BACKGROUND: Japanese encephalitis (JE) virus is the leading cause of vaccine-preventable encephalitis and a significant cause of disability in Asia and the western Pacific. Many countries have introduced JE vaccination programs, including several low resource countries following WHO's prioritization of JE vaccination in 2006. We sought to characterize the public health impact of JE vaccination programs. METHODOLOGY/PRINCIPAL FINDINGS: JE case data and vaccination coverage rates, were requested from country health officials in 23 JE endemic countries and Chinese Taipei. Additional data were extracted from meeting presentations and published literature. JE incidence was compared before and after vaccination using a minimum three year period pre and post program introduction or expansion. Data suitable for analysis were available for 13 JE-endemic countries and Chinese Taipei, for either all age groups or for children aged under 15 years only. Five countries and Chinese Taipei introduced vaccine prior to 2006 and the all-age JE incidence was reduced by 73-100% in about 5-20 years following introduction. Six countries have introduced JE vaccine since 2006, and JE incidence in children aged younger than 15 years has been reduced by 14-79% as of 2015-2021. JE-specific data were unavailable before introduction in Thailand and Vietnam, but vaccination programs reduced acute encephalitis incidence by 80% and 74%, respectively. Even in the programs with greatest impact, it took several years to achieve their results. CONCLUSIONS/SIGNIFICANCE: JE vaccination has greatly reduced JE in 13 JE-endemic countries and Chinese Taipei. Highest impact has been observed in countries that introduced prior to 2006, but it often took roughly two decades and substantial resources to achieve that level of success. For greatest possible impact, more recently introducing countries and funding agencies should commit to continuous improvements in delivery systems to sustain coverage after initial vaccine introduction.

Vaccines against Japanese encephalitis (JE) have been available for decades. Currently, most JE-endemic countries have vaccination programs for their at-risk populations. Even so, JE remains the leading recognized cause of viral encephalitis in Asia. In 2018, the U.S. Centers for Disease Control and Prevention and PATH co-convened a group of independent experts to review JE prevention and control successes, identify remaining scientific and operational issues that need to be addressed, discuss opportunities to further strengthen JE vaccination programs, and identify strategies and solutions to ensure sustainability of JE control during the next decade. This paper summarizes the key discussion points and recommendations to sustain and expand JE control.

In 2011, Bhutan's Royal Centre for Disease Control began Japanese encephalitis (JE) surveillance at 5 sentinel hospitals throughout Bhutan. During 2011-2018, a total of 20 JE cases were detected, indicating JE virus causes encephalitis in Bhutan. Maintaining JE surveillance will help improve understanding of JE epidemiology in this country.

BACKGROUND: Japanese encephalitis (JE) occurs in fewer than 1% of JE virus (JEV) infections, often with catastrophic sequelae including death and neuropsychiatric disability. JEV transmission in Pakistan was documented in 1980s and 1990s, but recent evidence is lacking. Our objective was to investigate JEV as a cause of acute encephalitis in Pakistan. METHODS: Persons aged >/=1 month with possible JE admitted to two acute care hospitals in Karachi, Pakistan from April 2015 to January 2018 were enrolled. Cerebrospinal fluid (CSF) or serum samples were tested for JEV immunoglobulin M (IgM) using the InBios JE DetectTM assay. Positive or equivocal samples had confirmatory testing using plaque reduction neutralization tests. RESULTS: Among 227 patients, testing was performed on CSF in 174 (77%) and on serum in 53 (23%) patients. Six of eight patient samples positive or equivocal for JEV IgM had sufficient volume for confirmatory testing. One patient had evidence of recent West Nile virus (WNV) neurologic infection based on CSF testing. One patient each had recent dengue virus (DENV) infection and WNV infection based on serum results. Recent flavivirus infections were identified in two persons, one each based on CSF and serum results. Specific flaviviruses could not be identified due to serologic cross-reactivity. For the sixth person, JEV neutralizing antibodies were confirmed in CSF but there was insufficient volume for further testing. CONCLUSIONS: Hospital-based JE surveillance in Karachi, Pakistan could not confirm or exclude local JEV transmission. Nonetheless, Pakistan remains at risk for JE due to presence of the mosquito vector, amplifying hosts, and rice irrigation. Laboratory surveillance for JE should continue among persons with acute encephalitis. However, in view of serological cross-reactivity, confirmatory testing of JE IgM positive samples at a reference laboratory is essential.

Estimating blood demand to determine collection goals challenges many low-income countries. We sampled Tanzanian hospitals to estimate national blood demand. A representative sample based on probability proportional to size sampling of 42 of 273 (15%) Tanzanian transfusing hospitals was selected. Blood bank registers, patient medical records, and blood component disposition records were reviewed prospectively from June to September 2013 to determine the number of components requested and the number and proportion issued, not issued due to nonavailability, and not issued for other reasons. Data were estimated for an annual national estimate. Of an estimated 278 371 components requested in 2013, 6648 (2.4%) were not issued due to nonavailability, 34 591 (12.4%) were not issued for other reasons, and 244 535 (87.8%) were issued. Of these 278 371 components, 86 753 (31.2%) were requested by adult medical, 74 499 (26.8%) by pediatric medical, and 57 312 (20.6%) by obstetric units. In these 3 units, the proportion of units not issued due to nonavailability was 1.8%. Private (4.1%) and large (6%) hospitals had the largest proportion of units not issued because of nonavailability. Of 244 535 issued components, 91 690 (37.5%) were collected, tested, and issued from blood banks that are not part of the Tanzania National Blood Transfusion Services (TNBTS). Nearly 98% of blood component demand was met. However, a large portion of the blood supply for the hospitals came from non-TNBTS blood banks. TNBTS could increase availability of safe blood through assuring the quality of donor selection and donation testing at non-TNBTS blood banks.

Japanese encephalitis (JE) virus is the most important vaccine-preventable cause of encephalitis in the Asia-Pacific region. The World Health Organization (WHO) recommends integration of JE vaccination into national immunization schedules in all areas where the disease is a public health priority (1). This report updates a previous summary of JE surveillance and immunization programs in Asia and the Western Pacific in 2012 (2). Since 2012, funding for JE immunization has become available through the GAVI Alliance, three JE vaccines have been WHO-prequalified,* and an updated WHO JE vaccine position paper providing guidance on JE vaccines and vaccination strategies has been published (1). Data for this report were obtained from a survey of JE surveillance and immunization practices administered to health officials in countries with JE virus transmission risk, the 2015 WHO/United Nations Children's Fund Joint Reporting Form on Immunization, notes and reports from JE meetings held during 2014-2016, published literature, and websites. In 2016, 22 (92%) of 24 countries with JE virus transmission risk conducted JE surveillance, an increase from 18 (75%) countries in 2012, and 12 (50%) countries had a JE immunization program, compared with 11 (46%) countries in 2012. Strengthened JE surveillance, continued commitment, and adequate resources for JE vaccination should help maintain progress toward prevention and control of JE.

BACKGROUND AND OBJECTIVES: Since 2004, several African countries, including Namibia, have received assistance from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Gains have been documented in the safety and number of collected units in these countries, but the distribution of blood has not been described. MATERIALS AND METHODS: Nine years of data on blood requests and issues from Namibia were stratified by region to describe temporal and spatial changes in the number and type of blood components issued to Namibian healthcare facilities nationally. RESULTS: Between 2004 and 2007 (early years of PEPFAR support) and 2008-2011 (peak years of PEPFAR support), the average number of red cell units issued annually increased by 23.5% in seven densely populated but less-developed regions in northern Namibia; by 30% in two regions with urban centres; and by 35.1% in four sparsely populated rural regions. CONCLUSION: Investments in blood safety and a policy decision to emphasize distribution of blood to underserved regions improved blood availability in remote rural areas and increased the proportion of units distributed as components. However, disparities persist in the distribution of blood between Namibia's urban and rural regions.

BACKGROUND: Few African countries separate blood donations into components; however, demand for platelets (PLTs) is increasing as regional capacity to treat causes of thrombocytopenia, including chemotherapy, increases. Namibia introduced single-donor apheresis PLT collections in 2007 to increase PLT availability while reducing exposure to multiple donors via pooling. This study describes the impact this transition had on PLT availability and safety in Namibia. STUDY DESIGN AND METHODS: Annual national blood collections and PLT units issued data were extracted from a database maintained by the Blood Transfusion Service of Namibia (NAMBTS). Production costs and unit prices were analyzed. RESULTS: In 2006, NAMBTS issued 771 single and pooled PLT doses from 3054 whole blood (WB) donations (drawn from 18,422 WB donations). In 2007, NAMBTS issued 486 single and pooled PLT doses from 1477 WB donations (drawn from 18,309 WB donations) and 131 single-donor PLT doses. By 2011, NAMBTS issued 837 single-donor PLT doses per year, 99.1% of all PLT units. Of 5761 WB donations from which PLTs were made in 2006 to 2011, a total of 20 (0.35%) were from donors with confirmed test results for human immunodeficiency virus or other transfusion-transmissible infections (TTIs). Of 2315 single-donor apheresis donations between 2007 and 2011, none of the 663 donors had a confirmed positive result for any pathogen. As apheresis replaced WB-derived PLTs, apheresis production costs dropped by a mean of 8.2% per year, while pooled PLT costs increased by an annual mean of 21.5%. Unit prices paid for apheresis- and WB-derived PLTs increased by 9 and 7.4% per year on average, respectively. CONCLUSION: Namibia's PLT transition shows that collections from repeat apheresis donors can reduce TTI risk and production costs.

National blood use patterns in sub-Saharan Africa are poorly described. Although malaria and maternal hemorrhage remain important drivers of blood demand across Africa, economic growth and changes in malaria, HIV/AIDS, and noncommunicable disease epidemiology may contribute to changes in blood demand. We evaluated indications for blood use in Namibia, a country in southern Africa, using a nationally representative sample and discuss implications for the region. Clinical and demographic data related to the issuance of blood component units in Namibia were reviewed for a 4-year period (August 1, 2007-July 31, 2011). Variables included blood component type, recipient age and sex, and diagnosis. Diagnoses reported by clinicians were reclassified into International Statistical Classification of Diseases, 10th Revision categories. Multiple imputation methods were used to complete a data set missing age, sex or diagnosis data. Descriptive analyses were conducted to describe indications for transfusions and use of red blood cells (RBCs), platelets, and plasma. A total of 39 313 records accounting for 91 207 blood component units were analyzed. The median age of Namibian transfusion recipients was 45 years (SD, +/-19). A total of 78 660 RBC units were issued in Namibia during the study period. Red blood cells transfused for "unspecified anemia" accounted for the single largest category of blood issued (24 798 units). Of the overall total, 38.9% were for diseases of the blood and blood-forming organs (D50-D89). Infectious disease (A00-B99), pregnancy (O00-O99), and gastrointestinal (K20-K93) accounted for 14.8%, 11.1%, and 6.1% of RBC units issued, respectively. Although a specific diagnosis of malaria accounted for only 2.7% of pediatric transfusions, an unknown number of additional transfusions for malaria may have been categorized by requesting physicians as unspecified anemia and counted under diseases of blood forming organs. During the study period, 9751 units of fresh-frozen plasma were issued. Nearly one-quarter of these units (23.1%) were issued for gastrointestinal (K20-K93) diagnoses. Malignant neoplasms (C00-C97) accounted for 38.1% of 2978 platelet units issued. Blood use in Namibia reflects changes in the health care system due to economic development, improvement in HIV/AIDS and malaria epidemiology, high rates of health care facility-based childbirth, and access to noncommunicable disease treatment. However, better documentation of the indications for transfusion is needed to confirm these observations. Changing patterns of health care will result in changing demands for blood components. Improved methods to evaluate blood use patterns in sub-Saharan Africa may help set realistic national blood collection goals.

BACKGROUND: External assistance can rapidly strengthen health programmes in developing countries, but such funding can also create sustainability challenges. From 2004-2011, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) provided more than $8 million to the Blood Transfusion Service of Namibia (NAMBTS) for supplies, equipment, and staff salaries. This analysis describes the impact that support had on actual production costs and the unit prices charged for red cell concentrate (RCC) units issued to public sector hospitals. MATERIALS AND METHODS: A costing system developed by NAMBTS to set public sector RCC unit prices was used to describe production costs and unit prices during the period of PEPFAR scale-up (2004-2009) and the 2 years in which PEPFAR support began to decline (2010-2011). Hypothetical production costs were estimated to illustrate differences had PEPFAR support not been available. RESULTS: Between 2004-2006, NAMBTS sold 22,575 RCC units to public sector facilities. During this time, RCC unit prices exceeded per unit cost-recovery targets by between 40.3% (US$16.75 or N$109.86) and 168.3% (US$48.72 or N$333.28) per year. However, revenue surpluses dwindled between 2007 and 2011, the final year of the study period, when NAMBTS sold 20,382 RCC units to public facilities but lost US$23.31 (N$170.43) on each unit. DISCUSSION: PEPFAR support allowed NAMBTS to leverage domestic cost-recovery revenue to rapidly increase blood collections and the distribution of RCC. However, external support kept production costs lower than they would have been without PEPFAR. If PEPFAR funds had not been available, RCC prices would have needed to increase by 20% per year to have met annual cost-recovery targets and funded the same level of investments as were made with PEPFAR support. Tracking the subsidising influence of external support can help blood services make strategic investments and plan for unit price increases as external funds are withdrawn.

We report a cluster of severe diarrheal disease caused by Vibrio mimicus infection among four persons who had consumed leftover crayfish the day after a private crayfish boil. Gastrointestinal illness caused by Vibrio mimicus has not been reported previously in Washington State. Three cases were laboratory confirmed by stool culture; using PCR, isolates were found to have ctx genes that encode cholera toxin (CT). Two of the cases were hospitalized under intensive care with a cholera-like illness. The illnesses were most likely caused by cross-contamination of cooked crayfish with uncooked crayfish; however, V. mimicus was not isolated nor were CT genes detected by PCR in leftover samples of frozen crayfish. Clinicians should be aware that V. mimicus can produce CT and that V. mimicus infection can cause severe illness.

OBJECTIVE: To update the estimated global incidence of Japanese encephalitis (JE) using recent data for the purpose of guiding prevention and control efforts. METHODS: Thirty-two areas endemic for JE in 24 Asian and Western Pacific countries were sorted into 10 incidence groups on the basis of published data and expert opinion. Population-based surveillance studies using laboratory-confirmed cases were sought for each incidence group by a computerized search of the scientific literature. When no eligible studies existed for a particular incidence group, incidence data were extrapolated from related groups. FINDINGS: A total of 12 eligible studies representing 7 of 10 incidence groups in 24 JE-endemic countries were identified. Approximately 67,900 JE cases typically occur annually (overall incidence: 1.8 per 100,000), of which only about 10% are reported to the World Health Organization. Approximately 33,900 (50%) of these cases occur in China (excluding Taiwan) and approximately 51,000 (75%) occur in children aged 0-14 years (incidence: 5.4 per 100,000). Approximately 55,000 (81%) cases occur in areas with well established or developing JE vaccination programmes, while approximately 12,900 (19%) occur in areas with minimal or no JE vaccination programmes. CONCLUSION: Recent data allowed us to refine the estimate of the global incidence of JE, which remains substantial despite improvements in vaccination coverage. More and better incidence studies in selected countries, particularly China and India, are needed to further refine these estimates.

Indigenous populations from Australia, Canada, and New Zealand have been found to have a three to eight times higher rate of hospitalization and death associated with infection with the 2009 pandemic influenza A (H1N1) virus. In October, two U.S. states (Arizona and New Mexico) observed a disproportionate number of deaths related to H1N1 among American Indian/Alaska Natives (AI/ANs). These observations, plus incomplete reporting of race/ethnicity at the national level, led to formation of a multidisciplinary workgroup comprised of representatives from 12 state health departments, the Council of State and Territorial Epidemiologists, tribal epidemiology centers, the Indian Health Service, and CDC. The workgroup assessed the burden of H1N1 influenza deaths in the AI/AN population by compiling surveillance data from the states and comparing death rates. The results indicated that, during April 15-November 13, AI/ANs in the 12 participating states had an H1N1 mortality rate four times higher than persons in all other racial/ethnic populations combined. Reasons for this disparity in death rates are unknown and need further investigation; however, they might include a high prevalence of chronic health conditions (e.g., diabetes and asthma) among AI/ANs that predisposes them to influenza complications, poverty (e.g., poor living conditions), and delayed access to care. Efforts are needed to increase awareness among AI/ANs and their health-care providers of the potential severity of influenza and current recommendations regarding the timely use of antiviral medications. Efforts to promote the use of 2009 H1N1 influenza monovalent vaccine in AI/AN populations should be expanded.

During March 2006-March 2009, a total of 6,355 suspected cases of avian influenza (H5N1) were reported to the Ministry of Health in Egypt. Sixty-three (1%) patients had confirmed infections; 24 (38%) died. Risk factors for death included female sex, age ≥15 years, and receiving the first dose of oseltamivir >2 days after illness onset. All but 2 case-patients reported exposure to domestic poultry probably infected with avian influenza virus (H5N1). No cases of human-to-human transmission were found. Greatest risks for infection and death were reported among women ≥15 years of age, who accounted for 38% of infections and 83% of deaths. The lower case-fatality rate in Egypt could be caused by a less virulent virus clade. However, the lower mortality rate seems to be caused by the large number of infected children who were identified early, received prompt treatment, and had less severe clinical disease.

Colorado tick fever (CTF) is a biphasic, febrile illness caused by a Coltivirus and transmitted by the Rocky Mountain wood tick, Dermacentor andersoni, in the western United States and Canada. Symptoms generally include acute onset of fever, headache, chills, and myalgias; illness often lasts for 3 weeks or more. Laboratory-confirmed cases of CTF were identified from public health department records in Montana, Utah, and Wyoming, and from the Centers for Disease Control and Prevention diagnostic laboratory records. Additional descriptive epidemiologic data were obtained by medical record abstraction. Ninety-one cases were identified from 1995 to 2003, resulting in an overall annual incidence of 2.7 per 1,000,000 population. The annual incidence decreased over the 9-year study period. Cases were 2.5 times more frequent in males than females. The highest incidence of cases occurred in persons aged 51-70. Tick exposure prior to illness onset was reported in 90% of the cases in which a more detailed history was available. The most common symptoms were fever, headache, and myalgia; 18% of the case patients were hospitalized. While there has been an overall decline in the recognized incidence of CTF cases, the reasons for the decline are unknown. Possibilities include a reduced intensity of surveillance and a true decrease in incidence. As more people continue to visit, move to and work in endemic areas, CTF should be considered in anyone presenting with a febrile illness following tick exposure in an endemic area. Heightened awareness for the disease and tick prevention messages should be part of public health measures to further decrease the incidence of disease.