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Routine vaccination coverage - worldwide, 2022
Kaur G , Danovaro-Holliday MC , Mwinnyaa G , Gacic-Dobo M , Francis L , Grevendonk J , Sodha SV , Sugerman C , Wallace A . MMWR Morb Mortal Wkly Rep 2023 72 (43) 1155-1161 In 2020, the World Health Assembly endorsed the Immunization Agenda 2030 (IA2030), the 2021-2030 global strategy that envisions a world where everyone, everywhere, at every age, fully benefits from vaccines. This report reviews trends in World Health Organization and UNICEF immunization coverage estimates at global, regional, and national levels through 2022 and documents progress toward improving coverage with respect to the IA2030 strategy, which aims to reduce the number of children who have not received the first dose of a diphtheria-tetanus-pertussis-containing vaccine (DTPcv1) worldwide by 50% and to increase coverage with 3 diphtheria-tetanus-pertussis-containing vaccine doses (DTPcv3) to 90%. Worldwide, coverage ≥1 dose of DTPcv1 increased from 86% in 2021 to 89% in 2022 but remained below the 90% coverage achieved in 2019. Estimated DTPcv3 coverage increased from 81% in 2021 to 84% in 2022 but also remained below the 2019 coverage of 86%. Worldwide in 2022, 14.3 million children were not vaccinated with DTPcv1, a 21% decrease from 18.1 million in 2021, but an 11% increase from 12.9 million in 2019. Most children (84%) who did not receive DTPcv1 in 2022 lived in low- and lower-middle-income countries. COVID-19 pandemic-associated immunization recovery occurred in 2022 at the global level, but progress was unevenly distributed, especially among low-income countries. Urgent action is needed to provide incompletely vaccinated children with catch-up vaccinations that were missed during the pandemic, restore national vaccination coverage to prepandemic levels, strengthen immunization programs to build resiliency to withstand future unforeseen public health events, and further improve coverage to protect children from vaccine-preventable diseases. |
Leaving no one behind: Defining and implementing an integrated life course approach to vaccination across the next decade as part of the Immunization Agenda 2030
Wallace AS , Ryman TK , Privor-Dumm L , Morgan C , Fields R , Garcia C , Sodha SV , Lindstrand A , Nic Lochlainn LM . Vaccine 2022 Strategic Priority 4 (SP4) of the Immunization Agenda 2030 aims to ensure that all people benefit from recommended immunizations throughout the life-course, integrated with essential health services. Therefore, it is necessary for immunization programs to have coordination and collaboration across all health programs. Although there has been progress, immunization platforms in the second year of life and beyond need continued strengthening, including booster doses and catch-up vaccination, for all ages, and recommended vaccines for older age groups. We note gaps in current vaccination programs policies and achieved coverage, in the second year of life and beyond. In 2021, the second dose of measles-containing vaccine (MCV2), given in the second year of life, achieved 71% global coverage vs 81% for MCV1. For adolescents, 60% of all countries have adopted human papillomavirus vaccines in their vaccination schedule with a global coverage rate of only 12 percent in 2021. Approximately 65% of the countries recommend influenza vaccines for older adults, high-risk adults and pregnant women, and only 25% recommended pneumococcal vaccines for older adults. To achieve an integrated life course approach to vaccination, we reviewed the evidence, gaps, and strategies in four focus areas: generating evidence for disease burden and potential vaccine impact in older age groups; building awareness and shifting policy beyond early childhood; building integrated delivery approaches throughout the life course; and identifying missed opportunities for vaccination, implementing catch-up strategies, and monitoring vaccination throughout the life course. We identified needs, such as tailoring strategies to the local context, conducting research and advocacy to mobilize resources and build political will. Mustering sufficient financial support and demand for an integrated life course approach to vaccination, particularly in times of COVID-19, is both a challenge and an opportunity. |
Routine vaccination coverage - Worldwide, 2021
Rachlin A , Danovaro-Holliday MC , Murphy P , Sodha SV , Wallace AS . MMWR Morb Mortal Wkly Rep 2022 71 (44) 1396-1400 In 2020, the World Health Assembly endorsed the Immunization Agenda 2030, an ambitious global immunization strategy to reduce morbidity and mortality from vaccine-preventable diseases (1). This report updates a 2020 report (2) with global, regional,* and national vaccination coverage estimates and trends through 2021. Global estimates of coverage with 3 doses of diphtheria-tetanus-pertussis-containing vaccine (DTPcv3) decreased from an average of 86% during 2015-2019 to 83% in 2020 and 81% in 2021. Worldwide in 2021, 25.0 million infants (19% of the target population) were not vaccinated with DTPcv3, 2.1 million more than in 2020 and 5.9 million more than in 2019. In 2021, the number of infants who did not receive any DTPcv dose by age 12 months (18.2 million) was 37% higher than in 2019 (13.3 million). Coverage with the first dose of measles-containing vaccine (MCV1) decreased from an average of 85% during 2015-2019 to 84% in 2020 and 81% in 2021. These are the lowest coverage levels for DTPcv3 and MCV1 since 2008. ​Global coverage estimates were also lower in 2021 than in 2020 and 2019 for bacillus Calmette-Guérin vaccine (BCG) as well as for the completed series of Haemophilus influenzae type b vaccine (Hib), hepatitis B vaccine (HepB), polio vaccine (Pol), and rubella-containing vaccine (RCV). The COVID-19 pandemic has resulted in disruptions to routine immunization services worldwide. Full recovery to immunization programs will require context-specific strategies to address immunization gaps by catching up missed children, prioritizing essential health services, and strengthening immunization programs to prevent outbreaks (3). |
Routine Vaccination Coverage - Worldwide, 2020
Muhoza P , Danovaro-Holliday MC , Diallo MS , Murphy P , Sodha SV , Requejo JH , Wallace AS . MMWR Morb Mortal Wkly Rep 2021 70 (43) 1495-1500 Endorsed by the World Health Assembly in 2020, the Immunization Agenda 2030 (IA2030) strives to reduce morbidity and mortality from vaccine-preventable diseases across the life course (1). This report, which updates a previous report (2), presents global, regional,* and national vaccination coverage estimates and trends as of 2020. Changes are described in vaccination coverage and the numbers of unvaccinated and undervaccinated children as measured by receipt of the first and third doses of diphtheria, tetanus, and pertussis-containing vaccine (DTP) in 2020, when the COVID-19 pandemic began, compared with 2019. Global estimates of coverage with the third dose of DTP (DTP3) and a polio vaccine (Pol3) decreased from 86% in 2019 to 83% in 2020. Similarly, coverage with the first dose of measles-containing vaccine (MCV1) dropped from 86% in 2019 to 84% in 2020. The last year that coverage estimates were at 2020 levels was 2009 for DTP3 and 2014 for both MCV1 and Pol3. Worldwide, 22.7 million children (17% of the target population) were not vaccinated with DTP3 in 2020 compared with 19.0 million (14%) in 2019. Children who did not receive the first DTP dose (DTP1) by age 12 months (zero-dose children) accounted for 95% of the increased number. Among those who did not receive DTP3 in 2020, approximately 17.1 million (75%) were zero-dose children. Global coverage decreased in 2020 compared with 2019 estimates for the completed series of Haemophilus influenzae type b (Hib), hepatitis B vaccine (HepB), human papillomavirus vaccine (HPV), and rubella-containing vaccine (RCV). Full recovery from COVID-19-associated disruptions will require targeted, context-specific strategies to identify and catch up zero-dose and undervaccinated children, introduce interventions to minimize missed vaccinations, monitor coverage, and respond to program setbacks (3). |
Cholera outbreak associated with contaminated water sources in paddy fields, Mandla District, Madhya Pradesh, India
Dutta BP , Kumar N , Meshram KC , Yadav R , Sodha SV , Gupta S . Indian J Public Health 2021 65 S46-s50 BACKGROUND: Mandla District in Madhya Pradesh, India, reported a suspected cholera outbreak from Ghughri subdistrict on August 18, 2016. OBJECTIVE: We investigated to determine risk factors and recommend control and prevention measures. METHODS: We defined a case as >3 loose stools in 24 h in a Ghughri resident between July 20 and August 19, 2016. We identified cases by passive surveillance in health facilities and by a house-to-house survey in 28 highly affected villages. We conducted a 1:2 unmatched case-control study, collected stool samples for culture, and tested water sources for fecal contamination. RESULTS: We identified 628 cases (61% female) from 96 villages; the median age was 27 years (range: 1 month-76 years). Illnesses began 7 days after rainfall with 259 (41%) hospitalizations and 14 (2%) deaths in people from remote villages who died before reaching a health facility; 12 (86%) worked in paddy fields. Illness was associated with drinking well water within paddy fields (odds ratio [OR] = 4.0, 95% confidence interval [CI] = 1.4-8.0) and not washing hands with soap after defecation (OR = 6.1, CI = 1.7-21). Of 34 stool cultures, 11 (34%) tested positive for Vibrio cholerae O1 Ogawa. We observed open defecation in affected villages around paddy fields. Of 16 tested water sources in paddy fields, eight (50%) were protected, but 100% had fecal contamination. CONCLUSION: We recommended education regarding pit latrine sanitation and safe water, especially in paddy fields, provision of oral rehydration solution in remote villages, and chlorine tablets for point-of-use treatment of drinking water. |
Shellfish poisoning outbreaks in Cuddalore District, Tamil Nadu, India.
Velayudhan A , Nayak J , Murhekar MV , Dikid T , Sodha SV . Indian J Public Health 2021 65 S29-s33 BACKGROUND: Two suspected shellfish poisoning events were reported in Cuddalore District in Tamil Nadu, India, between January and April 2015. OBJECTIVES: The study was conducted to confirm the outbreaks and to identify the source and risk factors. METHODS: For both outbreaks, a case was defined as a person with nausea, vomiting, or dizziness. Sociodemographic details and symptoms were noted down. Data were also collected in a standard 3-day food frequency questionnaire, along with a collection of clam samples. A case-control study was initiated in the April outbreak. Stool samples were collected from cases, and clam vendors were interviewed. RESULTS: In an outbreak that happened in January, all the twenty people reported to be consumed clams were diagnosed as cases (100% attack rate, 100% exposure rate). In the April outbreak, we identified 199 cases (95% attack rate). In both outbreaks, the clams were identified as genus Meretrix meretrix. The most common reported symptoms were dizziness and vomiting. The clams heated and consumed within 30-60 min. No heavy metals or chemicals were detected in the clams, but assays for testing shellfish toxins were unavailable. All 64 selected cases reported clam consumption (100% exposure rate) as did 11 controls (17% exposure rate). Illness was associated with a history of eating of clams (odds ratio = 314, 95% confidence interval = 39-512). Of the six stool samples tested, all were culture negative for Salmonella, Shigella, and Vibrio cholerae. The water at both sites was contaminated with garbage and sewage. CONCLUSION: Coordinated and timely efforts by a multidisciplinary team of epidemiologists, marine biologists, and food safety officers led to the outbreaks' containment. |
Acute diarrheal disease outbreak in Muzaffarpur Village, Chandauli District, Uttar Pradesh, India
Gupta G , Singh A , Dikid T , Saroha E , Sodha SV . Indian J Public Health 2021 65 S34-s40 BACKGROUND: Acute diarrheal disease (ADD) outbreaks frequently occur in the Gangetic plains of Uttar Pradesh, India. In August 2017, Muzaffarpur village, Uttar Pradesh, reported an ADD outbreak. OBJECTIVES: Outbreak investigation was conducted to find out the epidemiology and to identify the risk factors. METHODS: A 1:1 area-matched case-control study was conducted. Suspected ADD case was defined as ≥3 loose stools or vomiting within 24 h in a Muzaffarpur resident between August 7 and September 9, 2017. A control was defined as an absence of loose stools and vomiting in a resident between August 7 and September 9, 2017. A matched odds ratio (mOR) with 95% confidence intervals (CIs) was calculated. Drinking water was assessed to test for the presence of any contamination. Stool specimens were tested for Vibrio cholerae, and water samples were also tested for any fecal contamination and residual chlorine. RESULTS: Among 70 cases (female = 60%; median age = 12 years, range = 3 months-70 years), two cases died and 35 cases were hospitalized. Area-A in Muzaffarpur had the highest attack rate (8%). The index case washed soiled clothes at well - A1 1 week before other cases occurred. Among 67 case-control pairs, water consumption from well-A1 (mOR: 43.00; 95% CI: 2.60-709.88) and not washing hands with soap (mOR: 2.87; 95% CI: 1.28-6.42) were associated with illness. All seven stool specimens tested negative for V. cholerae. All six water samples, including one from well-A1, tested positive for fecal contamination with <0.2 ppm of residual chlorine. CONCLUSION: This outbreak was associated with consumption of contaminated well water and hand hygiene. We recommended safe water provision, covering wells, handwashing with soap, access to toilets, and improved laboratory capacity for testing diarrheal pathogens. |
Measles outbreak among children 15 years old, Jaintia Hills District, Meghalaya, India, 2017
Lowang D , Dhuria M , Yadav R , Mylliem P , Sodha SV , Khasnobis P . Indian J Public Health 2021 65 S5-s9 BACKGROUND: Of 1115 measles outbreaks during 2015 in India, 61,255 suspected measles cases were reported. In 2016, a measles outbreak was reported at East and West Jaintia Hills districts in Meghalaya State, India. OBJECTIVES: The outbreak was investigated to describe the epidemiology, estimate vaccination coverage and vaccine effectiveness (VE), determine risk factors for the disease, and recommend control and prevention measures. METHODS: A measles case was defined as new-onset fever with maculopapular rash occurring between May 1, 2016, and January 21, 2017, in a resident of East and West Jaintia Hills. Cases were identified by active and passive surveillance. Serum and urine samples were collected from cases with laboratory diagnosis for confirmation. A retrospective cohort study was conducted to estimate vaccination coverage, VE, and risk factors for the disease. RESULTS: We identified 382 cases (51% female). The attack rate was 24% with three deaths. The case fatality rate was <1%. The median age was 4 years (range: 3 months-12 years). Among children 12-60 months, 128 (56%) received measles-containing-vaccine first-dose (MCV1), 85 (37%) received measles-containing-vaccine second-dose (MCV2), and 80 (35%) received Vitamin A. VE for MCV1 was 78% and for MCV2 94%. Being unvaccinated for MCV1 (relative risk [RR] = 9.7, 95% confidence interval [CI] = 4.6-20.5) and MCV2 (RR = 17.4, 95% CI = 4.3-69.4) were both strongly associated with illness. CONCLUSIONS: Poor vaccination coverage led to the measles outbreak in East and West Jaintia Hills districts of Meghalaya. Strengthening the routine immunization systems and improving Vitamin A uptake is essential to prevent further outbreaks. |
Outbreak investigation of foodborne illness among political rally attendees, Cuddalore, Tamil Nadu, India
Patil AA , Velayudhan A , Durairaj GK , Khasnobis P , Sodha SV . Indian J Public Health 2021 65 S55-s58 In July 2015, we investigated a foodborne illness outbreak in Sithalikuppam and Verupachi villages, Cuddalore district, Tamil Nadu, among the political rally attendees to determine the risk factors for illness. We conducted a retrospective cohort study, calculated risk ratio for the food exposures, and cultured stool specimens. Of 55 rally attendees, we identified 36 (65%) case patients; 32 (89%) had diarrhea and 20 (56%) had vomiting. Median incubation period was 14 h. Eighty-nine percent (32/36) of those who ate lemon rice at dinner had illness compared to 21% (4/19) of those who did not (RR 4.2). Of the six nonattendees who ate leftovers on July 25, all ate only lemon rice and became ill. Stool cultures were negative for Salmonella, Shigella, and Vibrio species. Lemon rice was probably contaminated with enterotoxins such as from Bacillus cereus. Our findings highlighted need for community food safety education and importance of thorough outbreak investigations. |
Building public health capacity through India epidemic intelligence service and field epidemiology training programs in India
Singh SK , Murhekar M , Gupta S , Minh NNT , Sodha SV . Indian J Public Health 2021 65 S1-s4 India is a vast country with a population of 1.3 billion, 36 states and union territories, and 728 districts.[1],[2] Although India has rapidly modernized with sustained economic growth, preventable communicable diseases persist, particularly among lower socioeconomic and marginalized populations. Despite recent successes such as polio eradication, tuberculosis control progress, and growing routine immunization coverage, the COVID-19 pandemic has highlighted gaps in India's public health system including severe shortages of trained human resources.[3],[4],[5] As the COVID-19 pandemic was emerging in early 2020, the Ministry of Health and Family Welfare (MOHFW) issued a request to fill over 200 vacancies for epidemiologists across the country.[6],[7] | | Although a public health cadre exists at the central level, only a few states (e.g., Kerala, Maharashtra, Odisha, Tamil Nadu, and West Bengal) have a designated public health workforce. In addition, most postgraduate epidemiology training is provided through academic programs which do not include field-based training for outbreak investigations and public health responses. Field epidemiology training programs (FETPs) with an academic degree, such as the Master of Public Health (MPH) at the National Institute of Epidemiology (NIE), India Council of Medical Research (ICMR), or the historical MPH program at the National Centre for Disease Control (NCDC), were established to provide field-based training within the requirements of an academic model. |
Addressing reemergence of diphtheria among adolescents through program integration in India
Maramraj KK , Latha MLK , Reddy R , Sodha SV , Kaur S , Dikid T , Reddy S , Jain SK , Singh SK . Emerg Infect Dis 2021 27 (3) 953-956 We report a diphtheria outbreak mostly among children (median 12 years; range 4-26 years) of a religious minority in urban India. Case-fatality rate (15%, 19/124) was higher among unimmunized patients (relative risk 4.1, 95% CI 1.5-11.7). We recommend mandating and integrating immunization into school health programs to prevent reemergence. |
Progress toward regional measles elimination - worldwide, 2000-2019
Patel MK , Goodson JL , Alexander JP Jr , Kretsinger K , Sodha SV , Steulet C , Gacic-Dobo M , Rota PA , McFarland J , Menning L , Mulders MN , Crowcroft NS . MMWR Morb Mortal Wkly Rep 2020 69 (45) 1700-1705 In 2010, the World Health Assembly (WHA) set the following three milestones for measles control to be achieved by 2015: 1) increase routine coverage with the first dose of measles-containing vaccine (MCV1) among children aged 1 year to ≥90% at the national level and to ≥80% in every district, 2) reduce global annual measles incidence to <5 cases per 1 million population, and 3) reduce global measles mortality by 95% from the 2000 estimate* (1). In 2012, WHA endorsed the Global Vaccine Action Plan,(†) with the objective of eliminating measles(§) in five of the six World Health Organization (WHO) regions by 2020. This report describes progress toward WHA milestones and regional measles elimination during 2000-2019 and updates a previous report (2). During 2000-2010, estimated MCV1 coverage increased globally from 72% to 84% but has since plateaued at 84%-85%. All countries conducted measles surveillance; however, approximately half did not achieve the sensitivity indicator target of two or more discarded measles and rubella cases per 100,000 population. Annual reported measles incidence decreased 88%, from 145 to 18 cases per 1 million population during 2000-2016; the lowest incidence occurred in 2016, but by 2019 incidence had risen to 120 cases per 1 million population. During 2000-2019, the annual number of estimated measles deaths decreased 62%, from 539,000 to 207,500; an estimated 25.5 million measles deaths were averted. To drive progress toward the regional measles elimination targets, additional strategies are needed to help countries reach all children with 2 doses of measles-containing vaccine, identify and close immunity gaps, and improve surveillance. |
A community-wide acute diarrheal disease outbreak associated with drinking contaminated water from shallow bore-wells in a tribal village, India, 2017
Maramraj KK , Subbalakshmi G , Ali MS , Dikid T , Yadav R , Sodha SV , Jain SK , Singh SK . BMC Public Health 2020 20 (1) 231 BACKGROUND: In 2016, India reported 709 acute diarrheal disease (ADD) outbreaks (> 25% of all outbreaks). Tribal populations are at higher risk with 27% not having accessibility to safe drinking water and 75% households not having toilets. On June 26, 2017 Pedda-Gujjul-Thanda, a tribal village reported an acute diarrheal disease (ADD) outbreak. We investigated to describe the epidemiology, identify risk factors, and provide evidence-based recommendations. METHODS: We defined a case as >/=3 loose stools within 24 h in Pedda-Gujjul-Thanda residents from June 24-30, 2017. We identified cases by reviewing hospital records and house-to-house survey. We conducted a retrospective cohort study and collected stool samples for culture. We assessed drinking water supply and sanitation practices and tested water samples for faecal-contamination. RESULTS: We identified 191 cases (65% females) with median age 36 years (range 4-80 years) and no deaths. The attack-rate (AR) was 37% (191/512). Downhill colonies (located on slope of hilly terrains of the village) reported higher ARs (56%[136/243], p < 0.001) than others (20%[55/269]). Symptoms included diarrhea (100%), fever (17%), vomiting (16%) and abdominal pain (13%). Drinking water from five shallow bore-wells located in downhill colonies was significantly associated with illness (RR = 4.6, 95%CI = 3.4-6.1 and population attributable fraction 61%). In multi-variate analysis, drinking water from the shallow bore-wells located in downhill colonies (aOR = 7.9, [95% CI =4.7-13.2]), illiteracy (aOR =6, [95% CI = 3.6-10.1]), good hand-washing practice (aOR = 0.4, [95%CI = 0.2-0.7]) and household water treatment (aOR = 0.3, [95%CI = 0.2-0.5]) were significantly associated with illness. Two stool cultures were negative for Vibrio cholerae. Heavy rainfall was reported from June 22-24. Five of six water samples collected from shallow bore-wells located in downhill colonies were positive for faecal contamination. CONCLUSION: An ADD outbreak with high attack rate in a remote tribal village was associated with drinking water from shallow downhill bore-wells, likely contaminated via runoff from open defecation areas after heavy rains. Based on our recommendations, immediate public health actions including repair of leakages at contaminated water sources and alternative supply of purified canned drinking water to families, and as long-term public health measures construction of house-hold latrines and piped-water supply initiated. |
Progress toward regional measles elimination - worldwide, 2000-2018
Patel MK , Dumolard L , Nedelec Y , Sodha SV , Steulet C , Gacic-Dobo M , Kretsinger K , McFarland J , Rota PA , Goodson JL . MMWR Morb Mortal Wkly Rep 2019 68 (48) 1105-1111 In 2010, the World Health Assembly (WHA) set the following three milestones for measles control to be achieved by 2015: 1) increase routine coverage with the first dose of measles-containing vaccine (MCV1) among children aged 1 year to >/=90% at the national level and to >/=80% in every district, 2) reduce global annual measles incidence to less than five cases per 1 million population, and 3) reduce global measles mortality by 95% from the 2000 estimate* (1). In 2012, WHA endorsed the Global Vaccine Action Plan,(dagger) with the objective of eliminating measles( section sign) in five of the six World Health Organization (WHO) regions by 2020. This report updates a previous report (2) and describes progress toward WHA milestones and regional measles elimination during 2000-2018. During 2000-2018, estimated MCV1 coverage increased globally from 72% to 86%; annual reported measles incidence decreased 66%, from 145 to 49 cases per 1 million population; and annual estimated measles deaths decreased 73%, from 535,600 to 142,300. During 2000-2018, measles vaccination averted an estimated 23.2 million deaths. However, the number of measles cases in 2018 increased 167% globally compared with 2016, and estimated global measles mortality has increased since 2017. To continue progress toward the regional measles elimination targets, resource commitments are needed to strengthen routine immunization systems, close historical immunity gaps, and improve surveillance. To achieve measles elimination, all communities and countries need coordinated efforts aiming to reach >/=95% coverage with 2 doses of measles vaccine (3). |
A cutaneous anthrax outbreak in Koraput District of Odisha-India 2015
Nayak P , Sodha SV , Laserson KF , Padhi AK , Swain BK , Hossain SS , Shrivastava A , Khasnobis P , Venkatesh SR , Patnaik B , Dash KC . BMC Public Health 2019 19 470 Background: Cutaneous anthrax in humans is associated with exposure to infected animals or animal products and has a case fatality rate of up to 20% if untreated. During May to June 2015, an outbreak of cutaneous anthrax was reported in Koraput district of Odisha, India, an area endemic for anthrax. We investigated the outbreak to identify risk factors and recommend control measures. Method: We defined a cutaneous anthrax case as skin lesions (e.g., papule, vesicle or eschar) in a person residing in Koraput district with illness onset between February 1 and July 15, 2015. We established active surveillance through a house to house survey to ascertain additional cases and conducted a 1:2 unmatched case control study to identify modifiable risk factors. In case control study, we included cases with illness onset between May 1 and July 15, 2015. We defined controls as neighbours of case without skin lesions since last 3 months. Ulcer exudates and rolled over swabs from wounds were processed in Gram stain in the Koraput district headquarter hospital laboratory. Result: We identified 81 cases (89% male; median age 38 years [range 5-75 years]) including 3 deaths (case fatality rate = 4%). Among 37 cases and 74 controls, illness was significantly associated with eating meat of ill cattle (OR: 14.5, 95% CI: 1.4-85.7) and with close handling of carcasses of ill animals such as burying, skinning, or chopping (OR: 342, 95% CI: 40.5-1901.8). Among 20 wound specimens collected, seven showed spore-forming, gram positive bacilli, with bamboo stick appearance suggestive of Bacillus anthracis. Conclusion: Our investigation revealed significant associations between eating and handling of ill animals and presence of anthrax-like organisms in lesions. We immediately initiated livestock vaccination in the area, educated the community on safe handling practices and recommended continued regular anthrax animal vaccinations to prevent future outbreaks. |
Building health workforce capacity for planning and monitoring through the Strengthening Technical Assistance for routine immunization training (START) approach in Uganda
Ward K , Stewart S , Wardle M , Sodha SV , Tanifum P , Ayebazibwe N , Mayanja R , Luzze H , Ehlman DC , Conklin L , Abbruzzese M , Sandhu HS . Vaccine 2019 37 (21) 2821-2830 INTRODUCTION: The Global Vaccine Action Plan identifies workforce capacity building as a key strategy to achieve strong immunization programs. The Strengthening Technical Assistance for Routine Immunization Training (START) approach aimed to utilize practical training methods to build capacity of district and health center staff to implement routine immunization (RI) planning and monitoring activities, as well as build supportive supervision skills of district staff. METHODS: First implemented in Uganda, the START approach was executed by trained external consultants who used existing tools, resources, and experiences to mentor district-level counterparts and, with them, conducted on-the-job training and mentorship of health center staff over several site visits. Implementation was routinely monitored using daily activity reports, pre and post surveys of resources and systems at districts and health centers and interviews with START consultants. RESULTS: From July 2013 through December 2014 three START teams of four consultants per team, worked 6months each across 50 districts in Uganda including the five divisions of Kampala district (45% of all districts). They conducted on-the-job training in 444 selected under-performing health centers, with a median of two visits to each (range 1-7, IQR: 1-3). More than half of these visits were conducted in collaboration with the district immunization officer, providing the opportunity for mentorship of district immunization officers. Changes in staff motivation and awareness of challenges; availability and completion of RI planning and monitoring tools and systems were observed. However, the START consultants felt that potential durability of these changes may be limited by contextual factors, including external accountability, availability of resources, and individual staff attitude. CONCLUSIONS: Mentoring and on-the-job training offer promising alternatives to traditional classroom training and audit-focused supervision for building health workforce capacity. Further evidence regarding comparative effectiveness of these strategies and durability of observed positive change is needed. |
Risk factors for acquiring scrub typhus among children in Deoria and Gorakhpur Districts, Uttar Pradesh, India, 2017
Thangaraj JWV , Vasanthapuram R , Machado L , Arunkumar G , Sodha SV , Zaman K , Bhatnagar T , Hameed SKS , Kumar A , Abdulmajeed J , Velayudhan A , Deoshatwar A , Desai AS , Kumar KH , Gupta N , Laserson K , Murhekar M . Emerg Infect Dis 2018 24 (12) 2364-2367 Scrub typhus is associated with outbreaks of acute encephalitis syndrome in Uttar Pradesh, India. A case-control study indicated that children residing, playing, or visiting fields; living with firewood stored indoors; handling cattle fodder; and practicing open defecation were at increased risk for scrub typhus. Communication messages should focus on changing these behaviors. |
Mumps outbreak investigation in Jaisalmer, Rajasthan, India, June-September 2016
Moghe CS , Goel P , Singh J , Nayak NR , Dhuria M , Jain R , Yadav R , Saroha E , Sodha SV , Aggarwal CS , Venkatesh S . J Med Virol 2018 91 (3) 347-350 Mumps, a vaccine-preventable disease, causes inflammation of salivary glands and may cause severe complications such as encephalitis, meningitis, deafness, and orchitis/oophoritis. In India, mumps vaccine is not included in the universal immunization program and during 2009-2014, 72 outbreaks with >1500 cases were reported. In August 2016, a suspected mumps outbreak was reported in Jaisalmer block, Rajasthan. We investigated to confirm the etiology, describe epidemiology, and recommend prevention and control measures. We defined a case as swelling in the parotid region in a Jaisalmer block resident between June 23 and September 10, 2016. We searched for cases in health facilities and house-to-house in affected villages and hamlets. We tested blood samples of cases for mumps IgM ELISA. We found 162 cases (60% males) with median age of 9.4 years (range: 7 month-38 years) and 65 (40%) were females. Symptoms included fever (70%) and bilateral swelling in neck (65%). None were vaccinated against mumps. Most (84%) cases were school-going children (3-16 years old). The overall attack rate was 2%. Village A, with two hamlets, had the highest attack rate (hamlet 1=13% and hamlet 2=12%). School A of village A, hamlet 1 which accommodated 200 children in two classrooms had an attack rate of 55%. Of 18 blood samples from cases, 11 tested positive for mumps IgM ELISA. This was a confirmed mumps outbreak in Jaisalmer bl0ock that disproportionately affected school-going children. We recommended continued surveillance, five-day absence from school, and vaccination. This article is protected by copyright. All rights reserved. |
Produce-associated foodborne disease outbreaks, USA, 1998-2013
Bennett SD , Sodha SV , Ayers TL , Lynch MF , Gould LH , Tauxe RV . Epidemiol Infect 2018 146 (11) 1-10 The US Food Safety Modernization Act (FSMA) gives food safety regulators increased authority to require implementation of safety measures to reduce the contamination of produce. To evaluate the future impact of FSMA on food safety, a better understanding is needed regarding outbreaks attributed to the consumption of raw produce. Data reported to the US Centers for Disease Control and Prevention's Foodborne Disease Outbreak Surveillance System during 1998-2013 were analysed. During 1998-2013, there were 972 raw produce outbreaks reported resulting in 34 674 outbreak-associated illnesses, 2315 hospitalisations, and 72 deaths. Overall, the total number of foodborne outbreaks reported decreased by 38% during the study period and the number of raw produce outbreaks decreased 19% during the same period; however, the percentage of outbreaks attributed to raw produce among outbreaks with a food reported increased from 8% during 1998-2001 to 16% during 2010-2013. Raw produce outbreaks were most commonly attributed to vegetable row crops (38% of outbreaks), fruits (35%) and seeded vegetables (11%). The most common aetiologic agents identified were norovirus (54% of outbreaks), Salmonella enterica (21%) and Shiga toxin-producing Escherichia coli (10%). Food-handling errors were reported in 39% of outbreaks. The proportion of all foodborne outbreaks attributable to raw produce has been increasing. Evaluation of safety measures to address the contamination on farms, during processing and food preparation, should take into account the trends occurring before FSMA implementation. |
Post-flood rapid needs assessment in Srinagar City, Jammu and Kashmir State, India, September, 2014
Yadav R , Somashekar D , Sodha SV , Laserson KF , Venkatesh S , Chauhan H . Disaster Med Public Health Prep 2018 13 (2) 1-5 OBJECTIVES: Torrential rainfall and flooding from September 2-6, 2014 submerged >350 villages in Jammu and Kashmir state. We conducted rapid needs assessment in capital Srinagar from 27 September to 1 October to assess population health and safety needs. METHODS: Based on Community Assessment for Public Health Emergency Response (CASPER) methodology, we selected 7 households each from 30 census blocks using 2-stage cluster sampling. We collected information on demographics, needs, and illnesses using structured questionnaire. RESULTS: Of the 210 households surveyed, an estimated 57% (CI: 41%-73%) reported significant damage, 50% (CI: 36%-63%) were evacuated, and 16% (CI: 10%-22%) reported injuries. Households lacked electricity (22%; CI: 8.8%-36%), tap water (13%; CI: 5%-21%), working toilets (11%; CI: 4%-19%), and adequate food supply (14%; CI: 8%-20%). Moreover, 55% (CI: 45%-64%) of households reported cough, cold, fever, rashes, or diarrhea; 68% (CI: 59%-77%) experienced agitation, anxiety, depression, or nightmares since the flooding. Of the households with a member on medicines for non-communicable diseases, 40% did not have a week's supply. Restoring basic essentials (30%; CI: 22%-37%) and repairing houses (30%; CI: 19%-40%) were the most urgent needs expressed. CONCLUSIONS: Floods damaged >1/2 of households in Srinagar, disrupting basic essentials, and causing mental trauma. These findings helped authorities prioritize assistance with psychological symptoms and availability of prescription medicines. (Disaster Med Public Health Preparedness. 2018;page 1 of 5). |
Comparison of boiling and chlorination on the quality of stored drinking water and childhood diarrhoea in Indonesian households
Fagerli K , Trivedi KK , Sodha SV , Blanton E , Ati A , Nguyen T , Delea KC , Ainslie R , Figueroa ME , Kim S , Quick R . Epidemiol Infect 2017 145 (15) 1-9 We compared the impact of a commercial chlorination product (brand name Air RahMat) in stored drinking water to traditional boiling practices in Indonesia. We conducted a baseline survey of all households with children 1000 MPN/100 ml (RR 1.86, 95% CI 1.09-3.19) in stored water than in households without detectable E. coli. Although results suggested that Air RahMat water treatment was associated with lower E. coli contamination and diarrhoeal rates among children <5 years than water treatment by boiling, Air RahMat use remained low. |
Assessing strategies for increasing urban routine immunization coverage of childhood vaccines in low and middle-income countries: A systematic review of peer-reviewed literature
Nelson KN , Wallace AS , Sodha SV , Daniels D , Dietz V . Vaccine 2016 34 (46) 5495-5503 INTRODUCTION: Immunization programs in developing countries increasingly face challenges to ensure equitable delivery of services within cities where rapid urban growth can result in informal settlements, poor living conditions, and heterogeneous populations. A number of strategies have been utilized in developing countries to ensure high community demand and equitable availability of urban immunization services; however, a synthesis of the literature on these strategies has not previously been undertaken. METHODS: We reviewed articles published in English in peer-reviewed journals between 1990 and 2013 that assessed interventions for improving routine immunization coverage in urban areas in low- and middle-income countries. We categorized the intervention in each study into one of three groups: (1) interventions aiming to increase utilization of immunization services; (2) interventions aiming to improve availability of immunization services by healthcare providers, or (3) combined availability and utilization interventions. We summarized the main quantitative outcomes from each study and effective practices from each intervention category. RESULTS: Fifteen studies were identified; 87% from the African, Eastern Mediterranean and Southeast Asian regions of the World Health Organization (WHO). Six studies were randomized controlled trials, eight were pre- and post-intervention evaluations, and one was a cross-sectional study. Four described interventions designed to improve availability of routine immunization services, six studies described interventions that aimed to increase utilization, and five studies aiming to improve both availability and utilization of services. All studies reported positive change in their primary outcome indicator, although seven different primary outcomes indicators were used across studies. Studies varied considerably with respect to the type of intervention assessed, study design, and length of intervention assessment. CONCLUSION: Few studies have assessed interventions designed explicitly for the unique challenges facing immunization programs in urban areas. Further research on sustainability, scalability, and cost-effectiveness of interventions is needed to fill this gap. |
Vaccination Week in the Americas, 2011: an opportunity to assess the routine vaccination program in the Bolivarian Republic of Venezuela
Sanchez D , Sodha SV , Kurtis HJ , Ghisays G , Wannemuehler KA , Danovaro-Holliday MC , Ropero-Alvarez AM . BMC Public Health 2015 15 395 BACKGROUND: Vaccination Week in the Americas (VWA) is an annual initiative in countries and territories of the Americas every April to highlight the work of national expanded programs on immunization (EPI) and increase access to vaccination services for high-risk population groups. In 2011, as part of VWA, Venezuela targeted children aged less than 6 years in 25 priority border municipalities using social mobilization to increase institution-based vaccination. Implementation of social communication activities was decentralized to the local level. We conducted a survey in one border municipality of Venezuela to evaluate the outcome of VWA 2011 and provide a snapshot of the overall performance of the routine EPI at that level. METHODS: We conducted a coverage survey, using stratified cluster sampling, in the Venezuelan municipality of Bolivar (bordering Colombia) in August 2011. We collected information for children aged <6 years through caregiver interviews and transcription of vaccination card data. We estimated each child's eligibility to receive a specific vaccine dose during VWA 2011 and whether or not they were actually vaccinated during VWA activities. We also estimated baseline vaccination coverage, timeliness and 95% confidence intervals (CI), and used chi-square tests to compare coverage across age cohorts, taking into account the sampling design. RESULTS: We surveyed 839 children from 698 households; 93% of children had a vaccination card. Among households surveyed, 216 (31%) caregivers reported having heard about a vaccination activity during April or May 2011. Of the 528 children eligible to receive a vaccine during VWA, 24% received at least one dose, while 13% received all doses due. Overall, baseline coverage with routine vaccines, as measured by the survey, was >85%, with a few exceptions. CONCLUSION: Low levels of VWA awareness among caregivers probably contributed to the limited vaccination of eligible children during the VWA activities in Bolivar in 2011. However, vaccine coverage for most EPI vaccines was high. Additionally, high vaccination card availability and high participation in VWA among those caregivers aware of it in 2011 suggest public trust in the EPI program in the municipality. Health authorities have used survey findings to inform changes to the routine EPI and better VWA implementation in subsequent years. |
Strengthening routine immunization systems to improve global vaccination coverage
Sodha SV , Dietz V . Br Med Bull 2015 113 (1) 5-14 BACKGROUND: Global coverage with the third dose of diphtheria-tetanus-pertussis vaccine among children under 1 year of age stagnated at approximately 83-84% during 2008-13. SOURCES OF DATA: Annual World Health Organization and UNICEF-derived national vaccination coverage estimates. AREAS OF AGREEMENT: Incomplete vaccination is associated with poor socioeconomic status, lower education, non-use of maternal-child health services, living in conflict-affected areas, missed immunization opportunities and cancelled vaccination sessions. AREAS OF CONTROVERSY: Vaccination platforms must expand to include older ages including the second year of life. Immunization programmes, including eradication and elimination initiatives such as those for polio and measles, must integrate within the broader health system. GROWING POINTS: The Global Vaccine Action Plan (GVAP) 2011-20 is a framework for strengthening immunization systems, emphasizing country ownership, shared responsibility, equity, integration, sustainability and innovation. AREAS TIMELY FOR DEVELOPING RESEARCH: Immunization programmes should identify, monitor and evaluate gaps and interventions within the GVAP framework. |
Global routine vaccination coverage, 2013
Harris JB , Gacic-Dobo M , Eggers R , Brown DW , Sodha SV . MMWR Morb Mortal Wkly Rep 2014 63 (46) 1055-8 In 1974, the World Health Organization (WHO) established the Expanded Program on Immunization to ensure that all children have access to routinely recommended vaccines. Since then, global coverage with the four core vaccines (Bacille Calmette-Guerin vaccine [for protection against tuberculosis], diphtheria-tetanus-pertussis vaccine [DTP], polio vaccine, and measles vaccine) has increased from <5% to ≥84%, and additional vaccines have been added to the recommended schedule. Coverage with the third dose of DTP vaccine (DTP3) by age 12 months is a key indicator of immunization program performance. Estimated global DTP3 coverage has remained at 83%-84% since 2009, with estimated 2013 coverage at 84%. Global coverage estimates for the second routine dose of measles-containing vaccine (MCV2) are reported for the first time in 2013; global coverage was 35% by the end of the second year of life and 53% when including older age groups. Improvements in equity of access and use of immunization services will help ensure that all children are protected from vaccine-preventable diseases. |
National patterns of Escherichia coli O157 infections, USA, 1996-2011
Sodha SV , Heiman K , Gould LH , Bishop R , Iwamoto M , Swerdlow DL , Griffin PM . Epidemiol Infect 2014 143 (2) 1-7 US public health laboratories began reporting Escherichia coli O157 isolates to CDC in 1996. We describe temporal and geographical patterns of isolates reported from 1996 to 2011 and demographics of persons whose specimens yielded isolates. We calculated annual E. coli O157 isolation rates/100 000 persons by patient's state of residence, county of residence, age, and sex using census data. The average annual isolation rate was 0.84. The average isolation rate in northern states (1.52) was higher than in southern states (0.43). Counties with 76% rural population had a lower isolation rate (0.67) than counties with 25%, 26-50%, and 51-75% rural populations (0.81, 0.92, and 0.81, respectively). The highest isolation rate (3.19) was in children aged 1-4 years. Infections were seasonal with 49% of isolates collected during July to September. Research into reasons for higher incidence in northern states and for seasonality could guide strategies to prevent illnesses. |
US outbreak of human Salmonella infections associated with aquatic frogs, 2008-2011
Mettee Zarecki SL , Bennett SD , Hall J , Yaeger J , Lujan K , Adams-Cameron M , Winpisinger Quinn K , Brenden R , Biggerstaff G , Hill VR , Sholtes K , Garrett NM , Lafon PC , Behravesh CB , Sodha SV . Pediatrics 2013 131 (4) 724-31 OBJECTIVE: Although amphibians are known Salmonella carriers, no such outbreaks have been reported. We investigated a nationwide outbreak of human Salmonella Typhimurium infections occurring predominantly among children from 2008 to 2011. METHODS: We conducted a matched case-control study. Cases were defined as persons with Salmonella Typhimurium infection yielding an isolate indistinguishable from the outbreak strain. Controls were persons with recent infection with Salmonella strains other than the outbreak strain and matched to cases by age and geography. Environmental samples were obtained from patients' homes; traceback investigations were conducted. RESULTS: We identified 376 cases from 44 states from January 1, 2008, to December 31, 2011; 29% (56/193) of patients were hospitalized and none died. Median patient age was 5 years (range <1-86 years); 69% were children <10 years old (253/367). Among 114 patients interviewed, 69 (61%) reported frog exposure. Of patients who knew frog type, 79% (44/56) reported African dwarf frogs (ADF), a type of aquatic frog. Among 18 cases and 29 controls, illness was significantly associated with frog exposure (67% cases versus 3% controls, matched odds ratio 12.4, 95% confidence interval 1.9-infinity). Environmental samples from aquariums containing ADFs in 8 patients' homes, 2 ADF distributors, and a day care center yielded isolates indistinguishable from the outbreak strain. Traceback investigations of ADFs from patient purchases converged to a common ADF breeding facility. Environmental samples from the breeding facility yielded the outbreak strain. CONCLUSIONS: ADFs were the source of this nationwide pediatric predominant outbreak. Pediatricians should routinely inquire about pet ownership and advise families about illness risks associated with animals. |
A large outbreak of typhoid fever associated with a high rate of intestinal perforation in Kasese District, Uganda, 2008-2009
Neil KP , Sodha SV , Lukwago L , Tipo SO , Mikoleit M , Simington SD , Mukobi P , Balinandi S , Majalija S , Ayers J , Kagirita A , Wefula E , Asiimwe F , Kweyamba V , Talkington D , Shieh WJ , Adem P , Batten BC , Zaki SR , Mintz E . Clin Infect Dis 2012 54 (8) 1091-9 BACKGROUND: Salmonella enterica serovar Typhi (Salmonella Typhi) causes an estimated 22 million typhoid fever cases and 216,000 deaths annually worldwide. In Africa, the lack of laboratory diagnostic capacity limits the ability to recognize endemic typhoid fever and to detect outbreaks. We report a large laboratory-confirmed outbreak of typhoid fever in Uganda with a high proportion of intestinal perforations (IPs). METHODS: A suspected case of typhoid fever was defined as fever and abdominal pain in a person with either vomiting, diarrhea, constipation, headache, weakness, arthralgia, poor response to antimalarial medications, or IP. From March 4, 2009 to April 17, 2009, specimens for blood and stool cultures and serology were collected from suspected cases. Antimicrobial susceptibility testing and pulsed-field gel electrophoresis (PFGE) were performed on Salmonella Typhi isolates. Surgical specimens from patients with IP were examined. A community survey was conducted to characterize the extent of the outbreak. RESULTS: From December 27, 2007 to July 30, 2009, 577 cases, 289 hospitalizations, 249 IPs, and 47 deaths from typhoid fever occurred; Salmonella Typhi was isolated from 27 (33%) of 81 patients. Isolates demonstrated multiple PFGE patterns and uniform susceptibility to ciprofloxacin. Surgical specimens from 30 patients were consistent with typhoid fever. Estimated typhoid fever incidence in the community survey was 8092 cases per 100,000 persons. CONCLUSIONS: This typhoid fever outbreak was detected because of an elevated number of IPs. Underreporting of milder illnesses and delayed and inadequate antimicrobial treatment contributed to the high perforation rate. Enhancing laboratory capacity for detection is critical to improving typhoid fever control. |
Microbiologic effectiveness of boiling and safe water storage in South Sulawesi, Indonesia
Sodha SV , Menon M , Trivedi K , Ati A , Figueroa ME , Ainslie R , Wannemuehler K , Quick R . J Water Health 2011 9 (3) 577-85 In Indonesia, where diarrhea remains a major cause of mortality among children <5 years, the government promotes boiling of drinking water. We assessed the impact of boiling on water quality in South Sulawesi. We surveyed randomly selected households with at least one child <5 years old in two rural districts and tested source and stored water samples for Escherichia coli contamination. Among 242 households, 96% of source and 51% of stored water samples yielded E. coli. Unboiled water samples, obtained from 15% of households, were more likely to yield E. coli than boiled samples [prevalence ratios (PR) = 2.0, 95% confidence interval (CI) 1.7-2.5]. Water stored in wide-mouthed (PR = 1.4, 95% CI = 1.1-1.8) or uncovered (PR = 1.8, 95% CI = 1.3-2.4) containers, or observed to be touched by the respondent's hands (PR = 1.6, 95% CI = 1.3-2.1) was more likely to yield E. coli. A multivariable model showed that households that did not boil water were more likely to have contaminated stored water than households that did boil water (PR = 1.9, 95% CI = 1.5-2.3). Although this study demonstrated the effectiveness of boiling in reducing contamination, overall impact on water quality was suboptimal. Future studies are needed to identify factors behind the success of boiling water in Indonesia to inform efforts to scale up other effective water treatment practices. |
Salmonella typhimurium infections associated with peanut products
Cavallaro E , Date K , Medus C , Meyer S , Miller B , Kim C , Nowicki S , Cosgrove S , Sweat D , Phan Q , Flint J , Daly ER , Adams J , Hyytia-Trees E , Gerner-Smidt P , Hoekstra RM , Schwensohn C , Langer A , Sodha SV , Rogers MC , Angulo FJ , Tauxe RV , Williams IT , Behravesh CB . N Engl J Med 2011 365 (7) 601-10 BACKGROUND: Contaminated food ingredients can affect multiple products, each distributed through various channels and consumed in multiple settings. Beginning in November 2008, we investigated a nationwide outbreak of salmonella infections. METHODS: A case was defined as laboratory-confirmed infection with the outbreak strain of Salmonella Typhimurium occurring between September 1, 2008, and April 20, 2009. We conducted two case-control studies, product "trace-back," and environmental investigations. RESULTS: Among 714 case patients identified in 46 states, 166 (23%) were hospitalized and 9 (1%) died. In study 1, illness was associated with eating any peanut butter (matched odds ratio, 2.5; 95% confidence interval [CI], 1.3 to 5.3), peanut butter-containing products (matched odds ratio, 2.2; 95% CI, 1.1 to 4.7), and frozen chicken products (matched odds ratio, 4.6; 95% CI, 1.7 to 14.7). Investigations of focal clusters and single cases associated with nine institutions identified a single institutional brand of peanut butter (here called brand X) distributed to all facilities. In study 2, illness was associated with eating peanut butter outside the home (matched odds ratio, 3.9; 95% CI, 1.6 to 10.0) and two brands of peanut butter crackers (brand A: matched odds ratio, 17.2; 95% CI, 6.9 to 51.5; brand B: matched odds ratio, 3.6; 95% CI, 1.3 to 9.8). Both cracker brands were made from brand X peanut paste. The outbreak strain was isolated from brand X peanut butter, brand A crackers, and 15 other products. A total of 3918 peanut butter-containing products were recalled between January 10 and April 29, 2009. CONCLUSIONS: Contaminated peanut butter and peanut products caused a nationwide salmonellosis outbreak. Ingredient-driven outbreaks are challenging to detect and may lead to widespread contamination of numerous food products. |
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