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Abstract Background There is little information about influenza disease among the Cambodian population. To better understand the dynamics of influenza in Cambodia, the Cambodian National Influenza Center (NIC) was established in August 2006. To continuously monitor influenza activity, a hospital based sentinel surveillance system for ILI (influenza like illness) with a weekly reporting and sampling scheme was established in five sites in 2006. In addition, hospital based surveillance of acute lower respiratory infection (ALRI) cases was established in 2 sites. Methods The sentinel sites collect weekly epidemiological data on ILI patients fulfilling the case definition, and take naso-pharyngeal specimens from a defined number of cases per week. The samples are tested in the Virology Unit at the Institut Pasteur in Phnom Penh. From each sample viral RNA was extracted and amplified by a multiplex RT-PCR detecting simultaneously influenza A and influenza B virus. Influenza A viruses were then subtyped and analyzed by hemagglutination inhibition assay. Samples collected by the ALRI system were tested with the same approach. Results From 2006 to 2008, influenza circulation was observed mainly from June to December, with a clear seasonal peak in October shown in the data from 2008. Conclusion Influenza activity in Cambodia occurred during the rainy season, from June to December, and ended before the cool season (extending usually from December to February). Although Cambodia is a tropical country geographically located in the northern hemisphere, influenza activity has a southern hemisphere transmission pattern. Together with the antigenic analysis of the circulating strains, it is now possible to give better influenza vaccination recommendation for Cambodia.

Background. – Beside basal myocardial dysfunction, acute heart failure involves associated factors, which increase pulmonary capillary pressure or decrease colloid osmotic pressure. The aim of this study was to evaluate the prevalence of these precipitating factors in a population presenting with acute heart failure with preserved left ventricular systolic function.Methods. – Forty-eight patients (25 men, 78 ± 10 years) presenting pulmonary edema with a left ventricular ejection fraction >45% were included. All had a Doppler echocardiography at the time of intravenous loop diuretics initiation. Patients with severe valve disease or symptomatic coronary disease were excluded.Results. – A history of heart failure, coronary disease, hypertension and diabetes was present in 62%, 42%, 64% and 33% of patients, respectively. On admission, mean left ventricular ejection fraction was 61 ± 9% and 79% of patients had critical elevation in Doppler filling pressures. Associated factors were renal failure (creatinine clearance <30 ml/min) in 33% patients, silent myocardial ischemia (troponin I >0.5 ng/ml) in 31%, atrial fibrillation in 29%, high systolic blood pressure (≥160 mmHg) in 27%, major sepsis in 25%, severe hypoalbuminemia (≤2.5 g/dl) in 23%, and severe anemia (<10 g/dl) in 17%, respectively. Four patients had no aggravating factor, whereas 34 and 10 patients had 1–2 and 3–4 associated factors, respectively.Conclusion. – Besides diastolic dysfunction, factors leading to a critical decrease in the oncotic pressure such as pulmonary capillary pressure gradient are found in most of the elderly patients presenting acute diastolic heart failure and must be checked systematically. [Copyright &y& Elsevier]

Background: Complete reporting of seroepidemiologic studies is critical to their utility in evidence synthesis and public health decision making. The Reporting of Seroepidemiologic studies-SARS-CoV-2 (ROSES-S) guideline is a checklist that aims to improve reporting in SARS-CoV-2 seroepidemiologic studies. Adherence to the ROSES-S guideline has not yet been evaluated., Objectives: This study aims to evaluate the completeness of SARS-CoV-2 seroepidemiologic study reporting by the ROSES-S guideline during the COVID-19 pandemic, determine whether guideline publication was associated with reporting completeness, and identify study characteristics associated with reporting completeness., Methods: A random sample from the SeroTracker living systematic review database was evaluated. For each reporting item in the guideline, the percentage of studies that were adherent was calculated, as well as median and interquartile range (IQR) adherence across all items and by item domain. Beta regression analyses were used to evaluate predictors of adherence to ROSES-S., Results: One hundred and ninety-nine studies were analyzed. Median adherence was 48.1% (IQR 40.0%-55.2%) per study, with overall adherence ranging from 8.8% to 72.7%. The laboratory methods domain had the lowest median adherence (33.3% [IQR 25.0%-41.7%]). The discussion domain had the highest median adherence (75.0% [IQR 50.0%-100.0%]). Reporting adherence to ROSES-S before and after guideline publication did not significantly change. Publication source (p < 0.001), study risk of bias (p = 0.001), and sampling method (p = 0.004) were significantly associated with adherence., Conclusions: Completeness of reporting in SARS-CoV-2 seroepidemiologic studies was suboptimal. Publication of the ROSES-S guideline was not associated with changes in reporting practices. Authors should improve adherence to the ROSES-S guideline with support from stakeholders., (© 2024 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

The World Health Organization's Unity Studies global initiative provides a generic preparedness and readiness framework for conducting detailed investigations and epidemiological studies critical for the early and ongoing assessment of emerging respiratory pathogens of pandemic potential. During the COVID-19 pandemic, the initiative produced standardized investigation protocols and supported Member States to generate robust and comparable data to inform public health decision making. The subsequent iteration of the initiative is being implemented to develop revised and new investigation protocols, implementation toolkits and work to build a sustainable global network of sites, enabling the global community to be better prepared for the next emerging respiratory pathogen with epidemic or pandemic potential., (© 2024 World Health Organization; licensed by John Wiley & Sons Ltd. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Objectives: Systematic review of SARS-CoV-2 seroprevalence studies undertaken in the WHO European Region to measure pre-existing and cumulative seropositivity prior to the roll out of vaccination programmes., Design: A systematic review of the literature., Data Sources: We searched MEDLINE, EMBASE and the preprint servers MedRxiv and BioRxiv in the WHO 'COVID-19 Global literature on coronavirus disease' database using a predefined search strategy. Articles were supplemented with unpublished WHO-supported Unity-aligned seroprevalence studies and other studies reported directly to WHO Regional Office for Europe and European Centre for Disease Prevention and Control., Eligibility Criteria: Studies published before the widespread implementation of COVID-19 vaccination programmes in January 2021 among the general population and blood donors, at national and regional levels., Data Extraction and Synthesis: At least two independent researchers extracted the eligible studies; a third researcher resolved any disagreements. Study risk of bias was assessed using a quality scoring system based on sample size, sampling and testing methodologies., Results: In total, 111 studies from 26 countries published or conducted between 1 January 2020 and 31 December 2020 across the WHO European Region were included. A significant heterogeneity in implementation was noted across the studies, with a paucity of studies from the east of the Region. Sixty-four (58%) studies were assessed to be of medium to high risk of bias. Overall, SARS-CoV-2 seropositivity prior to widespread community circulation was very low. National seroprevalence estimates after circulation started ranged from 0% to 51.3% (median 2.2% (IQR 0.7-5.2%); n=124), while subnational estimates ranged from 0% to 52% (median 5.8% (IQR 2.3%-12%); n=101), with the highest estimates in areas following widespread local transmission., Conclusions: The low levels of SARS-CoV-2 antibody in most populations prior to the start of vaccine programmes underlines the critical importance of targeted vaccination of priority groups at risk of severe disease, while maintaining reduced levels of transmission to minimise population morbidity and mortality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The WHO Unity Studies initiative engaged low- and middle-income countries in the implementation of standardised SARS-CoV-2 sero-epidemiological investigation protocols and timely sharing of comparable results for evidence-based action. To gain a deeper understanding of the methodological challenges faced when conducting seroprevalence studies in the African region, we conducted unstructured interviews with key study teams in five countries. We discuss the challenges identified: participant recruitment and retention, sampling, sample and data management, data analysis and presentation. Potential solutions to aid future implementation include preparedness actions such as the development of new tools, robust planning and practice., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Background: Sarajevo Canton in the Federation of Bosnia and Herzegovina has recorded several waves of high SARS-CoV-2 transmission and has struggled to reach adequate vaccination coverage. We describe the evolution of infection- and vaccine-induced SARS-CoV-2 antibody response and persistence., Methods: We conducted repeated cross-sectional analyses of blood donors aged 18-65 years in Sarajevo Canton in November-December 2020 and 2021. We analyzed serum samples for anti-nucleocapsid (anti-N) and anti-spike (anti-S) antibodies. To assess immune durability, we conducted longitudinal analyses of seropositive participants at 6 and 12 months., Results: One thousand fifteen participants were included in Phase 1 (November-December 2020) and 1152 in Phase 2 (November-December 2021). Seroprevalence increased significantly from 19.2% (95% CI: 17.2%-21.4%) in Phase 1 to 91.6% (95% CI: 89.8%-93.1%) in Phase 2. Anti-S IgG titers were significantly higher among vaccinated (58.5%) than unvaccinated infected participants across vaccine products ( p  < 0.001), though highest among those who received an mRNA vaccine. At 6 months, 78/82 (95.1%) participants maintained anti-spike seropositivity; at 12 months, 58/58 (100.0%) participants were seropositive, and 33 (56.9%) had completed the primary vaccine series within 6 months. Among 11 unvaccinated participants who were not re-infected at 12 months, anti-S IgG declined from median 770.1 (IQR 615.0-1321.7) to 290.8 (IQR 175.7-400.3). Anti-N IgG antibodies waned earlier, from 35.4% seropositive at 6 months to 24.1% at 12 months., Conclusions: SARS-CoV-2 seroprevalence increased significantly over 12 months from end of 2020 to end of 2021. Although individuals with previous infection may have residual protection, COVID-19 vaccination is vital to strengthening population immunity., Competing Interests: VIS has served as a consultant for WHO Country Office in Bosnia and Herzegovina. Co‐authors report no conflicts of interest., (© 2023 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Background: Household transmission investigations (HHTIs) contribute timely epidemiologic knowledge in response to emerging pathogens. HHTIs conducted in the context of the COVID-19 pandemic in 2020-21 reported variable methodological approaches, producing epidemiological estimates that vary in meaning, precision and accuracy. Because specific tools to assist with the optimal design and critical appraisal of HHTIs are not available, the aggregation and pooling of inferences from HHTIs to inform policy and interventions may be challenging., Methods: In this manuscript, we discuss key aspects of the HHTI design, provide recommendations for the reporting of these studies and propose an appraisal tool that contributes to the optimal design and critical appraisal of HHTIs., Results: The appraisal tool consists of 12 questions that explore 10 aspects of HHTIs and can be answered 'yes', 'no' or 'unclear'. We provide an example of the use of this tool in the context of a systematic review that aimed to quantify the household secondary attack rate from HHTIs., Conclusion: We seek to fill a gap in the epidemiologic literature and contribute to standardised HHTI approaches across settings to achieve richer and more informative datasets., Competing Interests: The authors declare no conflicts of interest., (© 2023 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Background: The global surge in the omicron (B.1.1.529) variant has resulted in many individuals with hybrid immunity (immunity developed through a combination of SARS-CoV-2 infection and vaccination). We aimed to systematically review the magnitude and duration of the protective effectiveness of previous SARS-CoV-2 infection and hybrid immunity against infection and severe disease caused by the omicron variant., Methods: For this systematic review and meta-regression, we searched for cohort, cross-sectional, and case-control studies in MEDLINE, Embase, Web of Science, ClinicalTrials.gov, the Cochrane Central Register of Controlled Trials, the WHO COVID-19 database, and Europe PubMed Central from Jan 1, 2020, to June 1, 2022, using keywords related to SARS-CoV-2, reinfection, protective effectiveness, previous infection, presence of antibodies, and hybrid immunity. The main outcomes were the protective effectiveness against reinfection and against hospital admission or severe disease of hybrid immunity, hybrid immunity relative to previous infection alone, hybrid immunity relative to previous vaccination alone, and hybrid immunity relative to hybrid immunity with fewer vaccine doses. Risk of bias was assessed with the Risk of Bias In Non-Randomized Studies of Interventions Tool. We used log-odds random-effects meta-regression to estimate the magnitude of protection at 1-month intervals. This study was registered with PROSPERO (CRD42022318605)., Findings: 11 studies reporting the protective effectiveness of previous SARS-CoV-2 infection and 15 studies reporting the protective effectiveness of hybrid immunity were included. For previous infection, there were 97 estimates (27 with a moderate risk of bias and 70 with a serious risk of bias). The effectiveness of previous infection against hospital admission or severe disease was 74·6% (95% CI 63·1-83·5) at 12 months. The effectiveness of previous infection against reinfection waned to 24·7% (95% CI 16·4-35·5) at 12 months. For hybrid immunity, there were 153 estimates (78 with a moderate risk of bias and 75 with a serious risk of bias). The effectiveness of hybrid immunity against hospital admission or severe disease was 97·4% (95% CI 91·4-99·2) at 12 months with primary series vaccination and 95·3% (81·9-98·9) at 6 months with the first booster vaccination after the most recent infection or vaccination. Against reinfection, the effectiveness of hybrid immunity following primary series vaccination waned to 41·8% (95% CI 31·5-52·8) at 12 months, while the effectiveness of hybrid immunity following first booster vaccination waned to 46·5% (36·0-57·3) at 6 months., Interpretation: All estimates of protection waned within months against reinfection but remained high and sustained for hospital admission or severe disease. Individuals with hybrid immunity had the highest magnitude and durability of protection, and as a result might be able to extend the period before booster vaccinations are needed compared to individuals who have never been infected., Funding: WHO COVID-19 Solidarity Response Fund and the Coalition for Epidemic Preparedness Innovations., Competing Interests: Declaration of interests NB, HW, XM, ZL, RH, CC, AS, MW, BC, and RKA report grants unrelated to the present work from the WHO Health Emergencies Program, the Public Health Agency of Canada through Canada's COVID-19 Immunity Task Force (grant 2021-HQ-000056), the Robert Koch Institute, and the Canadian Medical Association Joule Innovation Fund. HI reports contracts unrelated to the present work from WHO. MMH reports contracts unrelated to the present work from WHO, Pfizer, and the Bill & Melinda Gates Foundation. VP is an unpaid governing board member and Royal Trustee at Cochrane. RKA reports consulting fees unrelated to the present work from the Bill & Melinda Gates Foundation Strategic Investment Fund, Health Canada, and Flagship Pioneering, and stock in Alethea Medical that is unrelated to the present work. MDVK, IB, DF, and LS are employed by WHO. MMH has contracts with WHO, CEPI, and the Asian Development Bank to gather data on COVID-19 vaccine efficacy, effectiveness, and safety from published studies, and reports unrelated grants from Pfizer and the Bill & Melinda Gates Foundation. AW-S and MKP consult on COVID-19 research and policy for WHO., (© 2023 World Health Organization; licensee Elsevier. This is an Open Access article published under the CC BY 3.0 IGO license which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, there should be no suggestion that WHO endorses any specific organisation, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.)

Background: The COVID-19 pandemic has global impacts but is relatively understudied in developing countries. Mongolia, a lower-middle-income country, instituted strict control measures in early 2020 and avoided widespread transmission until vaccines became available in February, 2021. Mongolia achieved its 60% vaccination coverage goal by July 2021. We investigated the distribution and determinants of SARS-CoV-2 seroprevalence in Mongolia over 2020 and 2021., Methods: We performed a longitudinal seroepidemiologic study aligned with WHO's Unity Studies protocols. We collected data from a panel of 5000 individuals in four rounds between October 2020 and December 2021. We selected participants through local health centres across Mongolia by age-stratified multi-stage cluster sampling. We tested serum for the presence of total antibodies against SARS-CoV-2 receptor-binding domain, and levels of anti-SARS-CoV-2 spike IgG and neutralising antibodies. We linked participant data with national mortality, COVID-19 case, and vaccination registries. We estimated population seroprevalence and vaccine uptake, as well as unvaccinated population prior-infection prevalence., Findings: At the final round in late 2021, 82% (n = 4088) of participants completed follow-up. Estimated seroprevalence increased from 1.5% (95% CI: 1.2-2.0), to 82.3% (95% CI: 79.5-84.8) between late-2020 and late-2021. At the final round an estimated 62.4% (95% CI: 60.2-64.5) of the population were vaccinated, and of the unvaccinated population 64.5% (95% CI: 59.7-69.0) had been infected. Cumulative case ascertainment in the unvaccinated was 22.8% (95% CI: 19.1%-26.9%) and the overall infection-fatality ratio was 0.100% (95% CI: 0.088-0.124). Health workers had higher odds for being COVID-19 confirmed cases at all rounds. Males (1.72 (95% CI: 1.33-2.22)) and adults aged 20 and above (12.70 (95% CI: 8.14-20.26)) had higher odds for seroconverting by mid-2021. Among the seropositive, 87.1% (95% CI: 82.3%-90.8%) had SARS-CoV-2 neutralising antibodies by late 2021., Interpretation: Our study enabled tracking of SARS-CoV-2 serological markers in the Mongolian population over one year. We found low SARS-CoV-2 seroprevalence in 2020 and early 2021, with seropositivity increasing over a 3-month interval in 2021 due to vaccine roll out and rapid infection of most of the unvaccinated population. Despite high seroprevalence in Mongolia amongst both vaccinated and unvaccinated individuals by end-2021, the SARS-CoV-2 Omicron immune escape variant caused a substantial epidemic., Funding: World Health Organization, WHO UNITY Studies initiative, with funding by the COVID-19 Solidarity Response Fund and the German Federal Ministry of Health (BMG) COVID-19 Research and development. The Ministry of Health, Mongolia partially funded this study., Competing Interests: We declare no competing interests., (© 2023 World Health Organization.)

It is impossible to address the many complex needs of respiratory virus surveillance with a single system. Therefore, multiple surveillance systems and complementary studies must fit together as tiles in a "mosaic" to provide a complete picture of the risk, transmission, severity, and impact of respiratory viruses of epidemic and pandemic potential. Below we present a framework (WHO Mosaic Respiratory Surveillance Framework) to assist national authorities to identify priority respiratory virus surveillance objectives and the best approaches to meet them; to develop implementation plans according to national context and resources; and to prioritize and target technical assistance and financial investments to meet most pressing needs., Competing Interests: All authors have declared no conflicts of interest., (© 2023 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Background: Our understanding of the global scale of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection remains incomplete: Routine surveillance data underestimate infection and cannot infer on population immunity; there is a predominance of asymptomatic infections, and uneven access to diagnostics. We meta-analyzed SARS-CoV-2 seroprevalence studies, standardized to those described in the World Health Organization's Unity protocol (WHO Unity) for general population seroepidemiological studies, to estimate the extent of population infection and seropositivity to the virus 2 years into the pandemic., Methods and Findings: We conducted a systematic review and meta-analysis, searching MEDLINE, Embase, Web of Science, preprints, and grey literature for SARS-CoV-2 seroprevalence published between January 1, 2020 and May 20, 2022. The review protocol is registered with PROSPERO (CRD42020183634). We included general population cross-sectional and cohort studies meeting an assay quality threshold (90% sensitivity, 97% specificity; exceptions for humanitarian settings). We excluded studies with an unclear or closed population sample frame. Eligible studies-those aligned with the WHO Unity protocol-were extracted and critically appraised in duplicate, with risk of bias evaluated using a modified Joanna Briggs Institute checklist. We meta-analyzed seroprevalence by country and month, pooling to estimate regional and global seroprevalence over time; compared seroprevalence from infection to confirmed cases to estimate underascertainment; meta-analyzed differences in seroprevalence between demographic subgroups such as age and sex; and identified national factors associated with seroprevalence using meta-regression. We identified 513 full texts reporting 965 distinct seroprevalence studies (41% low- and middle-income countries [LMICs]) sampling 5,346,069 participants between January 2020 and April 2022, including 459 low/moderate risk of bias studies with national/subnational scope in further analysis. By September 2021, global SARS-CoV-2 seroprevalence from infection or vaccination was 59.2%, 95% CI [56.1% to 62.2%]. Overall seroprevalence rose steeply in 2021 due to infection in some regions (e.g., 26.6% [24.6 to 28.8] to 86.7% [84.6% to 88.5%] in Africa in December 2021) and vaccination and infection in others (e.g., 9.6% [8.3% to 11.0%] in June 2020 to 95.9% [92.6% to 97.8%] in December 2021, in European high-income countries [HICs]). After the emergence of Omicron in March 2022, infection-induced seroprevalence rose to 47.9% [41.0% to 54.9%] in Europe HIC and 33.7% [31.6% to 36.0%] in Americas HIC. In 2021 Quarter Three (July to September), median seroprevalence to cumulative incidence ratios ranged from around 2:1 in the Americas and Europe HICs to over 100:1 in Africa (LMICs). Children 0 to 9 years and adults 60+ were at lower risk of seropositivity than adults 20 to 29 (p < 0.001 and p = 0.005, respectively). In a multivariable model using prevaccination data, stringent public health and social measures were associated with lower seroprevalence (p = 0.02). The main limitations of our methodology include that some estimates were driven by certain countries or populations being overrepresented., Conclusions: In this study, we observed that global seroprevalence has risen considerably over time and with regional variation; however, over one-third of the global population are seronegative to the SARS-CoV-2 virus. Our estimates of infections based on seroprevalence far exceed reported Coronavirus Disease 2019 (COVID-19) cases. Quality and standardized seroprevalence studies are essential to inform COVID-19 response, particularly in resource-limited regions., Competing Interests: I have read the journal policy and the authors of this manuscript have the following competing interests: RKA, MW, HW, ZL, XM, CC, MYL, DB, JP, MPC, ML, MS, GRD, NI, CZ, SP, HPR, TY, KCN, DK, SAA, ND, CD, NAD, EL, RKI, ASB, ELB, AS, JC and NB report grants from Canada’s COVID-19 Immunity Task Force through the Public Health Agency of Canada, and the Canadian Medical Association Joule Innovation Fund. RKA, MW, HW, ZL, CC, MYL, NB also report grants from the World Health Organisation and the Robert Koch Institute. RKA reports personal fees from the Public Health Agency of Canada and the Bill and Melinda Gates Foundation Strategic Investment Fund, as well as equity in Alethea Medical (Outside the submitted work). MPC reports grants from McGill Interdisciplinary Initiative in Infection and Immunity and Canadian Institute of Health Research, and personal fees from GEn1E Lifesciences (Outside the submitted work), nplex biosciences (Outside the submitted work), Kanvas biosciences (Outside the submitted work). JP reports grants from MedImmune (Outside the submitted work) and Sanofi-Pasteur (Outside the submitted work), grants and personal fees from Merck (Outside the submitted work) and AbbVie (Outside the submitted work), and personal fees from AstraZeneca (Outside the submitted work). DB reports grants from the World Health Organization, Canadian Institutes of Health Research, Natural Sciences and Engineering Council of Canada (Outside the submitted work), Institute national d excellence en sante et service sociaux (Outside the submitted work), and personal fees from McGill University Health Centre (Outside the submitted work) and Public Health Agency of Canada (Outside the submitted work). CC reports funding from Sanofi Pasteur (Outside of the submitted work). TY reports working for Health Canada as a part-time Senior Policy Analyst with the COVID-19 Testing and Screening Expert Panel, from Nov 2020-Jun 2021 (Outside of the submitted work). TH reports funding recieved from the United States Centers for Disease Control and Prevention for Columbia University (Outside of the submitted work). Author HCL declares receiving funding as a WHO consultant from WHO Solidarity Response Fund and the German Federal Ministry of Health COVID-19 Research and Development., (Copyright: © 2022 Bergeri et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

We aimed to estimate the household secondary infection attack rate (hSAR) of SARS-CoV-2 in investigations aligned with the WHO Unity Studies Household Transmission Investigations (HHTI) protocol. We conducted a systematic review and meta-analysis according to PRISMA 2020 guidelines. We searched Medline, Embase, Web of Science, Scopus and medRxiv/bioRxiv for "Unity-aligned" First Few X cases (FFX) and HHTIs published 1 December 2019 to 26 July 2021. Standardised early results were shared by WHO Unity Studies collaborators (to 1 October 2021). We used a bespoke tool to assess investigation methodological quality. Values for hSAR and 95% confidence intervals (CIs) were extracted or calculated from crude data. Heterogeneity was assessed by visually inspecting overlap of CIs on forest plots and quantified in meta-analyses. Of 9988 records retrieved, 80 articles (64 from databases; 16 provided by Unity Studies collaborators) were retained in the systematic review; 62 were included in the primary meta-analysis. hSAR point estimates ranged from 2% to 90% (95% prediction interval: 3%-71%; I 2  = 99.7%); I 2 values remained >99% in subgroup analyses, indicating high, unexplained heterogeneity and leading to a decision not to report pooled hSAR estimates. FFX and HHTI remain critical epidemiological tools for early and ongoing characterisation of novel infectious pathogens. The large, unexplained variance in hSAR estimates emphasises the need to further support standardisation in planning, conduct and analysis, and for clear and comprehensive reporting of FFX and HHTIs in time and place, to guide evidence-based pandemic preparedness and response efforts for SARS-CoV-2, influenza and future novel respiratory viruses., (© 2022 World Health Organization; licensed by John Wiley & Sons Ltd. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Introduction: Estimating COVID-19 cumulative incidence in Africa remains problematic due to challenges in contact tracing, routine surveillance systems and laboratory testing capacities and strategies. We undertook a meta-analysis of population-based seroprevalence studies to estimate SARS-CoV-2 seroprevalence in Africa to inform evidence-based decision making on public health and social measures (PHSM) and vaccine strategy., Methods: We searched for seroprevalence studies conducted in Africa published 1 January 2020-30 December 2021 in Medline, Embase, Web of Science and Europe PMC (preprints), grey literature, media releases and early results from WHO Unity studies. All studies were screened, extracted, assessed for risk of bias and evaluated for alignment with the WHO Unity seroprevalence protocol. We conducted descriptive analyses of seroprevalence and meta-analysed seroprevalence differences by demographic groups, place and time. We estimated the extent of undetected infections by comparing seroprevalence and cumulative incidence of confirmed cases reported to WHO., Prospero: CRD42020183634., Results: We identified 56 full texts or early results, reporting 153 distinct seroprevalence studies in Africa. Of these, 97 (63%) were low/moderate risk of bias studies. SARS-CoV-2 seroprevalence rose from 3.0% (95% CI 1.0% to 9.2%) in April-June 2020 to 65.1% (95% CI 56.3% to 73.0%) in July-September 2021. The ratios of seroprevalence from infection to cumulative incidence of confirmed cases was large (overall: 100:1, ranging from 18:1 to 954:1) and steady over time. Seroprevalence was highly heterogeneous both within countries-urban versus rural (lower seroprevalence for rural geographic areas), children versus adults (children aged 0-9 years had the lowest seroprevalence)-and between countries and African subregions., Conclusion: We report high seroprevalence in Africa suggesting greater population exposure to SARS-CoV-2 and potential protection against COVID-19 severe disease than indicated by surveillance data. As seroprevalence was heterogeneous, targeted PHSM and vaccination strategies need to be tailored to local epidemiological situations., Competing Interests: Competing interests: WHO had a role in study design, data collection, data analysis, data interpretation and writing of the report. No other funders had any such role. The corresponding authors had full access to all the data in the study and had final responsibility for the decision to submit for publication. Authors were not precluded from accessing data in the study, and they accept responsibility to submit for publication. Potential other competing interests of named coauthors include: RKA reports personal fees from the Public Health Agency of Canada and the Bill and Melinda Gates Foundation Strategic Investment Fund, as well as equity in Alethea Medical (outside the submitted work). MPC reports personal fees from GEn1E Lifesciences (outside the submitted work), nplex biosciences (outside the submitted work) and Kanvas biosciences (outside the submitted work). JP reports grants from MedImmune (outside the submitted work) and Sanofi-Pasteur (outside the submitted work), grants and personal fees from Merck (outside the submitted work) and AbbVie (outside the submitted work) and personal fees from AstraZeneca (outside the submitted work). CCo reports funding from Sanofi Pasteur (outside of the submitted work). KE reports being cochairman of ANRS group on public health and social science in France (outside of the submitted work). JDS reports consulting fees from ASLM, GIZ health-focus and l’Oréal (all outside of the submitted work)., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The declaration of Coronavirus disease 2019 (COVID-19) as a Public Health Emergency of International Concern (PHEIC) on 30 January 2020 required rapid implementation of early investigations to inform appropriate national and global public health actions., Methods: The suite of existing pandemic preparedness generic epidemiological early investigation protocols was rapidly adapted for COVID-19, branded the 'UNITY studies' and promoted globally for the implementation of standardized and quality studies. Ten protocols were developed investigating household (HH) transmission, the first few cases (FFX), population seroprevalence (SEROPREV), health facilities transmission (n = 2), vaccine effectiveness (n = 2), pregnancy outcomes and transmission, school transmission, and surface contamination. Implementation was supported by WHO and its partners globally, with emphasis to support building surveillance and research capacities in low- and middle-income countries (LMIC)., Results: WHO generic protocols were rapidly developed and published on the WHO website, 5/10 protocols within the first 3 months of the response. As of 30 June 2021, 172 investigations were implemented by 97 countries, of which 62 (64%) were LMIC. The majority of countries implemented population seroprevalence (71 countries) and first few cases/household transmission (37 countries) studies., Conclusion: The widespread adoption of UNITY protocols across all WHO regions indicates that they addressed subnational and national needs to support local public health decision-making to prevent and control the pandemic., (© 2021 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Background: With the global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in early 2020, Mongolia implemented rapid emergency measures and did not report local transmission until November 2020. We conducted a national seroprevalence survey to monitor the burden of SARS-CoV-2 in Mongolia in the months surrounding the first local transmission., Methods: During October-December 2020, participants were randomly selected using age stratification and invited for interviews and blood samples at local primary health centres. We screened for total SARS-CoV-2 antibodies, followed by two-step quantitative SARS-CoV-2 IgG serology tests for positive samples. Weighted and test-adjusted seroprevalences were estimated. We used chi-square, Fisher's exact and other tests to identify variables associated with seropositivity., Findings: A total of 5000 subjects were enrolled. We detected SARS-CoV-2 IgG antibodies in 72 samples. Crude seroprevalence of SARS-CoV-2 antibodies was 1·44% (95%CI,1·21-1·67). Population weighted and test-adjusted seroprevalences were 1·36% (95%CI,1·11-1·63) and 1·45% (95%CI,1·11-1·63), respectively. Age, sex, geographical, and occupational factors were not associated with seropositivity (p>0·05). Symptoms and signs within past 3 months and seropositivity were not associated at the time of the survey (p>0·05)., Interpretation: SARS-CoV-2 seroprevalence in Mongolia was low in the first year of the pandemic potentially due to strong public health measures, including border restrictions, educational facilities closure, earlier adoption of mask-wearing and others. Our findings suggest large-scale community transmission could not have occurred up to November 2020 in Mongolia. Additional serosurveys are needed to monitor the local pandemic dynamic and estimate how far from herd immunity Mongolia will be following-up with vaccination programme in 2021 and 2022., Funding: World Health Organisation, WHO UNITY Studies initiative, with funding by the COVID-19 Solidarity Response Fund and the German Federal Ministry of Health (BMG) COVID-19 Research and development., Translation: Cyrillic and Traditional Mongolian translation of abstract is available on appendix section., Competing Interests: None., (© 2021 The Authors.)

Influenza viruses with pandemic potential have been detected in humans in the Eastern Mediterranean Region. The Pandemic Influenza Preparedness (PIP) Framework aims to improve the sharing of influenza viruses with pandemic potential and increase access of developing countries to vaccines and other life-saving products during a pandemic. Under the Framework, countries have been supported to enhance their capacities to detect, prepare for and respond to pandemic influenza. In the Eastern Mediterranean Region, seven countries are priority countries for Laboratory and Surveillance (L&S) support: Afghanistan, Djibouti, Egypt, Jordan, Lebanon, Morocco and Yemen. During 2014-2017, US$ 2.7 million was invested in regional capacity-building and US$ 4.6 million directly in the priority countries. Countries were supported to strengthen influenza diagnostic capacities to improve detection, enhance influenza surveillance systems including sentinel surveillance for severe acute respiratory infection and influenza-like illness, and increase global sharing of surveillance data and influenza viruses. This paper highlights the progress made in improving influenza preparedness and response capacities in the Region from 2014 to 2017, and the challenges faced. By 2017, 18 of the 22 countries of the Region had laboratory-testing capacity, 19 had functioning sentinel influenza surveillance systems and 22 had trained national rapid response teams. The number of countries correctly identifying all influenza viruses in the WHO external quality assurance panel increased from 9 countries scoring 100% in 2014 to 15 countries in 2017, and the number sharing influenza viruses with WHO collaborating centres increased by 75% (from eight to 14 countries); more than half now share influenza data with regional or global surveillance platforms. Seven countries have estimated influenza disease burden and seven have introduced influenza vaccination for high-risk groups. Challenges included: protracted complex emergencies faced by nine countries which hindered implementation of influenza surveillance in areas with the most needs, high staff turnover, achieving timely virus sharing and limited utilization of influenza data where they are available to inform vaccine policies or establish threshold values to measure the start and severity of influenza seasons., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Students comprised the majority of early cases of influenza A(H1N1)pdm09 in Melbourne, Australia. Students and school settings were targeted for public health interventions following the emergence of pH1N1. This study was conducted to describe changes in social contacts among the earliest confirmed student cases of pH1N1 in Melbourne, Australia, to inform future pandemic control policy and explore transmission model assumptions., Methods: A retrospective cross-sectional behavioural study of student cases with laboratory-confirmed pH1N1 between 28 April and 3 June 2009 was conducted in 2009. Demographics, symptom onset dates and detailed information on regular and additional extracurricular activities were collected. Summary measures for activities were calculated, including median group size and median number of close contacts and attendance during the students' exposure and infectious periods or during school closures. A multivariable model was used to assess associations between rates of participation in extracurricular activities and both school closures and students' infectious periods., Results: Among 162 eligible cases, 99 students participated. Students reported social contact in both curricular and extra-curricular activities. Group size and total number of close contacts varied. While participation in activities decreased during the students' infectious periods and during school closures, social contact was common during periods when isolation was advised and during school closures., Discussion: This study demonstrates the potential central role of young people in pandemic disease transmission given the level of non-adherence to prevention and control measures. These finding have public health implications for both informing modelling estimates of future pandemics and targeting prevention and control strategies to young people., ((c) 2018 The authors; licensee World Health Organization.)

Evidence documenting the global burden of disease from viral hepatitis was essential for the World Health Assembly to endorse the first Global Health Sector Strategy (GHSS) on viral hepatitis in May 2016. The GHSS on viral hepatitis proposes to eliminate viral hepatitis as a public health threat by 2030. The GHSS on viral hepatitis is in line with targets for HIV infection and tuberculosis as part of the Sustainable Development Goals. As coordination between hepatitis and HIV programs aims to optimize the use of resources, guidance is also needed to align the strategic information components of the 2 programs. The World Health Organization monitoring and evaluation framework for viral hepatitis B and C follows an approach similar to the one of HIV, including components on the following: (1) context (prevalence of infection), (2) input, (3) output and outcome, including the cascade of prevention and treatment, and (4) impact (incidence and mortality). Data systems that are needed to inform this framework include (1) surveillance for acute hepatitis, chronic infections, and sequelae and (2) program data documenting prevention and treatment, which for the latter includes a database of patients. Overall, the commonalities between HIV and hepatitis at the strategic, policy, technical, and implementation levels justify coordination, strategic linkage, or integration, depending on the type of HIV and viral hepatitis epidemics. Strategic information is a critical area of this alignment under the principle of what gets measured gets done. It is facilitated because the monitoring and evaluation frameworks for HIV and viral hepatitis were constructed using a similar approach. However, for areas where elimination of viral hepatitis requires data that cannot be collected through the HIV program, collaborations are needed with immunization, communicable disease control, tuberculosis, and hepatology centers to ensure collection of information for the remaining indicators., (©Yvan Hutin, Daniel Low-Beer, Isabel Bergeri, Sarah Hess, Jesus Maria Garcia-Calleja, Chika Hayashi, Antons Mozalevskis, Annemarie Rinder Stengaard, Keith Sabin, Hande Harmanci, Marc Bulterys. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 15.12.2017.)

Despite high sexually transmitted infection (STI) prevalence in the Pacific, there are limited data on STIs and risk among men who have sex with men (MSM) and transgender people (TG). In 2011, an Integrated Bio-Behavioural Survey recruited self-identified MSM and TG in Port Vila, Vanuatu. Descriptive findings were stratified by sexuality. Among 28 (55%) MSM and 23 (45%) TG, recent anal sex with male partners was more common among MSM (94% vs 71%; P < 0.1), including with casual (47% vs 35%), regular (59% vs 29%) and paying partners (28% vs 12%). MSM more commonly reported lifetime (P < 0.01) and recent sex with female partners (P < 0.01). Reported condom use with any partner type was low. More MSM (35%) than TG (24%) were diagnosed with an STI; previous treatment-seeking behaviour when symptomatic was lower among TG (P < 0.1). Tailored strategies acknowledging differences between MSM and TG are required to reduce STI vulnerability in Vanuatu.

There is insufficient data on sexually transmitted infections (STI) and related behaviours among key populations, including female sex workers (FSW), in the Pacific region. Using respondent driven sampling, we conducted an integrated bio-behavioural survey with FSW in Vanuatu (aged ≥18 years) to investigate risk behaviours associations with Chlamydia trachomatis (CT). Weighted population estimates and correlates of CT infection were calculated. Among 149 FSW, prevalence of CT was 36 % (95 % CI 26-48 %). Few FSW reported consistent condom use with recent transactional sex partners (TSP) (8 %; 95 % CI 2-13 %). CT infection was positively associated with increasing number of TSP (adjusted odds ratio [AOR] 1.1; 95 % CI 1.0-1.2) and group sex (AOR 2.9; 95 % CI 1.1-8.2). CT was negatively associated with increasing age of first sex (AOR 0.6; 95 % CI 0.5-0.9) and previous STI treatment (AOR 0.1; 95 % CI 0.0-0.4). A comprehensive public health strategy for prevention and treatment of STI among FSW, incorporating community empowerment strategies, FSW-targeted health services and periodic presumptive treatment, is urgently needed in Vanuatu.

Background: Victoria was the first state in Australia to experience community transmission of influenza A(H1N1)pdm09. We undertook a descriptive epidemiological analysis of the first 1,000 notified cases to describe the epidemic associated with school children and explore implications for school closure and antiviral distribution policy in revised pandemic plans., Methods: Records of the first 1,000 laboratory-confirmed cases of influenza A(H1N1)pdm09 notified to the Victorian Government Department of Health between 20 May and 5 June 2009 were extracted from the state's notifiable infectious diseases database. Descriptive analyses were conducted on case demographics, symptoms, case treatment, prophylaxis of contacts and distribution of cases in schools., Results: Two-thirds of the first 1,000 cases were school-aged (5-17 years) with cases in 203 schools, particularly along the north and western peripheries of the metropolitan area. Cases in one school accounted for nearly 8% of all cases but the school was not closed until nine days after symptom onset of the first identified case. Amongst all cases, cough (85%) was the most commonly reported symptom followed by fever (68%) although this was significantly higher in primary school children (76%). The risk of hospitalisation was 2%. The median time between illness onset and notification of laboratory confirmation was four days, with only 10% of cases notified within two days of onset and thus eligible for oseltamivir treatment. Nearly 6,000 contacts were followed up for prophylaxis., Conclusions: With a generally mild clinical course and widespread transmission before its detection, limited and short-term school closures appeared to have minimal impact on influenza A(H1N1)pdm09 transmission. Antiviral treatment could rarely be delivered to cases within 48 hours of symptom onset. These scenarios and lessons learned from them need to be incorporated into revisions of pandemic plans.

To examine intrahousehold secondary transmission of pandemic (H1N1) 2009 virus in households in Victoria, Australia, we conducted a retrospective cross-sectional study in late 2009. We randomly selected case-patients reported during May-June 2009 and their household contacts. Information collected included household characteristics, use of prevention and control measures, and signs and symptoms. Secondary cases were defined as influenza-like illness in household contacts within the specified period. Secondary transmission was identified for 18 of 122 susceptible household contacts. To identify independent predictors of secondary transmission, we developed a model. Risk factors were concurrent quarantine with the household index case-patient, and a protective factor was antiviral prophylaxis. These findings show that timely provision of antiviral prophylaxis to household contacts, particularly when household members are concurrently quarantined during implementation of pandemic management strategies, delays or contains community transmission of pandemic (H1N1) 2009 virus.

Objective: To describe the proportion of 16-29-year-olds tested for chlamydia by Australian general practitioners in a 12-month period., Design and Setting: Between October 2007 and September 2008, the national chlamydia testing rate in 16-29-year-olds was calculated by dividing the number of Medicare-reimbursed chlamydia tests by two denominators: (i) Medicare-reimbursed GP consultations; and (ii) estimated resident populations adjusted for the proportion who were sexually active., Main Outcome Measures: GP chlamydia testing rates in 16-29-year-olds per 100 patients attending a GP consultation and per 100 sexually active population, by patient age and sex, state/territory of residence, and remoteness area., Results: Among the estimated Australian population of 16-29-year-olds, 85.6% of females and 64.4% of males had at least one GP consultation in the 12-month period. The national GP chlamydia testing rate per 100 patients was 8.9% (95% CI, 8.88%-8.94%). The national GP chlamydia testing rate per 100 sexually active population was 8.0% (95% CI, 7.92%-7.98%). The rate per 100 sexually active population was higher in females (12.5%) compared with males (3.7%) (P < 0.01); higher in 20-24-year-olds (9.0%) compared with 16-19-year-olds (8.7%) and 25-29-year-olds (6.6%) (P < 0.01); higher in those living in non-metropolitan areas (11.0%) compared with metropolitan areas (8.4%) (P < 0.01); and highest in those living in the Northern Territory (21.4%) compared with other jurisdictions (P < 0.01)., Conclusions: Despite clinical guidelines recommending annual chlamydia testing for sexually active 15-29-year-olds, our analysis showed that a high proportion of young people aged 16-29 years attend a GP each year, but few of the sexually active population in this age group were tested for chlamydia in general practice. Strategies are needed to support GPs to enhance chlamydia testing in young people.

Objective: To describe recent trends among men who have sex with men (MSM) in age at diagnosis of HIV in Victoria., Design and Setting: Analysis of Victorian HIV surveillance data from (i) passive surveillance (2000-2009) and (ii) the Victorian Primary Care Network for Sentinel Surveillance (VPCNSS) (2006-2009). Age-trend comparisons were made using syphilis and gonorrhoea enhanced surveillance., Main Outcome Measures: HIV diagnoses, HIV testing and behavioural indicators by year and age group among MSM., Results: Following a period of sustained increase between 2000 and 2007, the median age at HIV diagnosis among MSM declined significantly, from 38.8 years in 2007 to 35.3 years in 2008 (P=0.023), remaining at 35.9 years in 2009. Between 2007 and 2008, the median age of syphilis and gonorrhoea notifications also declined, from 40.6 to 36.0 years and from 32.3 to 29.3 years, respectively. The median age of HIV testing among MSM in the VPCNSS population remained constant between 2006 and 2009, at 33.0 years. Compared with older MSM, those aged less than 35 years were more likely to have never previously been tested for HIV (relative risk [RR], 1.36 [95% CI, 1.30-1.41]); to not know the HIV status of their regular partner (RR, 1.11 [95% CI, 1.01-1.21]); and to report inconsistent condom use with casual partners (RR, 1.07 [95% CI, 1.01-1.14]) and regular partners (RR, 1.07 [95% CI, 1.00-1.14])., Conclusions: Younger MSM in Victoria may be at increasing risk of HIV infection. Enhanced methods of monitoring HIV and sexually transmitted infection transmission in younger MSM are needed, as well as prevention messages to target this group, who may not fully understand their HIV risk.

Objective: To describe the attributes and key findings from implementation of a new blood-borne virus (BBV) and sexually transmissible infection (STI) sentinel surveillance system based on routine testing at clinical sites in Victoria, Australia., Methods: The Victorian Primary Care Network for Sentinel Surveillance (VPCNSS) on BBV and STI was established in 2006 at 17 sites. Target populations included men who have sex with men (MSM), young people and injecting drug users (IDU). Sites collected demographic and risk behaviour information electronically or using paper surveys from patients undergoing routine HIV or STI (syphilis, chlamydia (Chlamydia trachomatis)) or hepatitis C virus (HCV) testing. These data were linked with laboratory results., Results: Between April 2006 and June 2008, data were received for 67 466 tests and 52 042 questionnaires. In clinics providing electronic data, >90% of individuals tested for HIV, syphilis and chlamydia had risk behaviour information collected. In other clinics, survey response rates were >85% (HIV), 43.5% (syphilis), 42.7-66.5% (chlamydia) and <20% (HCV). Data completeness was >85% for most core variables. Over time, HIV, syphilis and chlamydia testing increased in MSM, and chlamydia testing declined in females (P = 0.05). The proportion of positive tests among MSM was 1.9% for HIV and 2.1% for syphilis. Among 16-24-year-olds, the proportion positive for chlamydia was 10.7% in males and 6.9% in females. Among IDU, 19.4% of HCV tests were antibody positive., Conclusions: The VPCNSS has collected a large, rich dataset through which testing, risk behaviours and the proportion positive can be monitored in high-risk groups, offering a more comprehensive BBV and STI surveillance system for Victoria. Building system sustainability requires an ongoing focus.

The Australian Collaboration for Chlamydia Enhanced Sentinel Surveillance (ACCESS) was established with funding from the Department of Health and Ageing to trial the monitoring of the uptake and outcome of chlamydia testing in Australia. ACCESS involved 6 separate networks; 5 clinical networks involving sexual health services, family planning clinics, general practices, antenatal clinics, Aboriginal community controlled health services, and 1 laboratory network. The program ran from May 2007 to September 2010. An evaluation of ACCESS was undertaken in early 2010, 2 years after the program was funded. At the time of the evaluation, 76 of the 91 participating sites were contributing data. The jurisdictional distribution of the 76 sites generally matched the jurisdictional distribution of the Australian population. In 2008, the chlamydia testing rates in persons aged 16-29 years attending the 26 general practices was 4.2% in males and 7.0% in females. At the 25 sexual health services, the chlamydia testing rates in heterosexuals aged less than 25 years in 2008 was 77% in males and 74% in females. Between 2004 and 2008, the chlamydia positivity rate increased significantly in heterosexual females aged less than 25 years attending the sexual health services, from 11.5% to 14.1% (P < 0.01). Data completeness was above 85% for all core variables except Aboriginal and/or Torres Strait Islander status and country of birth, which ranged from 68%-100%, and 74%-100%, respectively, per network. There were delays in establishment of the system due to recruitment of 91 sites, multiple ethics applications and establishment of automated extraction programs in 10 different database systems, to transform clinic records into a common, pre-defined surveillance format. ACCESS has considerable potential as a mechanism toward supporting a better understanding of long-term trends in chlamydia notifications and to support policy and program delivery.

Background: Since 2005, eight patients with H5N1 infection were laboratory confirmed in Cambodia. Despite the widespread of highly pathogenic avian influenza H5N1 virus and the intense exposure to poultry, there is growing evidence that H5N1 viruses may not be easily transmitted to human., Objectives: To evaluate the frequency of H5N1 transmission in rural Cambodia, to identify potential risk factors for H5N1 in humans and to explore the extent of asymptomatic and clinically mild illness among humans., Study Design: A seroepidemiologic survey was conducted, 9 weeks after the recognition that H5N1 infection caused the death of a 13 years old female in April 2007. Blood specimens were collected from 700 participants for H5N1 serological testing. All participants were interviewed with standardized questionnaire to collect information about poultry exposure., Results: Eighteen (2.6%) of the 700 villagers were tested positive cases for H5N1 antibodies. These 18 individuals were more likely than seronegative participants to report bathing or swimming in the community pond (p=0.04)., Conclusions: The seroprevalence of H5N1 antibodies was higher than previously reported in the other investigations conducted in Cambodia and Thailand. This finding reinforces the overwhelming evidence that the virus continues to circulate widely in settings where human have high exposure to poultry. Our results, provides additional evidence suggesting that bathing or swimming in the community ponds, remains important potential risk factor for H5N1 infection. Both wild birds and domestic poultry have free access to these ponds which are also used for aquaculture through the dumping of poultry feces for fish feeding., (Copyright 2010 Elsevier B.V. All rights reserved.)