ObjectivesTo assess the association between blood circulating vitamin D levels and colorectal cancer risk in the Asian population.DesignThis is a systematic review and dose-response meta-analysis of observational studies that investigated the relationship between blood circulating vitamin D levels and colorectal cancer risk in the Asian population.Data sourcesRelevant studies were identified through a literature search in Medline, Embase and Web of Science from 1st January 1980 to 31st January 2019. Eligibility criteria: original studies published in peer-reviewed journals investigating the association between blood circulating vitamin D levels and the risk of colorectal cancer and/or adenoma in Asian countries.Data extraction and synthesisTwo authors independently extracted data and assessed the quality of included studies. Study-specific ORs were pooled using a random-effects model. A dose-response meta-analysis was performed with generalised least squares regression. We applied the Newcastle-Ottawa Scale quality assessment to evaluate the quality of the selected studies.ResultsThe eight included studies encompassed a total of 2916 cases and 6678 controls. The pooled ORs of colorectal cancer for the highest versus lowest categories of blood circulating vitamin D levels was 0.75 (95% CI 0.58 to 0.97) up to 36.5 ng/mL in the Asian population. There was heterogeneity among the studies (I2=53.9%,Pheterogeneity=0.034). The dose-response meta-analysis indicated a significant linear relationship (Pnon-linearity=0.11). An increment of 16 ng/mL in blood circulating vitamin D level corresponded to an OR of 0.79 (95% CI 0.64 to 0.97).ConclusionsThe results of this meta‐analysis indicate that blood circulating vitamin D level is associated with decreased risk of colorectal cancer in Asian countries. The dose-response meta-analysis shows that the strength of this association among the Asian population is similar to that among the Western population. Our study suggests that the Asian population should improve nutritional status and maintain a higher level of blood circulating vitamin D.

No abstract

Objective: Provide justification for the collection and reporting of urgent care (UC) data for public health syndromic surveillance.Introduction: While UC does not have a standard definition, it can generally be described as the delivery of ambulatory medical care outside of a hospital emergency department (ED) on a walk-in basis, without a scheduled appointment, available at extended hours, and providing an array of services comparable to typical primary care offices.1 UC facilities represent a growing sector of the United States healthcare industry, doubling in size between 2008 and 2011.1 The Urgent Care Association of America (UCAOA) estimates that UC facilities had 160 million patient encounters in 2013.2 This compares to 130.4 million patient encounters in EDs in 2013, as reported by the National Hospital Ambulatory Medical Care Survey.3 Public Health (PH) is actively working to broaden syndromic surveillance to include urgent care data as more individuals use these services.4 PH needs justification when reaching out to healthcare partners to get buy-in for collecting and reporting UC data.Description: The International Society for Disease Surveillance (ISDS) Community of Practice (CoP) platform was used to host a webinar introducing the topic of urgent care participation in syndromic surveillance. This webinar provided a valuable opportunity to obtain insight from jurisdictions pursuing and using UC data. A workgroup was formed to create documentation justifying the collection and reporting of UC data. Using this forum, the workgroup brought together partners from various jurisdictions working with UC data to participate in a literature review of SCOPUS, PubMed, and the Online Journal of Public Health Informatics publications and to share their experiences. These two main sources of information – previous literature and jurisdictional experience – were combined and condensed to provide tangible justifications for the collection and use of UC data.While the workgroup found little in the literature to justify the collection of UC data as a part of syndromic surveillance, the shared experiences of the CoP jurisdictions working to onboard UC facilities provided valuable insight. From this collaborative response, three main reasons to collect UC data were identified.1) Healthcare reform is directing patients away from EDs and toward UC facilities. UC represents reduced cost and more efficient patient processing, thus easing the burden on both patient and healthcare system (according to a 2016 American Academy of Pediatrics article entitled “Urgent Care and Emergency Department Visits in the Pediatric Medicaid Population”). If syndromic surveillance does not adapt to include UC data, the potential exists to lose significant patient populations, which may lead to decreased situational awareness.2) According to the Centers for Medicare and Medicaid Services Stage 3 guidance, Meaningful Use (MU) will change the relationship between eligible professionals (EPs) and syndromic surveillance by restricting EPs to those who practice in a UC facility. This approach to EP participation simplifies the syndromic surveillance MU objective, thereby making it easier for PH jurisdictions to onboard UC facilities.3) Patients with certain conditions that are acute but non-emergent may report more frequently to an UC facility than to an ED. Broadening syndromic surveillance to include UC facilities may increase reporting of “rare event” encounters, which will lower the relative standard error for statistical calculation. Surveillance efforts for conditions like influenza-like illness and Zika virus may improve substantially with a larger data pool.How the Moderator Intends to Engage the Audience in Discussions on the Topic: The moderator will begin discussion with a brief presentation from the literature review and jurisdictional experience, highlighting three justifications for collecting and reporting UC data. The audience will be divided into 3 groups to discuss and validate 3 additional topics: creation of syndromic surveillance talking points to share with UC facility management, creation of jurisdictional UC facility listings, and UC onboarding best practices. Feedback from the 3 groups will be shared with the whole group, followed by a brief summary of the discussion and recommendations for next steps.

ObjectiveDevelop a free text query to track synthetic cannabinoid-related ED visits.Assess trends in synthetic cannabinoid use from 2013-2018 using spatial and time-series analysis.IntroductionMaryland utilizes ESSENCE for identification of emerging public health threats, including non-fatal overdoses. Synthetic cannabinoids are heterogeneous psychoactive compounds identified as substances of abuse.[1] In March 2018, the Illinois Department of Public Health received reports of unexplained bleeding in patients who reported using these products.[2] As a result, CDC initiated coordination of national surveillance activities for possible cases of coagulopathy associated with synthetic cannabinoids use. By May 2018, state health departments reported 202 cases, including five deaths. [3]On April 3, 2018, Maryland reported its index case - a female in her 20’s who presented to an ED with nausea, blood in her stool, vaginal bleeding, bruising, an elevated internal normalized ratio (> 12.2), and bleeding oral ulcers after quitting use of a synthetic cannabinoid. She was successfully treated with Vitamin K. The first reported mortality in a Maryland resident was a male in his 30’s who called EMS for fever and blood in his urine but subsequently went into cardiac arrest and was unable to be resuscitated. The patient was known to use synthetic cannabinoids. Brodifacoum exposure was confirmed by laboratory testing. As of September 2018, the Maryland Poison Control Center had received reports of 43 cases, and 3 deaths linked to the outbreak.MethodsTo support surveillance and timeliness of synthetic cannabinoids reporting, we developed a case definition by conducting key word searches to identify terms/phrases used by providers in Maryland ED’s to document synthetic cannabinoid visits. This process yielded the following terms: “synthetic marijuana”, “spice”, and “K2”.Subsequently, we created a free text query based on the case definition and variations of the terms/phrases. This query allowed us to capture data on ED visits for synthetic cannabinoid use in the chief complaint (CC), discharge diagnosis (DD), and clinical impression (CI) fields of ESSENCE data.Finally, descriptive and geographic spatial analyses were conducted of synthetic cannabinoid-related morbidity (ED visits) for 2013-2017 (data for 2018 is incomplete); and time trends analyzed for 2013-2018.ResultsFrom 2013 to 2017, a total of 1,097 ED visits across Maryland were synthetic cannabinoid-related (Table 1). The overall crude synthetic cannabinoid-related ED visit rate was 20 per 100,000 population. The number of synthetic cannabinoid-related ED visits increased 8-fold, from 40 in 2013 to 353 in 2017. Females made the most synthetic cannabinoid-related ED visits (n = 861, 78%). Adults aged 15-24 and 25-34 made 349 (32%) and 367 (33%) visits respectively to an ED for a synthetic cannabinoid-related event. Whites and blacks made 466 (42%) and 498 (45%) visits respectively to an ED for a synthetic cannabinoid-related event. People who were non-Hispanic (n= 988, 90%), black (n = 498, 45%), female (n = 861, 78%), and aged 25-34 (367, 33%) visited an ED for a synthetic cannabinoid-related event more than any other demographic group.Time trend analysis shows an increase from baseline in synthetic cannabinoid-related ED visits starting from July 2014 (Figure 1). Three spikes are noted thereafter in April, July, and September 2015 respectively. Consequently, ED visits for synthetic cannabinoid-related events dropped to a new baseline value in December 2015. Two spikes are also noted for synthetic cannabinoid-related ED visits in May and September 2017 respectively with a new baseline established starting January 2018.Spatial analysis shows geographic clustering of synthetic cannabinoid-related morbidity in three Maryland jurisdictions; Baltimore City, Fredrick County, and Washington County (Figure 2).The top five Maryland counties with crude synthetic cannabinoid-related ED visit rates included Allegany, Baltimore City, Frederick, St. Mary’s and Washington; ranging from 87 in Washington county to 38 in St. Mary’s county. The top ten crude synthetic cannabinoid-related ED visit rates per 100,000 population from 2013 to 2017 among all Maryland ZIP codes ranged from 87 in Washington county to 38 in St. Mary’s county.Spatial analysis also shows that hospitals with the greatest burden of synthetic cannabinoid-related ED visits were close to ZIP codes of communities with high crude synthetic cannabinoid-related ED visit rates (Figure 3).ConclusionsData from the ESSENCE program can be considered acceptable for monitoring synthetic cannabinoid-related ED visits in Maryland. It is useful for obtaining near real-time data about synthetic cannabinoid-related events, and as we have shown in our analysis, for the identification of key groups and geographic locations most in need of targeted interventions to reduce morbidity and mortality. Finally, it also provides us with the ability to retrospectively identify outbreaks, and to link data trends to ongoing interventions.References[1] Riederer, Anne et al. Acute Poisonings from Synthetic Cannabinoids — 50 U.S. Toxicology Investigators Consortium Registry Sites, 2010–2015. Centers for Disease Control and Prevention. MMWR. July 2016. Retrieved from: https://www.cdc.gov/mmwr/volumes/65/wr/mm6527a2.htm[2] Horth, Roberta. Notes from the Field: Outbreak of Severe Illness Linked to the Vitamin K Antagonist Brodifacoum and Use of Synthetic Cannabinoids — Illinois, March–April 2018[3] Centers for Disease Control and Prevention. Outbreak of life-threatening coagulopathy associated with synthetic cannabinoids use. May 2018. Retrieved from: https://emergency.cdc.gov/han/han00410.asp

Background Data on the prevalence of cancer in coronavirus disease 2019 (COVID-19)-infected patients and the severe illness incidence and mortality of COVID-19 patients with cancers remains unclear. Methods We systematically searched PubMed, Embase, Cochrane Library, and Web of Science, from database inception to July 15, 2020, for studies of patients with COVID-19 infection that had available comorbidity information on cancer. The primary endpoint was the pooled prevalence of cancer in COVID-19 patients and the secondary endpoint was the outcomes of COVID-19-infected cancer patients with incidence of severe illness and death rate. We calculated the pooled prevalence and corresponding 95% confidence intervals (95% CIs) using a random-effects model, and performed meta-regression analyses to explore heterogeneity. Subgroup analyses were conducted based on continent, country, age, sample size and study design. Findings A total of 107 eligible global studies were included in the systematic review. 90 studies with 94,845 COVID-19 patients in which 4,106 patients with cancer morbidity were included in the meta-analysis for prevalence of cancer morbidity among COVID-19 patients. 21 studies with 70,969 COVID-19 patients in which 3,351 patients with cancer morbidity who had severe illness or death during the studies. The overall prevalence of cancer among the COVID-19 patients was 0.07 (95% CI 0.05~0.09). The cancer prevalence in COVID-19 patients of Europe (0.22, 95% CI 0.17~0.28) was higher than that in Asia Pacific (0.04, 95% CI 0.03~0.06) and North America (0.05, 95% CI 0.04~0.06). The prevalence of COVID-19-infected cancer patients over 60 years old was 0.10 (95% CI 0.07~0.14), higher than that of patients equal and less than 60 years old (0.05, 95% CI 0.03~0.06). The pooled prevalence of severe illness among COVID-19 patients with cancers was 0.35 (95% CI 0.27~0.43) and the pooled death rate of COVID-19 patients with cancers was 0.18 (95% CI 0.14~0.18). The pooled incidence of severe illness of COVID-19 patients with cancers from Asia Pacific, Europe, and North America were 0.38(0.24, 0.52), 0.36(0.17, 0.55), and 0.26(0.20, 0.31), respectively; and the pooled death rate from Asia Pacific, Europe, and North America were 0.17(0.10, 0.24), 0.26(0.13, 0.39), and 0.19(0.13, 0.25), respectively. Interpretation To our knowledge, this study is the most comprehensive and up-to-date meta-analysis assessing the prevalence of cancer among COVID-19 patients, severe illness incidence and mortality rate. The prevalence of cancer varied significantly in geographical continents and ages. The COVID-19 patients with cancer were at-risk for severe illness and a high death rate. The European COVID-19 patients had the highest cancer prevalence among the three continents examined and were also the most likely to progress to severe illness and death. Although the Asia Pacific COVID-19 patients had the lowest cancer prevalence, their severe illness rate was similar to that of European.

Across the world, the level of pandemic preparedness varies and no country is fully prepared to respond to all public health events. The International Health Regulations 2005 require state parties to develop core capacities to prevent, detect, and respond to public health events of international concern. In addition to annual self-assessment, these capacities are peer reviewed once every 5 years through the voluntary Joint External Evaluation (JEE). In this article, we share Nigeria's experience of conducting a country-led midterm self-assessment using a slightly modified application of the second edition of the World Health Organization (WHO) JEE and the new WHO benchmarks tool. Despite more stringent scoring criteria in the revised JEE tool, average scoring showed modest capacity improvements in 2019 compared with 2017. Of the 19 technical areas assessed, 11 improved, 5 did not change, and 3 had lower scores. No technical area attained the highest-level scoring of 5. Understanding the level of, and gaps in, pandemic preparedness enables state parties to develop plans to improve health security; the outcome of the assessment included the development of a 12-month operational plan. Countries need to intentionally invest in preparedness by using existing frameworks (eg, JEE) to better understand the status of their preparedness. This will ensure ownership of developed plans with shared responsibilities by all key stakeholders across all levels of government.

Objectives: The objective of this study was to examine the association between several country-level systemic indices and the deaths from COVID-19 across African countries.Method: Regression analyses were conducted to test the association between selected indices and deaths from COVID-19 across African countries. All tests were run at the α = 0.05 level of significance.Result: We found a statistically significant correlation between total COVID-19 deaths per million and Stringency Index (p-value <0.001) and Human Development Index (p-value <0.001). Multiple regression analysis showed that Stringency Index was the only variable that remained significant when other factors are controlled for in the model.Conclusion: Countries in Africa with poorer governance, inadequate pandemic preparedness and lower levels of development have unexpectedly fared better with respect to COVID-19 deaths mainly because of having a younger population than the countries with better indices.

ObjectivesTo assess the association between blood circulating Vitamin D levels and colorectal cancer risk in the Asian population. DesignThis is a systematic review and dose-response meta-analysis of observational studies that investigated the relationship between blood circulating Vitamin D levels and colorectal cancer risk in the Asian population. Data SourcesRelevant studies were identified through a literature search in MEDLINE, EMBASE, studies published in peer-reviewed journals investigating the association between blood circulating Vitamin D levels and the risk of colorectal cancer and/or adenoma in Asian countries. Data extraction and synthesis:Two authors independently extracted data and assessed the quality of included studies. Studyspecific ORs were pooled using a random-effects model. A dose-response meta-analysis was performed with generalized least squares regression. We applied the Newcastle-Ottawa Scale quality assessment to evaluate the quality of the selected studies. ResultsThe eight included studies encompassed a total of 2,916 cases and 6,678 controls. The pooled ORs of colorectal cancer for the highest versus lowest categories of blood circulating Vitamin D levels was 0.75 [95% CI, 0.58-0.97] up to 36.5 ng/mL in the Asian population. There was heterogeneity among the studies (I 2 =53.9%, P heterogeneity =0.034). The dose-response metaanalysis indicated a significant linear relationship (P non-linearity =0.11). An increment of 16 ng/mL in blood circulating Vitamin D level corresponded to an OR of 0.79 [95% CI, 0.64-0.97]. ConclusionsThe results of this meta analysis indicate that blood circulating Vitamin D level is associated with decreased risk of colorectal cancer in Asian countries. The dose-response meta-analysis shows that the strength of this association among the Asian population is similar to that among the Western population. Our study suggests that the Asian population should improve nutritional status and maintain a higher level of blood circulating Vitamin D.