infusion sites were used to create a capacity planning tool to optimize resource utility and allocation in constrained pandemic conditions, and more efficiently treat COVID-19 patients at existing and future mAb infusion sites.

BackgroundMonoclonal antibodies (mAbs) against SARS-CoV-2 are a promising treatment for limiting the progression of COVID-19 and decreasing strain on hospitals. Their use, however, remains limited, particularly in disadvantaged populations.MethodsElectronic health records were reviewed from SARS-CoV-2 patients at a single medical center in the United States that initiated mAb infusions in January 2021 with the support of the U.S. Department of Health and Human Services’ National Disaster Medical System. Patients who received mAbs were compared to untreated patients from the time period before mAb availability who met eligibility criteria for mAb treatment. We used logistic regression to measure the effect of mAb treatment on the risk of hospitalization or emergency department (E.D.) visit within 30 days of laboratory-confirmed COVID-19.ResultsOf 598 COVID-19 patients, 270 (45%) received bamlanivimab and 328 (55%) were untreated. Two hundred and thirty-one patients (39%) were Hispanic. Among treated patients, 5/270 (1.9%) presented to the E.D. or required hospitalization within 30 days of a positive SARS-CoV-2 test, compared to 39/328 (12%) untreated patients (pConclusionsIn this diverse, real-world COVID-19 patient population, mAb treatment significantly decreased the risk of subsequent E.D. visit or hospitalization. Broader treatment with mAbs, including in disadvantaged patient populations, can decrease the burden on hospitals and should be facilitated in all populations in the United States to ensure health equity.SummaryIn a diverse, real-world COVID-19 patient population, treatment with monoclonal antibodies significantly decreased the risk of subsequent emergency department visit or hospitalization within 30 days of a positive SARS-CoV-2 viral test.

BackgroundThe COVID-19 pandemic caught the globe unprepared without targeted medical countermeasures, such as therapeutics, to target the emerging SARS-CoV-2 virus. However, in recent months multiple monoclonal antibody therapeutics to treat COVID-19 have been authorized by the U.S. Food and Drug Administration (FDA) under Emergency Use Authorization (EUA). Despite these authorizations and promising clinical trial efficacy results, monoclonal antibody therapies are currently underutilized as a treatment for COVID-19 across the U.S. Many barriers exist when deploying a new infused therapeutic during an ongoing pandemic with limited resources and staffing, and it is critical to better understand the process and site requirements of incorporating monoclonal antibody infusions into pandemic response activities.MethodsWe examined the monoclonal antibody infusion site process components, resources, and requirements during the COVID-19 pandemic using data from three initial infusion sites at medical centers in the U.S. supported by the National Disaster Medical System. A descriptive analysis was conducted using process assessment metrics to inform recommendations to strengthen monoclonal antibody infusion site implementation.ResultsThe monoclonal antibody infusion sites varied in physical environment and staffing models due to state polices, infection control mechanisms, and underlying medical system structure, but exhibited a common process workflow. Sites operationalized an infusion process staffing model with at least two nurses per ten infusion patients. Monoclonal antibody implementation success factors included tailoring the infusion process to the patient community, strong engagement with local medical providers, batch preparing the therapy before patient arrival, placing the infusion center in proximity to emergency services, and creating procedures resilient to EUA changes. Infusion process challenges stemmed from confirming patient SARS-CoV-2 positivity, strained staff, scheduling needs, and coordination with the pharmacy for therapy preparation.ConclusionsInfusion site processes are most effective when integrated into the pre-existing pandemic response ecosystems and can be implemented with limited staff and physical resources. As the pandemic and policy tools such as EUAs evolve, monoclonal antibody infusion processes must also remain adaptable, as practice changes directly affect resources, staffing, timing, and workflows. Future use may be aided by incorporating innovative emergency deployment techniques, such as vehicle and home-based therapy administration, and by developing drug delivery mechanisms that alleviate the need for observed intravenous infusions by medically-accredited staff.

Tasked with identifying digital health solutions to support dynamic learning health systems and their response to COVID-19, the US Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response partnered with the University of New Mexico’s Project ECHO and more than 2 dozen other organizations and agencies to create a real-time virtual peer-to-peer clinical education opportunity: the COVID-19 Clinical Rounds Initiative. Focused on 3 “pressure points” in the COVID-19 continuum of care—(1) the out-of-hospital and/or emergency medical services setting, (2) emergency departments, and (3) inpatient critical care environments—the initiative has created a massive peer-to-peer learning network for real-time information sharing, engaging participants in all 50 US states and more than 100 countries. One hundred twenty-five learning sessions had been conducted between March 24, 2020 and February 25, 2021, delivering more than 58,000 total learner-hours of contact in the first 11 months of operation.

Purpose In 2015, the Sierra Leone Ministry of Health and Sanitation (MoHS) and the Centers for Disease Control and Prevention (CDC) agreed to consolidate data recorded by MoHS and international partners during the Ebola epidemic and create the Sierra Leone Ebola Database (SLED). The primary objectives were helping families to identify the location of graves of their loved ones who died from any cause at the time of the Ebola epidemic and creating a data source for epidemiological research. The Family Reunification Program fulfills the first SLED objective. The purpose of this paper is to describe the Family Reunification Program (Program) development, functioning, and results. Methods The MoHS, CDC, SLED Team, and Concern Worldwide developed, tested, and implemented methodology and tools to conduct the Program. Family liaisons were trained in protection of the personally identifiable information. Results The SLED Family Reunification Program allows families in Sierra Leone, who did not know the final resting place of their loved ones, to be reunited with their graves and to bring them relief and closure. Conclusion Continuing family requests in search of the burial place of loved ones 5 years after the end of the epidemic shows that the emotional burden of losing a family member and not knowing the place of burial does not diminish with time. As of February 2021, the Program continues and is described to allow its replication for other emergency events including COVID-19 and new Ebola outbreaks.

Introduction Experimental Ebola vaccines were introduced during the 2014–2015 Ebola outbreak in West Africa. Planning for the Sierra Leone Trial to Introduce a Vaccine against Ebola (STRIVE) was underway in late 2014. We examined hypothetical acceptability and perceptions of experimental Ebola vaccines among health care workers (HCWs), frontline workers, and the general public to guide ethical communication of risks and benefits of any experimental Ebola vaccine. Methods Between December 2014 and January 2015, we conducted in-depth interviews with public health leaders (N = 31), focus groups with HCWs and frontline workers (N = 20), and focus groups with members of the general public (N = 15) in Western Area Urban, Western Area Rural, Port Loko, Bombali, and Tonkolili districts. Themes were identified using qualitative content analysis. Results Across all participant groups, not knowing the immediate and long-term effects of an experimental Ebola vaccine was the most serious concern. Some respondents feared that experimental vaccines may cause Ebola, lead to death, or result in other adverse events. Among HCWs, not knowing the level of protection provided by experimental Ebola vaccines was another concern. HCWs and frontline workers were motivated to help find a vaccine for Ebola to help end the outbreak. General public participants cited positive experiences with routine childhood immunization in Sierra Leone. Discussion Our formative assessment prior to STRIVE’s implementation in Sierra Leone helped identify concerns, motivations, and information gaps among potential participants of an experimental Ebola vaccine trial, at the time when an unprecedented outbreak was occurring in the country. The findings from this assessment were incorporated early in the process to guide ethical communication of risks and benefits when discussing informed consent for possible participation in the vaccine trial that was launched later in 2015.

Introduction While it is suspected that some ages were misreported during the 2014-2016 West African Ebola outbreak, an analysis examining age data quality has not been conducted. The study objective was to examine age heaping and terminal digit preference as indicators for quality of age data collected in the Sierra Leone Ebola Database (SLED). Methods Age data quality for adult patients was analyzed within SLED for the Viral Hemorrhagic Fever (VHF) database and the laboratory testing dataset by calculating Whipple´s index and Myers´s blended index, stratified by sex and region. Results Age data quality was low in both the VHF database (Whipple´s index for the 5-year range, 229.2) and the laboratory testing dataset (Whipple´s index for the 5-year range, 236.4). Age was reported more accurately in the Western Area and least accurately in the Eastern Province. Age data for females were less accurate than for males. Conclusion Age data quality was low in adult patients during the 2014-2016 Ebola outbreak in Sierra Leone, which may reduce its use as an identifying or stratifying variable. These findings inform future analyses using this database and describe a phenomenon that has relevance in data collection methods and analyses for future outbreaks in developing countries.

Health communication and social mobilization efforts to improve the public's knowledge, attitudes, and practices (KAP) regarding Ebola virus disease (Ebola) were important in controlling the 2014-2016 Ebola epidemic in Guinea (1), which resulted in 3,814 reported Ebola cases and 2,544 deaths.* Most Ebola cases in Guinea resulted from the washing and touching of persons and corpses infected with Ebola without adequate infection control precautions at home, at funerals, and in health facilities (2,3). As the 18-month epidemic waned in August 2015, Ebola KAP were assessed in a survey among residents of Guinea recruited through multistage cluster sampling procedures in the nation's eight administrative regions (Boke, Conakry, Faranah, Kankan, Kindia, Labe, Mamou, and Nzerekore). Nearly all participants (92%) were aware of Ebola prevention measures, but 27% believed that Ebola could be transmitted by ambient air, and 49% believed they could protect themselves from Ebola by avoiding mosquito bites. Of the participants, 95% reported taking actions to avoid getting Ebola, especially more frequent handwashing (93%). Nearly all participants (91%) indicated they would send relatives with suspected Ebola to Ebola treatment centers, and 89% said they would engage special Ebola burial teams to remove corpses with suspected Ebola from homes. Of the participants, 66% said they would prefer to observe an Ebola-affected corpse from a safe distance at burials rather than practice traditional funeral rites involving corpse contact. The findings were used to guide the ongoing epidemic response and recovery efforts, including health communication, social mobilization, and planning, to prevent and respond to future outbreaks or sporadic cases of Ebola.

Ensuring confidence in the health care system has been a challenge to Ebola virus disease (Ebola) response and recovery efforts in Sierra Leone (1). A national multistage cluster-sampled household survey to assess knowledge, attitudes, and practices (KAP) related to Sierra Leone's health care system was conducted in July 2015. Among 3,564 respondents, 93% were confident that a health care facility could treat suspected Ebola cases, and approximately 90% had confidence in the health system's ability to provide non-Ebola services, including immunizations, antenatal care, and maternity care. Respondents in districts with ongoing Ebola transmission ("active districts") and respondents with higher educational levels reported more confidence in the health care system than did respondents in nonactive districts and respondents with less education. Active districts were the focus of the Ebola response; these districts implemented intensified social mobilization and communication efforts, and established district response centers, Ebola-specific health care facilities, and ambulances. Greater infrastructure and response capacity might have resulted in higher confidence in the health care system in these areas. Respondents ranked Ebola and malaria as the country's most important health issues. Health system recovery efforts in Sierra Leone can build on existing public confidence in the health system.

In early October 2014, 7 months after the 2014–2015 Ebola epidemic in West Africa began, a cluster of reported deaths in Koinadugu, a remote district of Sierra Leone, was the first evidence of Ebola virus disease (Ebola) in the district. Prior to this event, geographic isolation was thought to have prevented the introduction of Ebola to this area. We describe our initial investigation of this cluster of deaths and subsequent public health actions after Ebola was confirmed, and present challenges to our investigation and methods of overcoming them. We present a transmission tree and results of whole genome sequencing of selected isolates to identify the source of infection in Koinadugu and demonstrate transmission between its villages. Koinadugu's experience highlights the danger of assuming that remote location and geographic isolation can prevent the spread of Ebola, but also demonstrates how deployment of rapid field response teams can help limit spread once Ebola is detected.

Sierra Leone is a country in West Africa with a population of between six and seven million people. To most of the world, Sierra Leone is best known for its natural resources—particularly diamonds—and the 11-year civil war that they fueled until 2002. Twelve years after the end of the war, a recovering but fragile Sierra Leone was thrust into global attention again—this time by the largest Ebola outbreak in history. During the outbreak, health care workers became 21–32 times more likely to be infected with Ebola than people in the general population. Over 350 health care workers were infected in Sierra Leone, 92 of whom worked in Kenema District, the site of one of the largest ever reported clusters of health care workers infected with Ebola. This chapter is the story of the first few months of the outbreak in Sierra Leone in Kenema District. It describes the challenges and successes of health care workers who tried to continue providing maternal, reproductive, and child health care, within the deadliest, longest, and most widespread epidemic of Ebola ever recorded. It focuses on the local health care workers and the lifesaving services they risked their lives to deliver.

Summary Background On April 25, 2017, a cluster of unexplained illnesses and deaths associated with a funeral was reported in Sinoe County, Liberia. Molecular testing identified Neisseria meningitidis serogroup C (NmC) in specimens from patients. We describe the epidemiological investigation of this cluster and metagenomic characterisation of the outbreak strain. Methods We collected epidemiological data from the field investigation and medical records review. Confirmed, probable, and suspected cases were defined on the basis of molecular testing and signs or symptoms of meningococcal disease. Metagenomic sequences from patient specimens were compared with 141 meningococcal isolate genomes to determine strain lineage. Findings 28 meningococcal disease cases were identified, with dates of symptom onset from April 21 to April 30, 2017: 13 confirmed, three probable, and 12 suspected. 13 patients died. Six (21%) patients reported fever and 23 (82%) reported gastrointestinal symptoms. The attack rate for confirmed and probable cases among funeral attendees was 10%. Metagenomic sequences from six patient specimens were similar to a sequence type (ST) 10217 (clonal complex [CC] 10217) isolate genome from Niger, 2015. Multilocus sequencing identified five of seven alleles from one specimen that matched ST-9367, which is represented in the PubMLST database by one carriage isolate from Burkina Faso, in 2011, and belongs to CC10217. Interpretation This outbreak featured high attack and case fatality rates. Clinical presentation was broadly consistent with previous meningococcal disease outbreaks, but predominance of gastrointestinal symptoms was unusual compared with previous African meningitis epidemics. The outbreak strain was genetically similar to NmC CC10217, which caused meningococcal disease outbreaks in Niger and Nigeria. CC10217 had previously been identified only in the African meningitis belt. Funding US Global Health Security.

As of February 17, 2016, a total of 14,122 cases (62% confirmed) of Ebola Virus Disease (Ebola) and 3,955 Ebola-related deaths had been reported in Sierra Leone since the epidemic in West Africa began in 2014. A key focus of the Ebola response in Sierra Leone was the promotion and implementation of safe, dignified burials to prevent Ebola transmission by limiting contact with potentially infectious corpses. Traditional funeral practices pose a substantial risk for Ebola transmission through contact with infected bodies, body fluids, contaminated clothing, and other personal items at a time when viral load is high; however, the role of funeral practices in the Sierra Leone epidemic and ongoing Ebola transmission has not been fully characterized. In September 2014, a sudden increase in the number of reported Ebola cases occurred in Moyamba, a rural and previously low-incidence district with a population of approximately 260,000. The Sierra Leone Ministry of Health and Sanitation and CDC investigated and implemented public health interventions to control this cluster of Ebola cases, including community engagement, active surveillance, and close follow-up of contacts. A retrospective analysis of cases that occurred during July 11-October 31, 2014, revealed that 28 persons with confirmed Ebola had attended the funeral of a prominent pharmacist during September 5-7, 2014. Among the 28 attendees with Ebola, 21 (75%) reported touching the man's corpse, and 16 (57%) reported having direct contact with the pharmacist before he died. Immediate, safe, dignified burials by trained teams with appropriate protective equipment are critical to interrupt transmission and control Ebola during times of active community transmission; these measures remain important during the current response phase.

BackgroundThe mental health impact of the 2014–2016 Ebola epidemic has been described among survivors, family members and healthcare workers, but little is known about its impact on the general population of affected countries. We assessed symptoms of anxiety, depression and post-traumatic stress disorder (PTSD) in the general population in Sierra Leone after over a year of outbreak response.MethodsWe administered a cross-sectional survey in July 2015 to a national sample of 3564 consenting participants selected through multistaged cluster sampling. Symptoms of anxiety and depression were measured by Patient Health Questionnaire-4. PTSD symptoms were measured by six items from the Impact of Events Scale-revised. Relationships among Ebola experience, perceived Ebola threat and mental health symptoms were examined through binary logistic regression.ResultsPrevalence of any anxiety-depression symptom was 48% (95% CI 46.8% to 50.0%), and of any PTSD symptom 76% (95% CI 75.0% to 77.8%). In addition, 6% (95% CI 5.4% to 7.0%) met the clinical cut-off for anxiety-depression, 27% (95% CI 25.8% to 28.8%) met levels of clinical concern for PTSD and 16% (95% CI 14.7% to 17.1%) met levels of probable PTSD diagnosis. Factors associated with higher reporting of any symptoms in bivariate analysis included region of residence, experiences with Ebola and perceived Ebola threat. Knowing someone quarantined for Ebola was independently associated with anxiety-depression (adjusted OR (AOR) 2.3, 95% CI 1.7 to 2.9) and PTSD (AOR 2.095% CI 1.5 to 2.8) symptoms. Perceiving Ebola as a threat was independently associated with anxiety-depression (AOR 1.69 95% CI 1.44 to 1.98) and PTSD (AOR 1.86 95% CI 1.56 to 2.21) symptoms.ConclusionSymptoms of PTSD and anxiety-depression were common after one year of Ebola response; psychosocial support may be needed for people with Ebola-related experiences. Preventing, detecting, and responding to mental health conditions should be an important component of global health security efforts.

On April 25, 2017, a cluster of unexplained illness and deaths among persons who had attended a funeral during April 21-22 was reported in Sinoe County, Liberia (1). Using a broad initial case definition, 31 cases were identified, including 13 (42%) deaths. Twenty-seven cases were from Sinoe County (1), and two cases each were from Grand Bassa and Monsterrado counties, respectively. On May 5, 2017, initial multipathogen testing of specimens from four fatal cases using the Taqman Array Card (TAC) assay identified Neisseria meningitidis in all specimens. Subsequent testing using direct real-time polymerase chain reaction (PCR) confirmed N. meningitidis in 14 (58%) of 24 patients with available specimens and identified N. meningitidis serogroup C (NmC) in 13 (54%) patients. N. meningitidis was detected in specimens from 11 of the 13 patients who died; no specimens were available from the other two fatal cases. On May 16, 2017, the National Public Health Institute of Liberia and the Ministry of Health of Liberia issued a press release confirming serogroup C meningococcal disease as the cause of this outbreak in Liberia.

Mortality surveillance and vital registration are limited in Sierra Leone, a country with one of the highest mortality rates among children aged

Vaccination against Ebola virus disease is a tool that may limit disease transmission and deaths in future outbreaks, integrated within traditional Ebola outbreak prevention and control measures. Although a licensed Ebolavirus vaccine (EV) is not yet available, the 2014–2016 West African Ebola outbreak has accelerated EV clinical trials and given public health authorities in Guinea, Liberia, and Sierra Leone experience with implementation of emergency ring vaccination. As evidence supporting the use of EV during an outbreak response has become available, public health authorities in at-risk countries are considering how to integrate EV into future emergency Ebola responses and for prevention in high-risk groups, such as healthcare workers and frontline workers (HCW/FLWs), even before an EV is licensed. This review provides an overview of Ebola epidemiology, immunology, and evidence to inform regional and country-level decisions regarding EV delivery during an emergency response and to at-risk populations before a licensed vaccine is available and beyond. Countries or regions planning to use EV will need to assess factors such as the likelihood of a future Ebolavirus outbreak, the most likely species to cause an out-break, the availability of a safe and effective EV (unlicensed or licensed) for the affected population, capacity to implement Ebola vaccination in conjunction with standard Ebola outbreak control measures, and availability of minimum essential resources and regulatory requirements to implement emergency Ebola vaccination. Potential emergency vaccination strategies for consideration include ring or geographically targeted community vaccination, HCW/FLW vaccination, and mass vaccination. The development of guidelines and protocols for Ebola vaccination will help ensure that activities are standardized, evidence-based, and well-coordinated with overall Ebola outbreak response efforts in the future.

SUMMARYWe performed a spatial-temporal analysis to assess household risk factors for Ebola virus disease (Ebola) in a remote, severely-affected village. We defined a household as a family's shared living space and a case-household as a household with at least one resident who became a suspect, probable, or confirmed Ebola case from 1 August 2014 to 10 October 2014. We used Geographic Information System (GIS) software to calculate inter-household distances, performed space-time cluster analyses, and developed Generalized Estimating Equations (GEE). Village X consisted of 64 households; 42% of households became case-households over the observation period. Two significant space-time clusters occurred among households in the village; temporal effects outweighed spatial effects. GEE demonstrated that the odds of becoming a case-household increased by 4·0% for each additional person per household (P< 0·02) and 2·6% per day (P< 0·07). An increasing number of persons per household, and to a lesser extent, the passage of time after onset of the outbreak were risk factors for household Ebola acquisition, emphasizing the importance of prompt public health interventions that prioritize the most populated households. Using GIS with GEE can reveal complex spatial-temporal risk factors, which can inform prioritization of response activities in future outbreaks.

To evaluate changes in Ebola-related knowledge, attitudes and prevention practices during the Sierra Leone outbreak between 2014 and 2015.Four cluster surveys were conducted: two before the outbreak peak (3499 participants) and two after (7104 participants). We assessed the effect of temporal and geographical factors on 16 knowledge, attitude and practice outcomes.Fourteen of 16 knowledge, attitude and prevention practice outcomes improved across all regions from before to after the outbreak peak. The proportion of respondents willing to: (i) welcome Ebola survivors back into the community increased from 60.0% to 89.4% (adjusted odds ratio, aOR: 6.0; 95% confidence interval, CI: 3.9-9.1); and (ii) wait for a burial team following a relative's death increased from 86.0% to 95.9% (aOR: 4.4; 95% CI: 3.2-6.0). The proportion avoiding unsafe traditional burials increased from 27.3% to 48.2% (aOR: 3.1; 95% CI: 2.4-4.2) and the proportion believing spiritual healers can treat Ebola decreased from 15.9% to 5.0% (aOR: 0.2; 95% CI: 0.1-0.3). The likelihood respondents would wait for burial teams increased more in high-transmission (aOR: 6.2; 95% CI: 4.2-9.1) than low-transmission (aOR: 2.3; 95% CI: 1.4-3.8) regions. Self-reported avoidance of physical contact with corpses increased in high but not low-transmission regions, aOR: 1.9 (95% CI: 1.4-2.5) and aOR: 0.8 (95% CI: 0.6-1.2), respectively.Ebola knowledge, attitudes and prevention practices improved during the Sierra Leone outbreak, especially in high-transmission regions. Behaviourally-targeted community engagement should be prioritized early during outbreaks.Évaluer l'évolution des connaissances, attitudes et techniques de prévention en matière d'Ebola durant l'épidémie qui a touché la Sierra Leone entre 2014 et 2015.Quatre enquêtes en grappes ont été menées: deux avant le pic de l'épidémie (3499 participants) et deux après (7104 participants). Nous avons mesuré l'impact des facteurs géographiques et temporels sur 16 résultats liés aux connaissances, aux attitudes et aux techniques de prévention.Quatorze des seize résultats liés aux connaissances, aux attitudes et aux techniques de prévention ont progressé dans toutes les régions entre la période avant le pic et celle après le pic. La proportion de répondants disposés à: (i) accueillir les survivants à Ebola de retour dans leur communauté est passée de 60,0% à 89,4% (odds ratio ajusté, ORA: 6,0; intervalle de confiance de 95%, IC: 3,9–9,1); et (ii) attendre l'équipe d'inhumation après la mort d'un proche a également augmenté, passant de 86,0% à 95,9% (ORA: 4,4; IC de 95%: 3,2–6,0). La proportion de répondants ayant abandonné la pratique risquée des funérailles traditionnelles est passée de 27,3% à 48,2% (ORA: 3,1; IC de 95%: 2,4–4,2), tandis que celle convaincue de l'efficacité des guérisseurs spirituels pour traiter Ebola a diminué, passant de 15,9% à 5,0% (ORA: 0,2; IC de 95%: 0,1-0,3). La probabilité que les répondants attendent les équipes d'inhumation a augmenté dans les régions à haut risque de transmission (ORA: 6,2; IC de 95%: 4,2–9,1), plus que dans les régions à faible risque de transmission (ORA: 2,3; IC de 95%: 1,4–3,8). Les répondants déclarent avoir davantage évité tout contact physique avec les corps dans les régions à haut risque de transmission, mais pas dans les régions à faible risque de transmission (ORA: 1,9; IC de 95%: 1,4–2,5 et ORA: 0,8; IC de 95%: 0,6–1,2).Les connaissances, attitudes et techniques de prévention en matière d'Ebola ont évolué durant l'épidémie qui a touché la Sierra Leone, surtout dans les régions à haut risque de transmission. Il faut privilégier l'engagement communautaire axé sur le comportement dès les premiers stades de l'épidémie.Evaluar los cambios en los conocimientos, las actitudes y las prácticas de prevención relacionadas con el ébola durante el brote ocurrido en Sierra Leona entre 2014 y 2015.Se realizaron cuatro encuestas por conglomerados: dos antes del pico del brote (3499 participantes) y dos después (7104 participantes). Se evaluó el efecto de los factores temporales y geográficos en 16 resultados de conocimientos, actitudes y prácticas de prevención.14 de 16 resultados de conocimientos, actitudes y prácticas de prevención mejoraron en todas las regiones desde antes hasta después del pico del brote. El porcentaje de los encuestados dispuestos a: (i) acoger a los supervivientes del ébola en la comunidad aumentó del 60,0 % al 89,4 % (proporción de probabilidad ajustada, aOR: 6,0; intervalo de confianza del 95 %, IC: 3,9-9,1); y (ii) esperar al servicio funerario tras la muerte de un familiar aumentó del 86,0 % al 95,9 % (aOR: 4,4; IC del 95 %: 3,2-6,0). El porcentaje de personas que evitaron los entierros tradicionales inseguros aumentó del 27,3 % al 48,2 % (aOR: 3,1; IC del 95 %: 2,4-4,2) y el porcentaje de personas que creen que los sanadores espirituales pueden tratar el ébola disminuyó del 15,9 % al 5,0 % (aOR: 0,2; IC del 95 %: 0,1-0,3). La probabilidad de que los encuestados esperan a los servicios funerarios aumentó más en las regiones de alta transmisión (aOR: 6,2; IC del 95 %: 4,2-9,1) que en las de baja transmisión (aOR: 2,3; IC del 95 %: 1,4-3,8). Según los reportes de los mismos encuestados, se evitó más el contacto físico con los cadáveres en las regiones de alta pero no de baja transmisión, aOR: 1,9 (IC del 95 %: 1,4-2,5) y aOR: 0,8 (IC del 95 %: 0,6-1,2), respectivamente.Los conocimientos, las actitudes y las prácticas de prevención del ébola mejoraron durante el brote en Sierra Leona, en especial en las regiones de alta transmisión. Se debe dar prioridad a la participación de la comunidad orientada al comportamiento en las primeras etapas de los brotes.تقييم التغييرات في المعارف والمواقف وممارسات الوقاية المتعلقة بفيروس إيبولا أثناء تفشيه في سيراليون بين عامي 2014 و2015.قم بإجراء أربعة مسوحات مجمعة: اثنين قبل ذروة التفشي (بمشاركة 3499 شخصاً)، واثنين بعدها (بمشاركة 7104 شخصاً). قمنا بتقييم تأثير العوامل الزمنية والجغرافية على 16 من النتائج المعرفية ونتائج المواقف والممارسة.تحسنت 14 من 16 نتيجةً للمعرفة والمواقف وممارسات الوقاية عبر كل المناطق، سواء من قبل أو بعد ذروة التفشي. نسبة المستجيبين الراغبين في: (1) الترحيب بعودة الناجين من الإصابة بإيبولا إلى المجتمع، ارتفعت من 60.0% إلى 89.4% (نسبة الاحتمالات المعدلة: 6.0؛ فاصل الثقة 95%: 3.9 إلى 9.1)؛ و(2) ارتفعت نسبة انتظار فريق الدفن بعد وفاة أحد الأقارب، من 86.0% إلى 95.9% (نسبة الاحتمالات المعدلة: 4.4؛ ‏بفاصل ثقة 95%: من 3.2 إلى 6.0). ارتفعت نسبة تجنب عمليات الدفن التقليدي غير الآمن من 27.3% إلى 48.2% (نسبة الاحتمالات المعدلة: 3.1؛ ‏بفاصل ثقة 95%: 2.4 إلى 4.2)، وانخفضت نسبة المصدقين بالمعالجين الروحيين الذين يمكنهم علاج إيبولا من 15.9% إلى 5.0% (نسبة الاحتمالات المعدلة: 0.2؛ ‏بفاصل ثقة 95%: من 0.1 إلى 0.3). ارتفعت نسبة احتمال انتظار المستجيبين لفرق الدفن في مناطق الانتشار السريع (نسبة الاحتمالات المعدلة: 6.2؛ ‏بفاصل ثقة 95%: 4.2 إلى 9.1) عن مناطق الانتشار المنخفض (نسبة الاحتمالات المعدلة: 2.3؛ ‏بفاصل ثقة 95%: 1.4 إلى 3.8). ازدادت نسبة الإبلاغ الذاتي عن تجنب التلامس الجسدي مع الجثث في المناطق ذات الانتشار المرتفع، وليس الانتشار المنخفض، نسبة الاحتمالات المعدلة: 1.9 (فاصل الثقة 95%: 1.4 إلى 2.5) ونسبة الاحتمالات المعدلة: 0.8 (فاصل الثقة 95%: 0.6 إلى 1.2)، على الترتيب.شهدت المعارف والمواقف وممارسات الوقاية المتعلقة بفيروس إيبولا، تحسناً أثناء تفشيه في سيراليون، وخاصة في المناطق ذات الانتشار المرتفع. يجب توجيه الأولوية لإشراك المجتمع المستهدف سلوكياً في وقت مبكر أثناء حالات التفشي.旨在评估 2014 年至 2015 年塞拉利昂疫情期间与埃博拉相关知识、态度和预防措施的变化。.进行四次群组调查：疫情高峰期前两次（3499 位参与者），疫情高峰期后两次（7104 位参与者）。我们评估了时间和地理因素对 16 个知识、态度和措施结果的影响。.16 个知识、态度和预防措施结果中有 14 个在各地区爆发高峰期前至爆发高峰期后都有所改善。受访者中，愿意：(i) 欢迎埃博拉幸存者重返社区的受访者比例从 60.0% 增加到 89.4%（调整后比值，aOR：6.0；95% 置信区间，CI：3.9–9.1）；和 (ii) 亲属死亡后等待埋葬队的受访者比例从 86.0% 增加到 95.9% (aOR：4.4；95% CI: 3.2-6.0）。避免不安全的传统葬礼的比例从 27.3% 增加到 48.2% (aOR：3.1；95% CI: 2.4–4.2) ，相信精神治疗师可以治疗埃博拉的比例从 15.9% 降低到 5.0% (aOR：0.2；95% CI: 0.1-0.3）。受访者等待埋葬队的可能性在高传播地区 (aOR：6.2；95% CI: 4.2–9.1) 比低传播地区 (aOR: 2.3；95% CI: 1.4-3.8) 更高。高传播地区受访者自述避免与尸体发生实际接触的情况有所增加，而低传播地区无此趋势，分别为 aOR：1.9 (95% CI: 1.4–2.5) 和 aOR: 0.8 (95% CI: 0.6–1.2)。.在塞拉利昂疫情期间，特别是在高传播地区，埃博拉知识、态度和预防措施已得到改善。在行为上，具有针对性的社区参与应在疫情爆发早期被确定优先事项。.Оценить изменения в наших знаниях о лихорадке Эбола, в поведении и в профилактических действиях во время вспышки заболевания в Сьерра-Леоне на протяжении 2014–2015 гг.Было проведено четыре кластерных опроса: два до пика заболевания (3499 участников) и два после (7104 участника). Мы оценили воздействие временного и географического факторов на 16 показателей, связанных со знаниями, поведением и действиями.Четырнадцать из 16 показателей в области знаний, поведения и профилактических действий улучшились по всем регионам после вспышки по сравнению с предшествующей ситуацией. Доля респондентов: (i) которые не возражали против возвращения выживших больных в общину, выросла с 60,0 до 89,4% (скорректированное отношение шансов, сОШ: 6,0; 95%-й ДИ: 3,9–9,1); (ii) которые дожидались прибытия похоронной команды после смерти родственника, выросла с 86,0 до 95,9% (сОШ: 4,4; 95%-й ДИ: 3,2–6,0). Доля тех, кто избегал небезопасных традиционных похоронных практик, выросла с 27,3 до 48,2% (сОШ: 3,1; 95%-й ДИ: 2,4–4,2), и доля тех, кто считал, что духовные целители могут вылечить лихорадку Эбола, снизилась с 15,9 до 5,0% (сОШ: 0,2; 95%-й ДИ: 0,1–0,3). Вероятность того, что респонденты будут ждать прибытия похоронной команды, сильнее выросла в зонах с высоким уровнем передачи инфекции (сОШ: 6,2; 95%-й ДИ: 4,2–9,1), чем в зоне с низким уровнем передачи (сОШ: 2,3; 95%-й ДИ: 1,4–3,8). Частота сообщений о том, что респондент избегает физического контакта с трупами, выросла в зонах высокой передачи инфекции, но не в зонах ее низкой передачи, сОШ 1,9 (95%-й ДИ: 1,4–2,5) и сОШ 0,8 (95%-й ДИ: 0,6–1,2) соответственно.Знания, поведение и действия, предотвращающие распространение лихорадки Эбола, в ходе вспышки в Сьерра-Леоне улучшились, особенно в регионах с высоким уровнем передачи инфекции. На ранних этапах развития вспышки следует на первое место поставить участие общины и организацию правильного ее поведения.

The US Centers for Disease Control and Prevention recently issued new recommendations to screen persons born between 1945 and 1965 for hepatitis C virus. Federal facilities in the US Indian Health Service were surveyed on knowledge and support for the hepatitis C virus recommendations, as well as barriers and concerns.

Background Routine childhood varicella vaccination, implemented in 1995, has resulted in significant declines in varicella-related hospitalizations in the United States. Varicella hospitalization rates among the American Indian (AI) and Alaska Native (AN) population have not been previously documented. Methods We selected varicella-related hospitalizations, based on a published definition, from the Indian Health Service inpatient database for AI/ANs in the Alaska, Southwest and Northern Plains regions (1995-2010) and from the Nationwide Inpatient Sample for the general US population (2007-2010). We analyzed average annual hospitalization rates prevaccine (1995-1998) and postvaccine (2007-2010) for the AI/AN population, and postvaccine for the general US population. Results From 1995-1998 to 2007-2010, the average annual varicella-related hospitalization rate for AI/ANs in the 3 regions decreased 95% (0.66-0.03/10,000 persons); the postvaccine rate appears lower than the general US rate (0.06, 95% confidence interval: 0.05-0.06). The rate declined in all AI/AN pediatric age groups. Infants experienced the highest prevaccine (14.07) and postvaccine (0.83) hospitalization rates. Adults experienced low rates in both periods. Varicella vaccination rates in 19- to 35-month-old AI/AN children during fiscal years 2008-2010 were 88.1-91.0%. Conclusions Widespread use of varicella vaccine in AI/AN children was accompanied by substantial declines in varicella-related hospitalizations consistent with high varicella vaccine effectiveness in preventing severe varicella outcomes.

Objectives. To examine the epidemiology of infectious disease (ID) hospitalisations among Alaska Native (AN) people. Methods. Hospitalisations with a first-listed ID diagnosis for American Indians and ANs residing in Alaska during 2001-2009 were selected from the Indian Health Service direct and contract health service inpatient data. ID hospitalisations to describe the general US population were selected from the Nationwide Inpatient Sample. Annual and average annual (2007-2009) hospitalization rates were calculated. Results. During 2007-2009, IDs accounted for 20% of hospitalisations among AN people. The 20072009 average annual age-adjusted ID hospitalisation rate (2126/100,000 persons) was higher than that for the general US population (1679/100,000; 95% CI 1639-1720). The ID hospitalisation rate for AN people increased from 2001 to 2009 (17%, p

The global reference list of 100 core health indicators is a standard set of indicators published by the World Health Organization in 2015. We reviewed core health indicators in the public domain and in-country for Sierra Leone, the African continent and globally. Review objectives included assessing available sources, accessibility and feasibility of obtaining data and informing efforts to monitor program progress. Our search strategy was guided by feasibility considerations targeting mainly national household surveys in Sierra Leone and topic-specific and health statistics reports published annually by WHO. We also included national, regional and worldwide health indicator estimates published with open access in the literature and compared them with cumulative annual indicators from the weekly national epidemiological bulletin distributed by the Sierra Leone Ministry of Health and Sanitation. We obtained 70 indicators for Sierra Leone from Internet sources and 2 (maternal mortality and malaria incidence) from the national bulletin. Of the 70 indicators, 14 (20%) were modified versions of WHO indicators and provided uncertainty intervals. Maternal mortality showed considerable differences between 2 international sources for 2015 and the most recent national bulletin. We were able to obtain the majority of core indicators for Sierra Leone. Some indicators were similar but not identical, uncertainty intervals were limited and estimates differed for the same year between sources. Current efforts to improve health and mortality surveillance in Sierra Leone will improve availability and quality of reporting in the future. A centralized core indicator reporting website should be considered.

By the end of the Ebola epidemic, death reporting in Sierra Leone (SL) became more acceptable amongst local populations, with nearly all deaths being reported to the Ebola hot line alert centers. To continue the positive momentum generated by the epidemic, the Sierra Leone Ministry of Health and Sanitation (MoHS) and the US Centers for Disease Control and Prevention (CDC) organized and conducted the two-day Inter-agency Consultations on Improving Mortality Reporting in Sierra Leone (Consultations). In conjunction with the Consultations, participants were also offered a one-day, in-person training on the major components, characteristics, and uses of a national Civil Registration and Vital Statistics (CRVS) system. To understand processes used by governmental and non-governmental organizations in collection of death data before and during the Ebola epidemic, and to develop recommendations on improving death reporting and CRVS in Sierra Leone. The Inter-agency Consultations were conducted in person over two days in October, 2015. Real-time notes were kept by CDC staff for later abstraction and summarizing. Presenters agreed to share their materials (usually PowerPoint presentations) and approved the summaries. Challenges to implementation and suggestions for improving death reporting were drawn from the presentations and from anonymous suggestions collected at the end of each of three days of the Consultations. The Consultations attracted more than 80 participants from 28 Sierra Leone governmental, business, and other non-governmental organizations. Over the course of 18 presentations, participants presented and discussed the ways deaths were reported before and during the Ebola epidemic and ways in which the CRVS in Sierra Leone might be improved. The presentations made clear the need to improve death reporting in order to improve the health status of Sierra Leone. Many presenters and participants discussed the challenges to improvements, including lack of infrastructure and country diversity. In addition, participants generally agreed upon the need for improving the government’s understanding of the benefits of death reporting at multiple levels: from local chiefdom authorities and councils to the community and individual families. Despite the many challenges identified, all participants stressed the need for modernizing and improving death registration in Sierra Leone. The recommendations from the presentations and notes collected at the end of each day can be categorized within the following five domains: capacity building (organizational, staffing, infrastructure, policies, guidelines and tools), awareness and sensitization (including strategies to use best practices and emerging technologies), political will (governmental support and prioritization), funding (providing resources to achieve sustainability), and monitoring and evaluation (developing charts of existing death reporting pathways and identifying challenges).

Developing a surveillance system during a public health emergency is always challenging but is especially so in countries with limited public health infrastructure. Surveillance for Ebola virus disease (Ebola) in the West African countries heavily affected by Ebola (Guinea, Liberia, and Sierra Leone) faced numerous impediments, including insufficient numbers of trained staff, community reticence to report cases and contacts, limited information technology resources, limited telephone and Internet service, and overwhelming numbers of infected persons. Through the work of CDC and numerous partners, including the countries' ministries of health, the World Health Organization, and other government and nongovernment organizations, functional Ebola surveillance was established and maintained in these countries. CDC staff were heavily involved in implementing case-based surveillance systems, sustaining case surveillance and contact tracing, and interpreting surveillance data. In addition to helping the ministries of health and other partners understand and manage the epidemic, CDC's activities strengthened epidemiologic and data management capacity to improve routine surveillance in the countries affected, even after the Ebola epidemic ended, and enhanced local capacity to respond quickly to future public health emergencies. However, the many obstacles overcome during development of these Ebola surveillance systems highlight the need to have strong public health, surveillance, and information technology infrastructure in place before a public health emergency occurs. Intense, long-term focus on strengthening public health surveillance systems in developing countries, as described in the Global Health Security Agenda, is needed.The activities summarized in this report would not have been possible without collaboration with many U.S and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).

SUMMARYIn 2008, nationwide investigations of a Salmonella serotype Saintpaul outbreak led first to consumer warnings for Roma and red round tomatoes, then later for jalapeño and serrano peppers. In New Mexico, where there were a large number of cases but no restaurant-based clusters, the NM Department of Health and the Indian Health Service participated with CDC in individual-level and household-level case-control studies of infections in New Mexico and the Navajo Nation. No food item was associated in the individual-level study. In the household-level study, households with an ill member were more likely to have had jalapeño peppers present during the exposure period and to have reported ever having serrano peppers in the household. This report illustrates the complexity of this investigation, the limitations of traditional individual-level case-control studies when vehicles of infection are ingredients or commonly eaten with other foods, and the added value of a household-level study.

SUMMARYWe investigated a possible outbreak ofH. pyloriin a rural Northern Plains community. In a cross-sectional survey, we randomly sampled 244 households from a geocoded emergency medical system database. We used a complex survey design and global positioning system units to locate houses and randomly selected one eligible household member to administer a questionnaire and a13C-urea breath test for activeH. pyloriinfection (n = 166). In weighted analyses, activeH. pyloriinfection was detected in 55·0% of the sample. Factors associated with infection on multivariate analysis included using a public drinking-water supply [odds ratio (OR) 12·2, 95% confidence interval (CI) 2·9–50·7] and current cigarette smoking (OR 4·1, 95% CI 1·7–9·6). People who lived in houses with more rooms, a possible indicator of decreased crowding in the home, were less likely to have activeH. pyloriinfections (OR 0·7, 95% CI 0·5–0·9 for each additional room).

Objectives. We examined trends and epidemiology of tuberculosis (TB) across racial/ethnic groups to better understand TB disparities in the United States, with particular focus on American Indians/Alaska Natives (AI/ANs) and Native Hawaiians/other Pacific Islanders (NH/PIs). Methods. We analyzed cases in the U.S. National Tuberculosis Surveillance System and calculated TB case rates among all racial/ethnic groups from 2003 to 2008. Socioeconomic and health indicators for counties in which TB cases were reported came from the Health Resources and Services Administration Area Resource File. Results. Among the 82,836 TB cases, 914 (1.1%) were in AI/ANs and 362 (0.4%) were in NH/PIs. In 2008, TB case rates for AI/ANs and NH/PIs were 5.9 and 14.7 per 100,000 population, respectively, rates that were more than five and 13 times greater than for non-Hispanic white people (1.1 per 100,000 population). From 2003 to 2008, AI/ANs had the largest percentage decline in TB case rates (–27.4%) for any racial/ethnic group, but NH/PIs had the smallest percentage decline (–3.5%). AI/ANs were more likely than other racial/ethnic groups to be homeless, excessively use alcohol, receive totally directly observed therapy, and come from counties with a greater proportion of people living in poverty and without health insurance. A greater proportion of NH/PIs had extrapulmonary disease and came from counties with a higher proportion of people with a high school diploma. Conclusions. There is a need to develop flexible TB-control strategies that address the social determinants of health and that are tailored to the specific needs of AI/ANs and NH/PIs in the U.S.

Raw produce is an increasingly recognized vehicle for salmonellosis. We investigated a nationwide outbreak that occurred in the United States in 2008.We defined a case as diarrhea in a person with laboratory-confirmed infection with the outbreak strain of Salmonella enterica serotype Saintpaul. Epidemiologic, traceback, and environmental studies were conducted.Among the 1500 case subjects, 21% were hospitalized, and 2 died. In three case-control studies of cases not linked to restaurant clusters, illness was significantly associated with eating raw tomatoes (matched odds ratio, 5.6; 95% confidence interval [CI], 1.6 to 30.3); eating at a Mexican-style restaurant (matched odds ratio, 4.6; 95% CI, 2.1 to ∞) and eating pico de gallo salsa (matched odds ratio, 4.0; 95% CI, 1.5 to 17.8), corn tortillas (matched odds ratio, 2.3; 95% CI, 1.2 to 5.0), or salsa (matched odds ratio, 2.1; 95% CI, 1.1 to 3.9); and having a raw jalapeño pepper in the household (matched odds ratio, 2.9; 95% CI, 1.2 to 7.6). In nine analyses of clusters associated with restaurants or events, jalapeño peppers were implicated in all three clusters with implicated ingredients, and jalapeño or serrano peppers were an ingredient in an implicated item in the other three clusters. Raw tomatoes were an ingredient in an implicated item in three clusters. The outbreak strain was identified in jalapeño peppers collected in Texas and in agricultural water and serrano peppers on a Mexican farm. Tomato tracebacks did not converge on a source.Although an epidemiologic association with raw tomatoes was identified early in this investigation, subsequent epidemiologic and microbiologic evidence implicated jalapeño and serrano peppers. This outbreak highlights the importance of preventing raw-produce contamination.

Alaska Native people have suffered disproportionately from previous influenza pandemics. We evaluated 3 separate syndromic data sources to determine temporal and geographic patterns of spread of 2009 pandemic influenza A H1N1 (pH1N1) in Alaska, and reviewed records from persons hospitalized with pH1N1 disease in 3 areas in Alaska to characterize clinical and epidemiologic features of disease in Alaskans. A wave of pH1N1 disease swept through Alaska beginning in most areas in August or early September. In rural regions, where Alaska Native people comprise a substantial proportion of the population, disease occurred earlier than in other regions. Alaska Native people and Asian/Pacific Islanders (A/PI) were 2-4 times more likely to be hospitalized than whites. Alaska Native people and other minorities remain at high risk for early and substantial morbidity from pandemic influenza episodes. These findings should be integrated into plans for distribution and use of vaccine and antiviral agents.

OBJECTIVES We sought to determine attitudes and needs among health care providers in the Indian Health Service toward implementing routine human immunodeficiency virus (HIV) screening among 13- to 64-year-olds as per Centers for Disease Control and Prevention (CDC) guidelines. METHODS We surveyed a random sample of Indian Health Service physicians and nurses by e-mail and telephone interview. A total of 205 eligible respondents (response rate = 70%) completed the survey. RESULTS A majority (58%) of respondents were familiar or somewhat familiar with the 2006 CDC guidelines on HIV screening for 13- to 64-year-olds. A proportion of respondents (43%) felt that community HIV prevalence was below the 0.1% threshold the CDC recommends to initiate screening. Respondents supported routine, rather than solely risk-based HIV testing (70%) and stated that HIV screening would be realistic in their health facility (51%). Respondents felt that they needed special qualification to offer an HIV test (49%) or to notify a patient of a "reactive" HIV test result (67%). CONCLUSIONS A majority of Indian Health Service physicians and nurses support the CDC HIV screening guidelines. Providers need more information and training on HIV screening guidelines, implementation strategies, and relevant state HIV regulations.

BACKGROUND. American Indians and Alaska Natives (AI/AN) experience higher morbidity and mortality from primary liver cancer than other United States (US) populations, but racial misclassification in medical records results in underestimates of disease burden. METHODS. To reduce misclassification, National Program of Cancer Registries and Surveillance, Epidemiology, and End Results data were linked with Indian Health Service (IHS) enrollment records to compare primary liver cancer incidence and stage at diagnosis between AI/AN and non-Hispanic whites (NHW) living within the regionalized IHS Contract Health Service Delivery Area counties. Incidence rates are expressed per 100,000 persons and age-adjusted by 19 age groups to the 2000 US standard population. RESULTS. Overall, AI/AN have a higher proportion of hepatocellular carcinoma compared with NHW, 77.8% versus 66.7%. Liver cancer incidence rates among AI/AN males and females were higher than those among NHW males and females for all regions except for the East. Among males, rates ranged from 7.3 (95% confidence interval [CI], 3.8‒12.6) in the East to 17.2 (95% CI, 10.4‒26.3) in Alaska. Among females, rates ranged from 3.8 (95% CI, 1.4‒8.2) in the East to 6.9 (95% CI, 3.6‒11.6) in Alaska. The AI/AN rates for all regions were consistently higher than the NHW rates at every age. An increasing trend among AI/AN was suggested but did not achieve statistical significance. CONCLUSIONS. Reducing racial misclassification revealed higher disparities in primary liver cancer incidence between NHW and AI/AN populations than previously reported. Further description of the reasons for regional differences in this disparity is needed, as are programs to reduce risk factors and to diagnose primary liver cancer at earlier, more treatable stages. Cancer 2008;113(5 supp):1244–55. Published 2008 by the American Cancer Society.

To end the largest known outbreak of Ebola virus disease (EVD) in West Africa and to prevent new transmissions, rapid epidemiological tracing of cases and contacts was required. The ability to quickly identify unknown sources and chains of transmission is key to ending the EVD epidemic and of even greater importance in the context of recent reports of Ebola virus (EBOV) persistence in survivors. Phylogenetic analysis of complete EBOV genomes can provide important information on the source of any new infection. A local deep sequencing facility was established at the Mateneh Ebola Treatment Centre in central Sierra Leone. The facility included all wetlab and computational resources to rapidly process EBOV diagnostic samples into full genome sequences. We produced 554 EBOV genomes from EVD cases across Sierra Leone. These genomes provided a detailed description of EBOV evolution and facilitated phylogenetic tracking of new EVD cases. Importantly, we show that linked genomic and epidemiological data can not only support contact tracing but also identify unconventional transmission chains involving body fluids, including semen. Rapid EBOV genome sequencing, when linked to epidemiological information and a comprehensive database of virus sequences across the outbreak, provided a powerful tool for public health epidemic control efforts., info:eu-repo/semantics/published

We used molecular epidemiologic techniques to document patient-to-patient transmission of hepatitis B virus (HBV) between 2 outpatient oral surgery patients operated on 161 min apart. Serological testing of 25 (93%) of 27 patients operated on after the source patient revealed that 19 (76%) of 25 were previously immune to HBV; no additional cases were identified. We found no deficiencies in infection control practices. Transmission may have been limited by the high prevalence (64%) of patients vaccinated against HBV. To our knowledge, this is the first documented case of patient-to-patient transmission of a bloodborne pathogen in a dental setting in the United States.

The first confirmed case of Ebola virus disease (Ebola) in Sierra Leone related to the ongoing epidemic in West Africa occurred in May 2014, and the outbreak quickly spread. To date, 8,704 Ebola cases and 3,955 Ebola deaths have been confirmed in Sierra Leone. The first Ebola treatment units (ETUs) in Sierra Leone were established in the eastern districts of Kenema and Kailahun, where the first Ebola cases were detected, and these districts were also the first to control the epidemic. By September and October 2014, districts in the western and northern provinces, including Bombali, had the highest case counts, but additional ETUs outside of the eastern province were not operational for weeks to months. Bombali became one of the most heavily affected districts in Sierra Leone, with 873 confirmed patients with Ebola during July-November 2014. The first ETU and laboratory in Bombali District were established in late November and early December 2014, respectively. T- evaluate the impact of the first ETU and laboratory becoming operational in Bombali on outbreak control, the Bombali Ebola surveillance team assessed epidemiologic indicators before and after the establishment of the first ETU and laboratory in Bombali. After the establishment of the ETU and laboratory, the interval from symptom onset to laboratory result and from specimen collection to laboratory result decreased. By providing treatment to Ebola patients and isolating contagious persons to halt ongoing community transmission, ETUs play a critical role in breaking chains of transmission and preventing uncontrolled spread of Ebola (4). Prioritizing and expediting the establishment of an ETU and laboratory by pre-positioning resources needed to provide capacity for isolation, testing, and treatment of Ebola are essential aspects of pre-outbreak planning.

Background In the largest Ebola virus disease (EVD) outbreak in history, nosocomial transmission of EVD increased spread of the disease. We report on 2 instances in Sierra Leone where patients unknowingly infected with EVD were admitted to a general hospital ward (1 pediatric ward and 1 maternity ward), exposing health care workers, caregivers, and other patients to EVD. Both patients died on the general wards, and were later confirmed as being infected with EVD. We initiated contact tracing and assessed risk factors for secondary infections to guide containment recommendations. Methods We reviewed medical records to establish the index patients' symptom onset. Health care workers, patients, and caregivers were interviewed to determine exposures and personal protective equipment (PPE) use. Contacts were monitored daily for EVD symptoms. Those who experienced EVD symptoms were isolated and tested. Results Eighty-two contacts were identified: 64 health care workers, 7 caregivers, 4 patients, 4 newborns, and 3 children of patients. Seven contacts became symptomatic and tested positive for EVD: 2 health care workers (1 nurse and 1 hospital cleaner), 2 caregivers, 2 newborns, and 1 patient. The infected nurse placed an intravenous catheter in the pediatric index patient with only short gloves PPE and the hospital cleaner cleaned the operating room of the maternity ward index patient wearing short gloves PPE. The maternity ward index patient's caregiver and newborn were exposed to her body fluids. The infected patient and her newborn shared the ward and latrine with the maternity ward index patient. Hospital staff members did not use adequate PPE. Caregivers were not offered PPE. Conclusions Delayed recognition of EVD and inadequate PPE likely led to exposures and secondary infections. Earlier recognition of EVD and adequate PPE might have reduced direct contact with body fluids. Limiting nonhealth-care worker contact, improving access to PPE, and enhancing screening methods for pregnant women, children, and inpatients may help decrease EVD transmission in general health care settings.

On January 14, 2016, the Sierra Leone Ministry of Health and Sanitation was notified that a buccal swab collected on January 12 from a deceased female aged 22 years (patient A) in Tonkolili District had tested positive for Ebola virus by reverse transcription-polymerase chain reaction (RT-PCR). The most recent case of Ebola virus disease (Ebola) in Sierra Leone had been reported 4 months earlier on September 13, 2015 (1), and the World Health Organization had declared the end of Ebola virus transmission in Sierra Leone on November 7, 2015 (2). The Government of Sierra Leone launched a response to prevent further transmission of Ebola virus by identifying contacts of the decedent and monitoring them for Ebola signs and symptoms, ensuring timely treatment for anyone with Ebola, and conducting an epidemiologic investigation to identify the source of infection.

A toll-free, nationwide phone alert system was established for rapid notification and response during the 2014–2015 Ebola epidemic in Sierra Leone. The system remained in place after the end of the epidemic under a policy of mandatory reporting and Ebola testing for all deaths, and, from June 2016, testing only in case of suspected Ebola. We describe the design, implementation and changes in the system; analyse calling trends during and after the Ebola epidemic; and discuss strengths and limitations of the system and its potential role in efforts to improve death reporting in Sierra Leone. Numbers of calls to report deaths of any cause (death alerts) and persons suspected of having Ebola (live alerts) were analysed by province and district and compared with numbers of Ebola cases reported by the WHO. Nearly 350 000 complete, non-prank calls were made to 117 between September 2014 and December 2016. The maximum number of daily death and live alerts was 9344 (October 2014) and 3031 (December 2014), respectively. Call volumes decreased as Ebola incidence declined and continued to decrease in the post-Ebola period. A national social mobilisation strategy was especially targeted to influential religious leaders, traditional healers and women’s groups. The existing infrastructure and experience with the system offer an opportunity to consider long-term use as a death reporting tool for civil registration and mortality surveillance, including rapid detection and control of public health threats. A routine social mobilisation component should be considered to increase usage.