Evaluation of the capability of decentralized management of epidemiological surveillance in the state of Bahia

Evaluative research into the capability of decentralized management of epidemiological vigilance (EV) was conducted in the operational, organizational and sustainable dimensions in the state of Bahia, Brazil. The quantitative approach was used in the construction of a baseline, with primary data obtained through an online questionnaire answered by thirty-eight municipal EV managers. In the qualitative approach to analyze the context and assess the management capability of municipalities in two case studies, techniques adapted to the analysis of discursive practices were used. This was done through semi-structured interviews with managers of regional and municipal government, health workers and representatives of the municipal health council. The case studies showed that the municipality with enhanced management capability is that in which the manager has the greatest potential of using the resources of his position, in addition to his ability to control, negotiate and coordinate with other actors. Due to decentralization of EV, considering the shared nature of management between the three spheres of government, there is a marked variation in the management capability of municipalities, determined by social, economic, political inequalities and management mechanisms adopted.

An epidemiological surveillance network of lumbar disc surgery to help prevention of and compensation for low back pain

International audience

"Portuguese Observatory of Taeniasis and Cysticercosis": A "One Health" example for epidemiological surveillance of one neglected disease in a European country

Cysticercosis results from the ingestion Taenia solium eggs directly by faecal-oral route or contaminated food or water. Human tapeworm carriers who have become infected after ingesting pork meat contaminated with cysticerci release these eggs. Cysticercosis occurs after tapeworm eggs are ingested by an intermediate host (pig or human) and then hatch, migrate, and lodge in the host's tissues, where they develop onto larval cysticerci. When they lodged in the central nervous system of humans, results in the disease condition called Neurocysticercosis (NCC), with a heterogeneous manifestations depending of the locations of cysts, number, size and their stage of evolution (1). Consequently the prognostic ranges from asymptomatic to situations leading to death in 2% to 9.8%. of cases (7) In swine’s there are few studies, but recent works have proved that animals, for the same reasons, also have neurological abnormalities, expressed by seizures, stereotypic walk in circles, chewing motions with foamy salivation included tonic muscle contractions followed by a sudden diminution in all muscle tone leading to collapse (2). Conventional domestic wastewater treatment processes may not be totally effective in inactivating parasites eggs from Taenia solium, allowing some contamination of soils and agricultural products (11). In Portugal there are some evidence of aggregation of human cysticercosis cases in specific regions, bases in ecological design studies (6). There are few information about human tapeworm carriers and social and economic factors associated with them. Success in knowledge and consequently in lowering transmission is limited by the complex network of biological and social factors that maintain the spread. Effective control of mostly zoonosis require One Health approach, after a real knowledge and transparency in the information provided by the institutions responsible for both animal and human health, allowing sustained interventions targeted at the transmission cycle's crucial nodes. In general, the model used to control, reflects a rural reality, where pigs are raised freely, poor sanitation conditions and incipient sanitary inspection. In cysticercosis, pigs are obligate intermediate hosts and so considered as first targets for control and used as sentinels to monitor environmental T. solium contamination (3). Usually environmental contamination with Taenia spp. eggs is a key issue in most of studies with landscape factors influencing presence of Taenia spp. antigens in both pigs and humans (5). Soil-related factors as well as socio-economic and behavioural factors are associated with the emergence of significant clustering human cysticercosis (4,5). However scarce studies has been produced in urban environmental and in developed countries with the finality to characterize the spatial pattern. There are still few data available regarding its prevalence and spatial distribution; Transmission patterns are likely to exhibit correlations as housing conditions, water supply, basic sanitation, schooling and birthplace of the individual or relatives, more than pigs rearing free, soil conditions (9). As a matter of fact, tapeworm carriers from endemic zones can auto-infect or transmit infection to other people or arrive already suffering NCC (as a result of travelling to or being a citizen from an endemic cysticercosis country) to a free cysticercosis country. Transmission is fecal-oral; this includes transmission through person-to-person contact, through autoinfection, or through contaminated food This has been happening in different continents as North America (5.4–18% been autochthonous), Europe and Australia (7). Recently, case reports of NCC have also emerged from Muslim countries. (10). Actually, different papers relate an epidemic situation in Spain and Portugal (7, 8). However the kind of study done does not authorize such conclusion. There are no evidence that infections were acquired in Portugal and there are not characterized the mode of transmission. Papers with these kind of information will be allow to have economic consequences resulted from artificial trade barriers with serious consequences for pig producers and pig meat trade. We need transparency in information’s that allow provide the basis to support the development and targeting of future effective control programmes (and prove we need that). So, to have a real picture of the disease, it is necessary integrate data from human, animal and environmental factors surrounding human and pig cases to characterize the pattern of the transmission. The design needs to be able to capture unexpected, and not common outcomes (routine data). We need to think “One Health” to get a genuine image of the situation.

Risk-based surveillance for avian influenza control along poultry market chains in South China: The value of social network analysis.

Over the past two decades, the poultry sector in China went through a phase of tremendous growth as well as rapid intensification and concentration. Highly pathogenic avian influenza virus (HPAIV) subtype H5N1 was first detected in 1996 in Guangdong province, South China and started spreading throughout Asia in early 2004. Since then, control of the disease in China has relied heavily on wide-scale preventive vaccination combined with movement control, quarantine and stamping out. This strategy has been successful in drastically reducing the number of outbreaks during the past 5 years. However, HPAIV H5N1 is still circulating and is regularly isolated in traditional live bird markets (LBMs) where viral infection can persist, which represent a public health hazard for people visiting them. The use of social network analysis in combination with epidemiological surveillance in South China has identified areas where the success of current strategies for HPAI control in the poultry production sector may benefit from better knowledge of poultry trading patterns and the LBM network configuration as well as their capacity for maintaining HPAIV H5N1 infection. We produced a set of LBM network maps and estimated the associated risk of HPAIV H5N1 within LBMs and along poultry market chains, providing new insights into how live poultry trade and infection are intertwined. More specifically, our study provides evidence that several biosecurity factors such as daily cage cleaning, daily cage disinfection or manure processing contribute to a reduction in HPAIV H5N1 presence in LBMs. Of significant importance is that the results of our study also show the association between social network indicators and the presence of HPAIV H5N1 in specific network configurations such as the one represented by the counties of origin of the birds traded in LBMs. This new information could be used to develop more targeted and effective control interventions.

Molecular methods for the epidemiological analysis of methicillin-resistant Staphylococcus aureus (MRSA) and Streptococcus pneumoniae

Methicillin-resistant Staphylococcus aureus (MRSA) and Streptococcus pneumoniae are major health problems worldwide, both found in symptomless carriage but also causing even life-threatening infections. The aim of this thesis was to characterise MRSA and S. pneumoniae in detail by using several molecular typing methods for various epidemiological purposes: clonality analysis, epidemiological surveillance, outbreak investigation, and virulence factor analysis. The characteristics of MRSA isolates from the strain collection of the Finnish National Infectious Disease Register (NIDR) and pneumococcal isolates collected from military recruits and children with acute otitis media (AOM) were analysed using various typing techniques. Antimicrobial susceptibility testing, pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), spa typing, staphylococcal cassette chromosome mec (SCCmec) typing, and the detection of Panton-Valentine leukocidin (PVL) genes were performed for MRSA isolates. Pneumococcal isolates were analysed using antimicrobial susceptibility testing, serotyping, MLST, and by detecting pilus islet 1 (PI-1) and 2 (PI-2) genes. Several international community- and hospital-associated MRSA clones were recognised in Finland. The genetic diversity among MRSA FIN-4 isolates and among FIN-16 isolates was low. Overall, MRSA blood isolates from 1997 to 2006 were genetically diverse. spa typing was found to be a highly discriminatory, rapid and accurate typing method and it also qualifies as the primary typing method in countries with a long history of PFGE-based MRSA strain nomenclature. However, additional typing by another method, e.g. PFGE, is needed in certain situations to be able to provide adequate discrimination for epidemiological surveillance and outbreak investigation. An outbreak of pneumonia was associated with one pneumococcal strain among military recruits, previously healthy young men living in a crowded setting. The pneumococcal carriage rate after the outbreak was found to be exceptionally high. PI-1 genes were detected at a rather low prevalence among pneumococcal isolates from children with AOM. However, the study demonstrated that PI-1 has existed among pneumococcal isolates prior to pneumococcal conjugate vaccine and the increased antimicrobial resistance era. Moreover, PI-1 was found to associate with the serotype rather than the genotype. This study adds to our understanding of the molecular epidemiology of MRSA strains in Finland and the importance of an appropriate genotyping method to be able to perform high-level laboratory-based surveillance of MRSA. Epidemiological and molecular analyses of S. pneumoniae add to our knowledge of the characteristics of pneumococcal strains in Finland.

L’analyse de l’introduction du changement dans les systèmes de santé des pays en développement : le cas d’un système de surveillance épidémiologique en Haïti

Les systèmes de santé des pays en développement font face à de nombreux enjeux organisationnels pour améliorer l’état de santé de leur population. Au nombre de ces enjeux, il est fréquemment mentionné la présence d’organisations internationales ayant des objectifs et caractéristiques peu convergents et qui interviennent de façon non nécessairement coordonnée. Cette thèse explore la thématique de l’introduction du changement dans ces systèmes de santé en mettant un accent spécifique sur l’enjeu lié à la présence de ces organisations internationales. La méthodologie utilisée est une analyse de concept. Cette approche méthodologique consiste à effectuer des revues critiques de la littérature sur des concepts, à mobiliser de nouvelles approches théoriques pour clarifier ces concepts et à réaliser des études de cas pour leur mise à l’épreuve empirique. En nous appuyant sur la théorie de l’action sociale de Parsons, la théorie de la complexité ainsi que les expériences d’introduction du changement dans différents systèmes de santé, nous avons développé un cadre théorique d’analyse de l’introduction du changement dans les systèmes de santé des pays en développement (1er concept). Ce cadre théorique, qui suggère de concevoir le processus d’introduction du changement comme un système d’action sociale complexe et émergent, a été appliqué à l’analyse de l’introduction d’un système de surveillance épidémiologique en Haïti. Plus précisément, nous avons analysé une étape ainsi que certains aspects du mécanisme sous-jacent au processus d’introduction du changement. Ce faisant, nous avons analysé, dans les deux premiers articles de la thèse, l’étape d’adoption du système de surveillance épidémiologique (2ème concept) ainsi que les déterminants de la collaboration entre les organisations impliquées dans le processus d’introduction du changement (3ème concept). Les résultats de ces analyses nous ont permis d’objectiver de faibles niveaux d’adoption, ainsi qu’une faible articulation des déterminants de la collaboration entre les différentes organisations impliquées dans le processus d’introduction du changement. Partant de ces constats, nous avons pu mettre en évidence, dans le troisième article, une phase de « chaos » dans le fonctionnement du système de santé d’Haïti. Cette phase de « chaos », qui pourrait expliquer les difficultés liées à l’introduction du changement dans les systèmes de santé des pays en développement en général et plus particulièrement en Haïti, était caractérisée par la présence d’un ordre sous-jacent au désordre apparent dans le fonctionnement de certaines composantes du système de santé d’Haïti, l’existence d’une instabilité, d’une imprédictibilité ainsi que d’une invariance structurelle aux différents niveaux de gouvernance. Par ailleurs, cette recherche a également permis de démontrer que les caractéristiques du « chaos » sont entretenues par la présence de trois groupes de systèmes d’action sociale bien articulés et bien cohérents à tous les échelons de la pyramide sanitaire en Haïti. Il s’agissait des systèmes d’action liés aux agences de coopération bilatérale, ceux liés aux initiatives ou fondations internationales de lutte contre le sida et finalement ceux associés aux organisations onusiennes. Ces systèmes d’action sociale sont en outre associés à d’autres systèmes d’action plus complexes qui sont situés à l’extérieur du système de santé d’Haïti. Au regard de ces résultats, nous avons proposé une nouvelle approche permettant de mieux appréhender l’introduction du changement dans les systèmes de santé des pays en développement et qui s’inscrit dans une logique permettant de favoriser une plus grande variété et une plus grande diversification. Cette variété et cette diversification étant soutenue par la création et la mise en place de plusieurs interconnections entre tous les systèmes d’action en présence dans les systèmes de santé qu’ils soient d’appartenance nationale, internationale ou qu’ils agissent au niveau central, départemental ou local. La finalité de ce processus étant l’émergence de propriétés systémiques issues non seulement des propriétés des groupes de systèmes d’action individuels qui interviennent dans la constitution du système émergent, mais aussi d’autres propriétés résultant de leur mise en commun.

Surveillance Programme for Healthcare Associated Infections in the State of São Paulo, Brazil. Implementation and the first three years' results

Governmental programmes should be developed to collect and analyse data on healthcare associated infections (HAIs). This study describes the healthcare setting and both the implementation and preliminary results of the Programme for Surveillance of Healthcare Associated Infections in the State of São Paulo (PSHAISP), Brazil, from 2004 to 2006. Characterisation of the healthcare settings was carried out using a national database. The PSHAISP was implemented using components for acute care hospitals (ACH) or long term care facilities (LTCF). The components for surveillance in ACHs were surgical unit, intensive care unit and high risk nursery. The infections included in the surveillance were surgical site infection in clean surgery, pneumonia, urinary tract infection and device-associated bloodstream infections. Regarding the LTCF component, pneumonia, scabies and gastroenteritis in all inpatients were reported. In the first year of the programme there were 457 participating healthcare settings, representing 51.1% of the hospitals registered in the national database. Data obtained in this study are the initial results and have already been used for education in both surveillance and the prevention of HAI. The results of the PSHAISP show that it is feasible to collect data from a large number of hospitals. This will assist the State of São Paulo in assessing the impact of interventions and in resource allocation. (C) 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

Clinical and epidemiological aspects of feline leishmaniasis in Brazil

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Trachoma epidemiological school survey in the city of Embu das Artes - SP

Purpose: To estimate the trachoma prevalence in school children in Embu das Artes - SP, aiming the implementation of the disease epidemiological surveillance. Methods: The city of Embu das Artes - SP, is 25 km far from the capital of the State. In the years of 2003-2004, a trachoma survey was conducted in a cluster sample of school children with the same methodology of the national trachoma student's survey of the Ministry of Health. Previously to the trachoma active search, activities of health education were performed in all schools. External ocular examinations were done in all students to detect trachoma according to the WHO criteria. All cases of trachoma were notified and their families were submitted to an external ocular examination. The cases were treated with 1% tetracycline ointment or systemic azithromycin. Results: 2,374 students from nine sampled selected public schools were examined. The prevalence of follicular inflammatory trachoma (TF) was 3.1% (IC 95%: 2.4-3.9), varying from 0.5% to 4.2% in the examined schools. The prevalence for males was 3.2% and for females was 3.0%. The greater prevalence (8.6%) was found in 6 year-old children. Conclusion: The disease showed a mild behavior in this city, because no cases of intense inflammatory trachoma or cicatricial trachoma were detected. However, the prevalence was greater than the one found in the city of Sao Paulo. Epidemiological surveillance activities of trachoma must be continuous, mainly in places where the greater prevalence had been found.

Absence of prenatal ultrasound surveillance: Data from the Portuguese congenital anomalies registry

In Portugal, prenatal care guidelines advocate two prenatal ultrasound scans for all pregnant women. Not following this recommendation is considered inadequate prenatal surveillance. The National Registry of Congenital Anomalies (RENAC in Portuguese) is an active population-based registry and an important instrument for the epidemiological surveillance of congenital anomalies (CA) in Portugal. Regarding pregnancies with CA, this study aims to describe the epidemiology of absent prenatal ultrasound scans and factors associated with this inadequate surveillance.

Prevalence of thoracic spine pain in a surveillance network

International audience

Molecular markers for discriminating Streptococcus pyogenes and S.dysgalactiae subspecies equisimilis

Given the increasing aetiological importance of Streptococcus dysgalactiae subspecies equisimilis in diseases which are primarily attributed to S. pyogenes, molecular markers are essential to distinguish these species and delineate their epidemiology more precisely. Many clinical microbiology laboratories rely on agglutination reactivity and biochemical tests to distinguish them. These methods have limitations which are particularly exacerbated when isolates with mixed properties are encountered. In order to provide additional distinguishing parameters that could be used to unequivocally discriminate these two common pathogens, we assess here three molecular targets: the speB gene, intergenic region upstream of the scpG gene (IRSG) and virPCR. Of these, the former two respectively gave positive and negative results for S. pyogenes, and negative and positive results for S. dysgalactiae subsp. equisimilis. Thus,a concerted use of these nucleic acid-based methods is particularly helpful in epidemiological surveillance to accurately assess the relative contribution of these species to streptococcal infections and diseases.

Vigilância hospitalar: possibilidades e obstáculos de uma prática integrada

O presente estudo discute a questão da integração das vigilâncias em âmbito hospitalar (vigilância epidemiológica hospitalar e vigilância do controle de infecção hospitalar), analisando as possibilidades e impossibilidades dessa integração. Examina os aspectos histórico-políticos e as concepções teórico-práticas de organização dos serviços de vigilância hospitalar, buscando identificar as diferenças e semelhanças entre as duas vigilâncias. A análise inicial permitiu examinar em que medida os limites impostos pelas especificidades de cada vigilância contribuem para sua prática de forma desintegrada. Em seguida realizou-se pesquisa de natureza qualitativa, por meio de entrevistas com grupos focais de profissionais que atuam na vigilância das infecções hospitalares e da vigilância epidemiológica em âmbito hospitalar. O material localizado nos grupos focais foi analisado utilizando-se categorias construídas a partir do próprio material. As vigilâncias hospitalares têm tentado encontrar formas de mudar suas práticas, buscando romper com os caminhos neutralizados, buscando uma aproximação entre as vigilâncias, pois havia muito conflito relacionado a questões técnicas advindas da formação diversificada entre os profissionais que atuam na área. Hoje a busca de novos caminhos foi possível pela mudança da percepção dos profissionais apenas, sem a imposição da gestão, ao perceberem a necessidade de reorganizar o serviço de vigilância hospitalar de forma horizontalizada, construindo um diagnóstico com múltiplos olhares/saberes, como práticas aliançadas com a transformação da realidade de sua unidade hospitalar. Alguns apontam a necessidade de se discutir um novo conceito para Vigilância Hospitalar, capaz de reconhecer além da vigilância das infecções hospitalares e vigilância epidemiológica, capaz de incluir também a vigilância ambiental, assim o conceito de vigilância em saúde no território hospitalar deve possibilitar uma visão mais ampla para a VH. Esta vem enfrentando dificuldades ao tentar reorganizar suas práticas, principalmente em sua infra-estrutura, e os recursos humanos têm sido o maior problema. Reconhecem que um serviço de VH requer normas, fluxos, protocolos, etc. para integrar suas práticas, o que exige construir a integração. Embora acreditem que a integração não deva começar pela mudança da estrutura do serviço, mas pelo processo de trabalho, esperam que, ao final dessa construção, seja criada uma regulamentação que proponha a integração das vigilâncias, efetivando a proposta.