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Over the past decade, the world has radically changed. New advances in information and communication technologies (ICT) connect the world in ways never imagined. Public health informatics (PHI) leveraged for public health surveillance (PHS), can enable, enhance, and empower essential PHS functions (i.e., detection, reporting, confirmation, analyses, feedback, response). However, the tail doesn't wag the dog; as such, ICT cannot (should not) drive public health surveillance strengthening. Rather, ICT can serve PHS to more effectively empower core functions. In this review, we explore promising ICT trends for prevention, detection, and response, laboratory reporting, push notification, analytics, predictive surveillance, and using new data sources, while recognizing that it is the people, politics, and policies that most challenge progress for implementation of solutions.

The objective of the study is to evaluate the quality of the data, the sensitivity of the surveillance, and the completeness of identification and investigation of tuberculosis (TB) patient’s contacts. The study covered the TB surveillance program in Al-Madinah province in 2011. First, we reviewed all the notifications, treatment cards, and register books, as well as monthly and quarterly reports, for completeness and accuracy of data. Then, we searched for the missed cases that were not reported. Finally, we reviewed all the patients’ household contacts’ reports to assess the degree of completion of identification and investigation. There were 444 cases detected during the study period; only 200 cases were reported. The sensitivity of the TB surveillance system was 45%. Among the 200 reported cases, the results revealed high completeness rates for demographic and disease data and low completeness rates for the test result fields. The contact identification and investigation showed that 34.4% of smear-positive cases’ contacts were not identified. Only 67% of identified contacts were investigated. The review of hospital records and lab registers showed that 244 cases were not reported. In conclusion, the TB surveillance system has several areas that need improvement.

Human brucellosis is an important zoonotic disease and is especially concerning in the Kingdom of Saudi Arabia (KSA), where livestock importation is significant. We analyzed reported human brucellosis disease trends in KSA over time to help policymakers understand the magnitude of the disease and guide the design of prevention and control measures. By using data from the national registry from 2004 to 2012, we calculated the cumulative numbers by age group and months. Trends of incidence rates (IRs) by gender, nationality, and region were also calculated. We found that there was a greater number of cases (19,130) in the 15–44years age group than in any other age group. The IRs significantly decreased from 22.9 in 2004 [95% confidence interval (CI)=22.3, 23.5] to 12.5 in 2012 (95% CI=12.1, 13). Males had a significantly greater IR than females. Most cases were reported during spring and summer seasons. The IR of Saudi citizens was significantly greater than that of non-Saudis, but this difference reduced over time. The IRs of Al-Qassim, Aseer, and Hail were in the highest 25th percentile. Young, male Saudi citizens living in highly endemic areas were at greatest risk of acquiring brucellosis. We recommend vaccinating susceptible animals against brucellosis and increasing the public’s awareness of preventive measures.

This was an evaluation of home respiratory therapy (HRT) services administered through the Madinah Home Medical Program (MHMP) Center of the Ministry of Health (MoH), Kingdom of Saudi Arabia (KSA). Using a retrospective design and descriptive analyses, we analyzed 83 patient records for the clinical care received, outcomes, and patient satisfaction. We also assessed a subset from an economic perspective. Demographically, 72% were >60years of age, 80% were female, and 90% were Saudi. Asthma accounted for 34% of the diagnosed respiratory diseases, followed by chronic obstructive pulmonary disease (11%). Most patients (71%) required two or three respiratory modalities: 94% used oxygen therapy and 14% were on mechanical ventilation. A full 90% of HMP patients expressed a high level of satisfaction with the HMP overall care, and 43% saw an improvement in their condition. The MHMP lowered healthcare costs for HRT-receiving patients by decreasing the frequency of emergency room (ER) and outpatient visits by 50.8% from 59 to 30 visits. HRT administered through the MHMP Center improved clinical outcomes and increased patient satisfaction while reducing hospital utilization and associated costs. A prospective study is recommended to assess HMP services in comparison with hospitalization.

Background Middle East Respiratory Syndrome coronavirus (MERS-CoV) continues to cause intermittent community and nosocomial outbreaks. Obtaining data on specific source(s) and transmission dynamics of MERS-CoV during nosocomial outbreaks has been challenging. We performed a clinical, epidemiological and phylogenetic investigation of an outbreak of MERS-CoV at a University Hospital in Riyadh, Kingdom of Saudi Arabia. Methods Clinical, epidemiological and infection control data were obtained from patients and Healthcare workers (HCWs). Full genome sequencing was conducted on nucleic acid extracted directly from MERS-CoV PCR-confirmed clinical samples and phylogenetic analysis performed. Phylogenetic analysis combined with published MERS-CoV genomes was performed. HCWs compliance with infection control practices was also assessed. Results Of 235 persons investigated, there were 23 laboratory confirmed MERS cases, 10 were inpatients and 13 HCWs. Eight of 10 MERS inpatients died (80% mortality). There were no deaths among HCWs. The primary index case assumed from epidemiological investigation was not substantiated phylogenetically. 17/18 MERS cases were linked both phylogenetically and epidemiologically. One asymptomatic HCW yielded a MERS-CoV genome not directly linked to any other case in the investigation. Five HCWs with mild symptoms yielded >75% full MERS-CoV genome sequences. HCW compliance with use of gowns was 62.1%, gloves 69.7%, and masks 57.6%. Conclusions Several factors and sources, including a HCW MERS-CoV ‘carrier phenomenon’, occur during nosocomial MERS-CoV outbreaks. Phylogenetic analyses of MERS-CoV linked to clinical and epidemiological information is essential for outbreak investigation. The specific role of apparently healthy HCWs in causing nosocomial outbreaks requires further definition.

Objective The goal of this editorial is to shed light on the lack of transparency that exists in the sharing of Public Health data and to reverse this presumption in favour of open public health information properly vetted and openly accessible. Open public health information is a critical step to revitalize public health practice and is a human right. Introduction Public health practice that prevents, detects, and responds to communicable and noncommunicable disease threats is hindered by poor access to public health data and information. This includes timely sharing of case-based information, respecting patent and publication rights, and the ethical sharing of specimens. Disagreements about information shared and under what circumstances plus who has right to the data, clinical specimens, and their derivative products impede research and countermeasures. Delayed or inaction by public health authorities undermines trust and exacerbates the crisis. Evident in 2014 by the delayed Public Health Emergency of International Concern declaration of the Ebola virus outbreak in West Africa by the World Health Organization, the governing presumption is that access to public health information should be restricted, constrained, or even hoarded; this is a failed approach. This lack of transparency prevents information availability when and where it is needed and obstructs public health efforts to efficiently and ethically prevent, detect, and respond to emerging threats. A better way forward is to reverse this presumption in favour of open public health information properly vetted and openly accessible. Open public health information is a critical step to revitalize public health practice and is a human right. While there is limited global consensus among scientists and public health practitioners on best practices to guide national health authorities, researchers, NGOs, and industry as they navigate the ethical, political, technical, and economic challenges associated with the sharing of essential public health information (e.g., pathogen isolates, clinical specimens, and patient-related data), grounding this discussion on the guiding principles of open public health information can help navigate the complex privacy, security, communication, and access needs, and ensure that collaboration and sharing occur in a manner that is ethically and socially just, efficient, and equitable. Built on existing governance frameworks such as the International Health Regulations (IHRs) and the Pandemic Influenza Preparedness Framework (PIP), open public health can transform public health surveillance, allowing for the rapid sharing of data and products during outbreaks for mutual benefit and enhanced global health security. Methods This abstract represents a larger editorial style manuscript, thus no methods were developed in the abstract. Results This editorial style manuscript aims to reverse the presumption that public health data is damaging to one in favour of open public health information properly vetted and openly accessible. Conclusions Similar to other open movements (i.e., open data, open government, open development, and open science) that seek to address the world’s greatest challenges through transparency, collaboration, reuse of and free access to ideas, open public health offers an ideal solution to overcome the challenges in the 21st century.

Pertussis is a vaccine preventable disease (VPD) monitored by the World Health Organization (WHO). Despite a long-established Pertussis immunization system, the re-emergence of the disease in some countries stressed the need to have well-trained field epidemiologists at the forefront in the fight against these VPDs, especially during an outbreak. Practical, hands-on training is useful for clearer understanding of the principles and development of competencies relevant to outbreak investigation, which will enhance field practice; case method training using realistic public health scenarios helps trainees put into practice learned theory. As such, this case study was adopted from a real Pertussis outbreak investigation that was conducted by Ghana's Field Epidemiology Training Program residents, together with the rapid response team members of Dormaa Municipal health directorate in August 2016. It was primarily designed for training novice public health practitioners in a facilitated classroom setting. Participants should be able to complete the exercises in approximately 3 hours.

The occurrence of communicable diseases highlights the need to have well-trained field epidemiologists at the forefront in the fight against these diseases, especially during an outbreak. Training for outbreak investigation is most effective when participants can develop their competencies in a practical exercise. This is a simulation of the steps in meningitis outbreak investigation conducted in Ghana in February 2016 by Ghana Field Epidemiology Training Programme (FELTP) residents and the public health technical team of the Nkoranza South Municipality as a field epidemiologist. This case study is suited to reinforce principles and skills already covered in a lecture or in background reading by providing a practical training beyond the scope of theoretical learning. It is primarily intended for training novice public health practitioners who should be able to complete the exercises in 3 hours.

Allergic diseases have increased in developed countries during the past decades. A cohort of Slovak children was followed from birth to track allergic symptoms dynamics in early childhood. Information on allergic symptoms (atopic dermatitis = AD, rhino conjunctivitis = RC, wheezing = Wh, urticaria = Ur) and food allergies among children was based on clinical evaluation of children by allergists at three developmental stages (infant, toddler, preschool). Out of 320 cases of allergies, 64 infants, 145 toddlers, and 195 preschool children suffered from AD, RC, Wh, Ur, or their combinations (i.e., significant increase with age, p 0.001). AD first appeared in infants, Wh and/or RC rose mainly in toddlers, and Ur among preschool children. AD in infants or toddlers disappeared in the subsequent developmental stage in approximately one third of all cases. Single AD persistence without remission or extension was not common and accounted only for 6.9% of AD infants' allergic manifestations. In addition to single-symptom allergic diseases, this study also identified several combinations of atopic symptoms.Conclusions: The proportion of multi-symptom allergies increased while single-symptom forms decreased. The observed temporal trends of allergic symptoms correspond to the atopic march. What is Known: • The observed temporal trends of allergic symptoms correspond to the atopic march. What is New: • Allergic diseases in children were first manifested as single forms, with atopic dermatitis (AD) commonly functioning as the "entry point" to allergies. • The overall proportion of single-symptom allergic disorders decreased over time while the proportion of multi-symptom allergies increased.

Introduction : schistosomiasis is an acute and chronic disease caused by parasitic worm Schistosoma. There are urogenital and intestinal forms of schistosomiasis, leading to chronic ill-health, anaemia and end-organ damage, including renal failure. Transmission is by contact with water infested by infected water snail. Schistosoma haematobium and Schistosoma mansoni are prevalent in Liberia. On August 23, 2016, the Bokomu District Health Team received reports of increased cases of haematuria in Gbarnga, Bokomu District from a community volunteer after two suspected cases from the community reported to the hospital. We investigated to confirm the outbreak, identify the causative agent, determine the extent of the disease, and identify the source of transmission and to control the spread. Methods : the total population of Gbarnga community was 2,100. We screened community members who availed themselves by conducting laboratory testing of their urine samples. We conducted an environmental assessment of water bodies. We analyzed the data using Microsoft Excel. Results : of 256 persons screened, 96% (247) tested positive for S. haematobium. More community members declined to report for screening although some were symptomatic. Median age of screened persons was 14 (range 1.8 to 43years). Majority (64%) of these were of school-going age. Duration of symptoms ranged from 1 week to 3 years. The main source of water is a swamp; for bathing, farming activities and recreational swimming. We observed some water snails around the swamp but could not test the water for cercaria worms. Conclusion : an outbreak of urinary schistosomiasis was confirmed, caused by S. haematobium. Prevalence was at least 11.8% (247 out of 2100). The community swamp was the likely reservoir of the infection. The County Health Team conducted mass education and treatment and recommended that the Government provide the community with potable water. Surveillance is ongoing.

Objective To enable coordination of Swaziland Ministry of Health units for public health surveillance (PHS). Introduction In the Kingdom of Swaziland, a baseline assessment found that multiple functional units within the Ministry of Health (MoH) perform PHS activities. There is limited data sharing and coordination between units; roles and responsibilities are unclear. The Epidemiology and Disease Control Unit (EDCU) is mandated to coordinate efforts and strengthen PHS through implementing Integrated Disease Surveillance and Response (IDSR) to fulfill requirements of International Health Regulations (2005) (IHR[2005]), and the Global Health Security Agenda (GHSA). Methods A baseline assessment that included key informant interviews of unit representatives was conducted. Data flows were developed. Results were disseminated at a facilitated stakeholder workshop with unit representatives. A database was then built containing all distinct activities found within the IDSR Technical Guidelines (2010), IHR [2005], GHSA Action Packages, the baseline assessment, a previous CDC IDSR assessment, and suggestions from the stakeholder workshop. Activities were categorized by IDSR function (identify, report, analyze, investigate, prepare, respond, provide feedback, and evaluate) and designated as an ongoing “role” or a one-time implementation activity. A document containing all PHS roles was presented at a facilitated consensus workshop; unit representatives discussed and designated a lead unit/agency for each role. One-time implementation activities were assigned a lead actor, target completion date, and compiled into a 3-year IDSR Roadmap to guide implementation. Results A Roles and Responsibilities Framework was developed that presents a consensus on lead units for all roles within an IDSR-based PHS system that fulfills requirements of IHR [2005] and GHSA. This document enables coordination by EDCU. The IDSR Roadmap provides time-bound activities with assigned actors to implement IDSR. EDCU is using these documents to guide coordination of multiple MOH units already performing PHS activities. Conclusions Coordinating well-established programs that already collect epidemiological data increases efficiency and enables more complete epidemiologic analysis. Stakeholder engagement and clarity of roles is critical for EDCU to coordinate PHS. Consolidating activities for IDSR, IHR [2005], and GHSA in guiding documents enables a streamlined approach for public health surveillance strengthening. Future work aims to achieve data sharing through an electronic platform and introduce data standards for interoperability among data sets. K

Objective To assess essential support functions for Integrated Disease Surveillance and Response(IDSR) in the Kingdom of Swaziland and make recommendations for a national IDSR Roadmap. Introduction Implementation of the IDSR framework for fulfillment of the International Health Regulations (2005) ([IHR 2005]) has been challenging in Swaziland due to distribution of IDSR functions across units within the Strategic Information Department (SID) and other external departments within the Ministry of Health. We conducted a qualitative assessment and a Strength, Weaknesses, Opportunities and Threats (SWOT) analysis of current public health surveillance (PHS) support structures to inform implementation of IDSR. Methods Key informant interviews, focus group discussions, and a desk review were performed. Participants were personnel at essential units, departments and programs at the national level as well as at health facilities and clinics at regional and local levels. Transcripts were coded into SWOT matrices using MAXQDA for each building block of PHS: structures, workforce, resources, processes (detect, report, assess/analyze, respond, feedback), and informatics. Results Selected Strengths included existence of immediate notifiable disease reporting through the Epidemic and Pandemic Response unit (EPR) and reporting of summary health facility data to the Health Management Information System (HMIS) unit and laboratory network. Weaknesses included lack of clear roles and responsibilities for IDSR among SID units, limited coordination between SID units, lack of data sharing, lack of Standard Operating Procedures (SOPs), uncoordinated case investigations and response, minimal analysis conducted for public health surveillance and limited feedback for reporters.. Identified opportunities were political will for establishing of roles and responsibilities and mechanisms for coordination and data sharing. Threats were limited data access, limited funding for feedback, lack of analysis for IDSR and paper-based reporting Conclusions Currently there is limited use of surveillance data for decision making due to lack of coordination. Findings were presented at a dissemination meeting to representatives of relevant departments, and there was consensus on the need to clearly define the role and responsibilities of different programs for IDSR. In March 2016, a consensus meeting was held to designate roles and responsibilities for IDSR, a direct result of this assessment. Additional resources and funding is needed to support these highly important initiatives to ensure the safety and health security of the Swazi nation.

Electronic surveillance (e-Surveillance) is the use of electronic systems to empower the digitization of the PHS functions of prevention, detection, and response. The African One Health e-Surveillance Initiative (OHSI) established a project framework consisting of One Health teams conducting a national assessment of ICT capacity to support e-Surveillance. Results will be used to inform national strategic planning. OHSI stimulated efforts of an African Surveillance Informatics Governance Board chaired by the World Health Organization Regional Office for Africa.

Health care providers are legally obliged to report cases of specified diseases to public health authorities, but existing manual, provider-initiated reporting systems generally result in incomplete, error-prone, and tardy information flow. Automated laboratory-based reports are more likely accurate and timely, but lack clinical information and treatment details. Here, we describe the Electronic Support for Public Health (ESP) application, a robust, automated, secure, portable public health detection and messaging system for cases of notifiable diseases. The ESP application applies disease specific logic to any complete source of electronic medical data in a fully automated process, and supports an optional case management workflow system for case notification control. All relevant clinical, laboratory and demographic details are securely transferred to the local health authority as an HL7 message. The ESP application has operated continuously in production mode since January 2007, applying rigorously validated case identification logic to ambulatory EMR data from more than 600,000 patients. Source code for this highly interoperable application is freely available under an approved open-source license at http://esphealth.org.

A recent assessment of the Sudan public health surveillance system found fragmented and siloed disease programs and an overburdened workforce due to vertical systems and inefficient processes. A plan of action was developed to support improving public health surveillance strengthening by: 1) implementing a strategic approach to achieving IHR (2005), 2) implementing One Health and IDSR aims, and 3) establishing an E-surveillance ICT platform for increasing public health surveillance capacity to safely and rapidly detect and report infectious diseases in Sudan.

Purpose Evaluation improves efficiency and effectiveness. Current U.S. tuberculosis (TB) control policies emphasize the treatment of latent TB infection (LTBI). However, this policy, if not targeted, may be inefficient. We determined the efficiency of a state-law mandated TB screening program and a non state-law mandated one in terms of cost, morbidity, treatment, and disease averted. Methods We evaluated two publicly funded metropolitan TB prevention and control programs through retrospective analyses and modeling. Main outcomes measured were TB incidence and prevalence, TB cases averted, and cost. Results A non state-law mandated TB program for homeless persons in Tarrant County screened 4.5 persons to identify one with LTBI and 82 persons to identify one with TB. A state-law mandated TB program for jail inmates screened 109 persons to identify one with LTBI and 3274 persons to identify one with TB. The number of patients with LTBI treated to prevent one TB case was 12.1 and 15.3 for the homeless and jail inmate TB programs, respectively. Treatment of LTBI by the homeless and jail inmate TB screening programs will avert 11.9 and 7.9 TB cases at a cost of $14,350 and $34,761 per TB case, respectively. Conclusions Mandated TB screening programs should be risk-based, not population-based. Non mandated targeted testing for TB in congregate settings for the homeless was more efficient than state-law mandated targeted testing for TB among jailed inmates.

Infantile atopic eczema (AE) is a risk marker for future asthma. This study assesses the contribution of modifiable exposures to infantile AE. If modifiable exposures contribute substantially to infantile AE, its prevention might be a sensible approach to asthma prevention. Pregnant women (n = 1978) were systematically recruited from maternity hospitals of the Slovak Republic; their birthed cohort of 1990 children were prospectively followed for 1 yr. Children's exposures to selected environmental and dietary factors were assessed via maternal questionnaires administered at delivery and 1 yr of age. A child was considered to have AE, based on physical examination (SCORAD index >2) or mother's report of a previous physician diagnosis. Multivariate logistic regression was used to calculate adjusted odds ratios and percent total regression scores (TRS) for each variable. At 1 yr of age 1326 (67%) of the children remained in the cohort and 207 (15.6%) developed AE. Various modifiable environmental and dietary exposures increased the likelihood of AE (ownership of cats; consumption of infant formula, eggs, and fish) while others decreased the likelihood of AE (ownership of livestock; exclusive breast feeding for > or =4 months). Overall, modifiable exposures contributed less to the TRS than did non-modifiable exposures (38% vs. 62%, respectively). The modifiable exposure category that contributed most to the TRS was infant feeding practices (27.5% TRS). Modifiable exposures -- especially those related to infant feeding practices -- significantly contribute to infantile AE, although modifiable factors contribute less overall than do non-modifiable exposures.

Background Tuberculosis (TB) transmission in nontraditional settings and relationships (non-TSR) often eludes detection by conventional contact investigation and is increasingly common. The U.S.-based National Tuberculosis Genotyping and Surveillance Network collected epidemiologic data and genotyping results of Mycobacterium tuberculosis isolates from 1996 to 2000. Methods In 2003–2004, we determined the number and characteristics of TB patients in non-TSR that were involved in recent transmission, generated a decision tree to profile those patients, and performed a case-control study to identify predictors of being in non-TSR. Results Of 10,844 culture-positive reported TB cases that were genotyped, 4724 (43.6%) M. tuberculosis isolates were clustered with at least one other isolate. Among these, 520 (11%) had epidemiologic linkages discovered during conventional contact investigation or cluster investigation and confirmed by genotyping results. The decision tree identified race/ethnicity (non-Hispanic white or black) as having the greatest predictive ability to determine patients in non-TSR, followed by being aged 15 to 24 years and having positive or unknown HIV infection status. From the 520, 85 (16.4%) had non-TSR, and 435 (83.6%) had traditional settings and relationships (TSR). In multivariate analyses, patients in non-TSR were significantly more likely than those in TSR to be non-Hispanic white (adjusted odds ratio [aOR]=6.1; 95% confidence interval [CI]=1.7–21.1]) or to have an M. tuberculosis isolate resistant to rifampin (aOR=5.2; 95% CI=1.5–17.7). Conclusions Decision-tree analyses can be used to enhance both the efficiency and effectiveness of TB prevention and control activities in identifying patients in non-TSR.

Purpose Tuberculosis (TB) elimination is an important US public health goal and improving the performance of TB surveillance and action and reducing the costs will help achieve it. But, there exists the need to better evaluate the performance and measure the costs. Methods We pilot tested an evaluation strategy in Hillsborough County, Florida using a conceptual framework of TB surveillance and action with eight core and four support activities. To evaluate performance, we developed indicators and validated their accuracy, usefulness, and measurability. To measure the costs, we obtained financial information. Results In 2001, Hillsborough County reported 78 (7%) of the 1145 Florida TB cases. Nineteen (24%) were previously arrested. While 13 (68%) of the 19 were incarcerated during the 2 years prior to being reported, only 1 (5%) of 19 was reported from the jail. From 111 TB suspects, 219 (25%) of 894 sputum specimens were inadequately collected. Of the $1.08 million annual budget, 22% went for surveillance, 29% for support, and 49% for action. Conclusions This conceptual framework allowed measurement of TB surveillance and action performance and cost. The evaluation performed using it revealed missed opportunities for detection of TB cases and wasted resources. This conceptual framework could serve as a model for evaluation of TB surveillance and action.

DNA fingerprinting of Mycobacterium tuberculosis--a relatively new laboratory technique--offers promise as a powerful aid in the prevention and control of tuberculosis (TB). Established in 1996 by the Centers for Disease Control and Prevention (CDC), the National Tuberculosis Genotyping and Surveillance Network was a 5-year prospective, population-based study of DNA fingerprinting conducted from 1996 to 2000. The data from this study suggest multiple molecular epidemiologic and program management uses for DNA fingerprinting in TB public health practice. From these data, we also gain a clearer understanding of the overall diversity of M. tuberculosis strains as well as the presence of endemic strains in the United States. We summarize the key findings and the impact that DNA fingerprinting may have on future approaches to TB control. Although challenges and limitations to the use of DNA fingerprinting exist, the widespread implementation of the technique into routine TB prevention and control practices appears scientifically justified.

In May 2013, over 100 WHO Member States (MS) reported not having met their national International Health Regulations (2005) core capacity requirements. Many MS need support in identifying activities and associated costs to support building capacity. WHO developed a costing tool organized by the IHR (2005) Core Capacities and public health core functions. The tool will provide users with estimated annualized costs for developing and sustaining public health activities relevant to IHR (2005) implementation. Providing National Focal Points with costs estimates and generalized plans of action facilitates allocation of funds and development of IHR capacities and public health functions.

The diphtheria epidemic that began in Russia in 1990 reached Kazakhstan in 1992 when 45 case-patients (a 50% increase over 1991) were reported. In 1993, 82 case-patients were reported, and 489 were reported in 1994. The epidemic peaked in 1995 when 1105 case-patients were reported (incidence rate=6.7/100,000 population). In 1996, after public health practice modifications and several mass vaccinations, 455 case-patients were reported. From 1990 to 1996, children

The annual Hajj pilgrimage of more than 2.5 million pilgrims from more than 160 countries is held in the Kingdom of Saudi Arabia (KSA) ( 1 ) (see the figure). Hajj is a deeply spiritual journey undertaken by Muslims at least once in their lifetimes. Hajj-related infectious disease outbreaks in recent decades have focused attention on Hajj as a global public health security challenge of extraordinary dimensions ( 1 – 5 ). This past summer, a KSA–World Health Organization (WHO) consultation process developed the Jeddah recommendations on mitigation for the effects of the current pandemic influenza A (H1N1) virus during the 2009 Hajj, which is the last week of November ( 6 ). Here, we outline some of the realities associated with meeting those recommendations and the most recent plans to help mitigate the transmission burden.

Objective To develop a toolset to monitor and assess laboratory biosafety program performance and cost Introduction Laboratory biosafety – a component of biosecurity – has specific elements that together, comprise a facility’s capability to both protect employees and the surrounding public and environment. Measuring these elements permits assessment and the costing of program-specific safety interventions. In the absence of a strategy and toolset, we developed a conceptual framework and toolset that monitors and assesses laboratory biosafety programs (LBPs) and provides useful information (e.g., return on investment [ROI]) for decision makers. Methods We conducted academic and open source literature reviews of LBPs and affiliated organizations laboratory manuals to identify objectives, goals, and indicators. These findings were aligned to laboratory biosafety-specific inputs, activities, outputs, and outcomes to create a strategic, conceptual framework (logic models) used to assess performance and measure the cost and ROI. Indicators were identified in existing literature or developed and mapped to the logic model elements. Results Six logic models were created: laboratory biosafety, biosurety, procedural, biocontainment, information security, and training. The laboratory biosafety logic model served as the overall framework for the remaining five sub-logic models. We also established a database containing 161 indicators mapped to each of the logic model elements. Conclusions We developed a strategic framework that monitors and evaluates LBPs. While evaluation of cost-impacts in LBPs provides business intelligence for resource planning, this integrated approach also provides information about gaps. We plan to pilot this toolset and refine indicators using principal component analysis.

Objective To conceive and develop a model to identify gaps in public health surveillance performance and provide a toolset to assess interventions, cost, and return on investment (ROI). Introduction Under the revised International Health Regulations (IHR [2005]) one of the eight core capacities is public health surveillance. In May 2012, despite a concerted effort by the global community, the World Health Organization (WHO) reported out that a significant number of member states would not achieve targeted capacity in the IHR (2005) surveillance core capacity. Currently, there is no model to identify and measure these gaps in surveillance performance. Likewise, there is no toolset to assess interventions by cost and estimate the ROI. We developed a new conceptual framework that: (1) described the work practices to achieve effective and efficient public health surveillance; (2) could identify impediments or gaps in performance; and (3) will assist program managers in decision making. Methods Published articles and grey-literature reports, manuals and logic model examples were gathered through a literature review of PubMed, Web of Science, Google Scholar, and other databases. Logic models were conceived by categorizing discrete surveillance inputs, activities, outputs, and outcomes. Indicators were selected from authoritative sources or developed and then mapped to the logic model elements. These indicators will be weighted using the principle component analysis (PCA), a method for enhanced precision of statistical analysis. Finally, on the front end of the tool, indicators will graphically measure the surveillance gap expressed through the tool’s architecture and provide information using an integrated cost-impact analysis. Results We developed five public health surveillance logic models: for IHR (2005) compliance; event-based; indicator-based; syndromic; and predictive surveillance domains. The IHR (2005) domain focused on national-level functionality, and the others described the complexities of their specific surveillance work practices. Indicators were then mapped and linked to all logic model elements. Conclusions This new framework, intended for self-administration at the national and subnational levels, measured public health surveillance gaps in performance and provided cost and ROI information by intervention. The logic model framework and PCA methodology are tools that both describe work processes and define appropriate variables used for evaluation. However, both require real-world data. We recommend pilot testing and validation of this new framework. Once piloted, the framework could be adapted for the other IHR (2005) core capacities.

The objective of this study was to evaluate the impact of the tuberculosis (TB) mobile teams on treatment outcomes in Riyadh Region by comparing patients who received treatment under mobile teams and those who did not, from 2013 to 2015. This was a retrospective descriptive study using National TB Control and Prevention Program data from 2013 to 2015 from Riyadh, Kingdom of Saudi Arabia. Descriptive analyses were used to summarize characteristics of TB case-patients served by mobile teams and those who were not served. The χ2 test measured the significant differences between mobile-served and non-mobile-served case-patients. Exposure was whether or not the TB case-patient was under the care of the mobile team; the outcome of interest was whether or not treatment was successful, defined as treatment completed and cured. We found that the ratio of treatment success among mobile team case-patients was 1.28 greater than among those not served by mobile teams. The χ2 test showed a statistically significant finding (probability ratio = 1.28; 95% confidence interval = 1.21–1.35, p

Tuberculosis (TB) remains a public health threat in the Kingdom of Saudi Arabia (KSA) with many challenges that limit its prevention and control. To understand how to meet these challenges, this study calculated the TB incidence rates (IRs) in KSA from 2005 to 2012, which were stratified by nationality, sex, and administrative regions. Furthermore, laboratory capabilities were assessed by determining the proportion of laboratory-confirmed TB cases. The overall TB IRs decreased from 15.80/100,000 population in 2005 [95% confidence interval (CI) = 15.29–16.31] to 13.16/100,000 population in 2012 (95% CI = 12.74–13.58). The IRs were greater for males than for females from 2009 to 2012. The IRs of non-Saudis were approximately two times those of Saudis during the study period. Mecca had greater IR during the study period compared with other regions [25.13/100,000 (95% CI = 24.7–25.56)]. Among non-Saudis, those from Indonesia and Yemen had the greatest proportion of TB cases (15.4% and 12.9%, respectively). Individuals

Infectious disease surveillance for mass gatherings (MGs) can be directed locally and globally; however, epidemic intelligence from these two levels is not well integrated. Modelling activities related to MGs have historically focused on crowd behaviours around MG focal points and their relation to the safety of attendees. The integration of developments in internet-based global infectious disease surveillance, transportation modelling of populations travelling to and from MGs, mobile phone technology for surveillance during MGs, metapopulation epidemic modelling, and crowd behaviour modelling is important for progress in MG health. Integration of surveillance across geographic frontiers and modelling across scientific specialties could produce the first real-time risk monitoring and assessment platform that could strengthen awareness of global infectious disease threats before, during, and immediately after MGs. An integrated platform of this kind could help identify infectious disease threats of international concern at the earliest stages possible; provide insights into which diseases are most likely to spread into the MG; help with anticipatory surveillance at the MG; enable mathematical modelling to predict the spread of infectious diseases to and from MGs; simulate the effect of public health interventions aimed at different local and global levels; serve as a foundation for scientific research and innovation in MG health; and strengthen engagement between the scientific community and stakeholders at local, national, and global levels.

Armenia, a republic of the former Soviet Union, currently suffers from hyperinflation of its currency, a five-year countrywide blockade, and a war with Azerbaijan. Pensioners 60 years of age or older may be at high risk for significant nutritional deficits. We drew a stratified systematic sample (with a random starting point) of 456 pensioner names from all eight administrative regions in Yerevan, the capital of Armenia. We administered a questionnaire that gathered data including self-reported weight and height, demographic characteristics, living conditions, medical and dietary history, income, and aid received from various sources. The survey yielded 381 of 456 (84%) completed interviews. Ninety-one percent reported their diet had gotten worse during the past six months, including less variety (83%) and quantity (85%) of food. Seventy-six percent reported they did not have enough money to buy food, and 91% had cut the size of their meals or skipped meals. Forty-five percent reported a weight loss of ^5 kg in the previous year. After we adjusted for potential confounders, weight loss of >5 kg was associated with illness affecting eating (adjusted odds ratio [OR] = 2.2, 95% confidence intervals [CI] = 1.4, 3.4), not having received aid (adjusted OR = 2.2, 95% CI = 1.1, 4.1), and cutting the size of or skipping meals (OR = 2.7, 95% CI = 1.1, 6.7). Using self-reported current and recalled height and weight, we found that the mean body mass indices (BMI) of pensioners in 1992 were significantly less (P

PURPOSE: Policymakers should know the distribution and determinants of tuberculosis (TB) over time. This is especially true for the Kingdom of Saudi Arabia (KSA), a country at increased risk for TB transmission because of mass gatherings (e.g., Hajj) and a large number of immigrant workers. METHODS: Using national TB notification data reported from 13 provinces from 2005 through 2009, trends in annual TB incidence were calculated by nationality, age, and gender. RESULTS: Compared with Saudis, non-Saudis had a 2-fold greater TB incidence rate each year. In 2009 amongallKSAprovinces,Makkahhadthegreatestproportionofnon-Saudis(38%),thegreatestnumberof TB cases (1648), and the highest TB incidence rate (26 per 100,000). We observed significantly increasing yearly trends of TB incidence among Saudis in the Najran province (21.3%) and in Riyadh (8.5%). Conversely, we observed a significantly decreasing yearly trend among non-Saudis in Baha (23.1%), Hail (17.4%), and the Eastern region (22.6%). CONCLUSIONS: Disparate KSA regional and longitudinal TB trends existed from 2005 through 2009, by nationality. We recommend a review of all TB policies in KSA that addresses screening for latent TB infection and drug resistance. Additionally, we recommend a new TB public health education program.

A new statistical method, developed for detection of changes in reporting, has proved useful in analysis of provisional data reported by state health departments to the National Notifiable Diseases Surveillance System (NNDSS). In this system, data from the current four-week period can be compared with data from the previous, same, and subsequent four-week periods from each of the preceding five years, and reports exceeding historical limits are highlighted in a horizontal bar graph. To evaluate the usefulness of this method at the state level, we applied it to weekly reports of seven notifiable diseases in six states over a four-month period. Participating state health departments investigated all events exceeding historical limits and reported known outbreaks that were not identified by the method. During the four-month period, the method identified 27 episodes of disease reports exceeding historical limits. Of these, 14 (52%) represented outbreaks. None was detectable by analysis of aggregate national surveillance data. Five outbreaks known to state health department officials were not identified by the method, because of increased disease activity during the baseline period or lack of timely provisional reporting of outbreak-related cases. Methods for detection of increases in reporting at the state level may identify events of public health importance that are obscured in aggregate national data and may supplement other local sources of information available to state health departments in the recognition of significant public health events.

At a crossroads, global public health surveillance exists in a fragmented state. Slow to detect, register, confirm, and analyze cases of public health significance, provide feedback, and communicate timely and useful information to stakeholders, global surveillance is neither maximally effective nor optimally efficient. Stakeholders lack a globa surveillance consensus policy and strategy; officials face inadequate training and scarce resources. Three movements now set the stage for transformation of surveillance: 1) adoption by Member States of the World Health Organization (WHO) of the revised International Health Regulations (IHR[2005]); 2) maturation of information sciences and the penetration of information technologies to distal parts of the globe; and 3) consensus that the security and public health communities have overlapping interests and a mutual benefit in supporting public health functions. For these to enhance surveillance competencies, eight prerequisites should be in place: politics, policies, priorities, perspectives, procedures, practices, preparation, and payers. To achieve comprehensive, global surveillance, disparities in technical, logistic, governance, and financial capacities must be addressed. Challenges to closing these gaps include the lack of trust and transparency; perceived benefit at various levels; global governance to address data power and control; and specified financial support from globa partners. We propose an end-state perspective for comprehensive, effective and efficient global, multiple-hazard public health surveillance and describe a way forward to achieve it. This end-state is universal, global access to interoperable public health information when it’s needed, where it’s needed. This vision mitigates the tension between two fundamental human rights: first, the right to privacy, confidentiality, and security of personal health information combined with the right of sovereign, national entities to the ownership and stewardship of public health information; and second, the right of individuals to access real-time public health information that might impact their lives. The vision can be accomplished through an interoperable, global public health grid. Adopting guiding principles, the global community should circumscribe the overlapping interest, shared vision, and mutual benefit between the security and public health communities and define the boundaries. A global forum needs to be established to guide the consensus governance required for public health information sharing in the 21st century.