Shiga toxin-producing Escherichia coli (STEC) cause illnesses ranging from mild diarrhea to ischemic colitis and hemolytic uremic syndrome (HUS); serogroup O157 is the most common cause. We describe the epidemiology and transmission routes for U.S. STEC outbreaks during 2010–2017. Health departments reported 466 STEC outbreaks affecting 4769 persons; 459 outbreaks had a serogroup identified (330 O157, 124 non-O157, 5 both). Among these, 361 (77%) had a known transmission route: 200 foodborne (44% of O157 outbreaks, 41% of non-O157 outbreaks), 87 person-to-person (16%, 24%), 49 animal contact (11%, 9%), 20 water (4%, 5%), and 5 environmental contamination (2%, 0%). The most common food category implicated was vegetable row crops. The distribution of O157 and non-O157 outbreaks varied by age, sex, and severity. A significantly higher percentage of STEC O157 than non-O157 outbreaks were transmitted by beef (p = 0.02). STEC O157 outbreaks also had significantly higher rates of hospitalization and HUS (p < 0.001).
Background/setting Only 47% of HIV-positive Sierra Leoneans knew their status in 2017, making expanded HIV testing a priority. National guidelines endorse provider-initiated HIV testing and counselling (PITC) to increase testing coverage, but PITC is rarely provided in Sierra Leone. In response, a Quality Improvement Collaborative (QIC) was implemented to improve PITC coverage amongst adult inpatients. Methods Ten hospitals received the intervention between October 2017 and August 2018; there were no control facilites. Each hospital aimed to improve PITC coverage to � 95% of eligible patients. Staff received training on PITC and QIC methods and a package of PITC best practices and tools. They then worked to identify additional contextually-appropriate interventions, conducted rapid tests of change, and tracked performance using shared indicators and time-series data. Supportive supervision bolstered QI skills, and quarterly meetings enabled diffusion of innovations while spurring friendly competition. Results Baseline PITC coverage was 4%. The hospital teams tested diverse interventions using QI methods, including staff training; data review meetings; enhanced workflow processes and supervision; and patient education and sensitization activities Nine hospitals reached and sustained the 95% target, and all saw rapid and durable improvement, which was sustained for a median of six months. Of the 5,238 patients tested for HIV, 311 (6%) were found to be HIV-positive and were referred for treatment. HIV rapid test kit stockouts occurred during the project period, limiting PITC services in some cases.
Background Intermittent preventive treatment of malaria in infants (IPTi) with sulfadoxine-pyrimethamine (SP) is a proven strategy to protect infants against malaria. Sierra Leone is the first country to implement IPTi nationwide. IPTi implementation was evaluated in Kambia, one of two initial pilot districts, to assess quality and coverage of IPTi services. Methods This mixed-methods evaluation had two phases, conducted 3 (phase 1) and 15–17 months (phase 2) after IPTi implementation. Methods included: assessments of 18 health facilities (HF), including register data abstraction (phases 1 and 2); a knowledge, attitudes and practices survey with 20 health workers (HWs) in phase 1; second-generation sequencing of SP resistance markers (pre-IPTi and phase 2); and a cluster-sample household survey among caregivers of children aged 3–15 months (phase 2). IPTi and vaccination coverage from the household survey were calculated from child health cards and maternal recall and weighted for the complex sampling design. Interrupted time series analysis using a Poisson regression model was used to assess changes in malaria cases at HF before and after IPTi implementation. Results Most HWs (19/20) interviewed had been trained on IPTi; 16/19 reported feeling well prepared to administer it. Nearly all HFs (17/18 in phase 1; 18/18 in phase 2) had SP for IPTi in stock. The proportion of parasite alleles with dhps K540E mutations increased but remained below the 50% WHO-recommended threshold for IPTi (4.1% pre-IPTi [95%CI 2–7%]; 11% post-IPTi [95%CI 8–15%], p < 0.01). From the household survey, 299/459 (67.4%) children ≥ 10 weeks old received the first dose of IPTi (versus 80.4% for second pentavalent vaccine, given simultaneously); 274/444 (62.5%) children ≥ 14 weeks old received the second IPTi dose (versus 65.4% for third pentavalent vaccine); and 83/217 (36.4%) children ≥ 9 months old received the third IPTi dose (versus 52.2% for first measles vaccine dose). HF register data indicated no change in confirmed malaria cases among infants after IPTi implementation. Conclusions Kambia district was able to scale up IPTi swiftly and provide necessary health systems support. The gaps between IPTi and childhood vaccine coverage need to be further investigated and addressed to optimize the success of the national IPTi programme.
The first confirmed case of Ebola virus disease (Ebola) in Sierra Leone related to the ongoing epidemic in West Africa occurred in May 2014, and the outbreak quickly spread. To date, 8,704 Ebola cases and 3,955 Ebola deaths have been confirmed in Sierra Leone. The first Ebola treatment units (ETUs) in Sierra Leone were established in the eastern districts of Kenema and Kailahun, where the first Ebola cases were detected, and these districts were also the first to control the epidemic. By September and October 2014, districts in the western and northern provinces, including Bombali, had the highest case counts, but additional ETUs outside of the eastern province were not operational for weeks to months. Bombali became one of the most heavily affected districts in Sierra Leone, with 873 confirmed patients with Ebola during July-November 2014. The first ETU and laboratory in Bombali District were established in late November and early December 2014, respectively. T- evaluate the impact of the first ETU and laboratory becoming operational in Bombali on outbreak control, the Bombali Ebola surveillance team assessed epidemiologic indicators before and after the establishment of the first ETU and laboratory in Bombali. After the establishment of the ETU and laboratory, the interval from symptom onset to laboratory result and from specimen collection to laboratory result decreased. By providing treatment to Ebola patients and isolating contagious persons to halt ongoing community transmission, ETUs play a critical role in breaking chains of transmission and preventing uncontrolled spread of Ebola (4). Prioritizing and expediting the establishment of an ETU and laboratory by pre-positioning resources needed to provide capacity for isolation, testing, and treatment of Ebola are essential aspects of pre-outbreak planning.
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