The Dry Season in Haiti: a Window of Opportunity to Eliminate Cholera Citation Revisions Authors

International audienceBACKGROUND:Since the beginning of the cholera epidemic in Haiti, attack rates have varied drastically with alternating peak and lull phases, which were partly associated with the fluctuating dry, rainy and cyclonic seasons. According to a study conducted in 2012, the toxigenic V. cholerae O1 strain responsible for the outbreak did not settle at a significant level in the Haitian aquatic environment. Therefore, we hypothesize that some areas of lingering cholera transmission during the dry season could play an important role in the re-emergence of outbreaks during the rainy season. Our objective was therefore to describe the dynamics of cholera and assess the fight against the disease during the dry season.METHODS:A field study was conducted from February 19 to March 29, 2013. After identifying the affected communes by analyzing the national cholera database, we visited corresponding health facilities to identify patient origins. We then conducted a field assessment of these foci to confirm the presence of cholera, assess factors associated with transmission and examine the activities implemented to control the epidemic since the beginning of the current dry season.RESULTS:We found that the great majority of Haitian communes (109/140) presented no sign of cholera transmission in February and March 2013. Suspected cases were concentrated in a small number of urban and rural areas, almost all of which were located in the northern half of the country and often in inland locales. In these areas, community health activities appeared insufficient and were often inappropriately targeted. Out of 49 analyzed foci, only 10 had benefited from at least one intervention involving the distribution of water treatment products together with an awareness campaign since December 2012.CONCLUSION:Cholera continues to affect Haiti as observed in early 2013; however, activities implemented to interrupt cholera transmission appear insufficient and poorly suited. This deficiency in the fight against cholera, especially at a period when transmission is weak, may explain the persistence of cholera even in the absence of significant aquatic reservoirs in Haiti

Hypoparathyroidism-related health care utilization and expenditure during the first postoperative year after total thyroidectomy for cancer: a comprehensive national cohort study

ObjectivesHypoparathyroidism is the most common complication of total thyroidectomy for cancer, and requires calcium and/or vitamin D supplementation for an unpredictable period of time. The additional cost associated with this complication has not hitherto been assessed. The aim of this study was to assess the economic burden of postoperative hypoparathyroidism after total thyroidectomy for cancer in France.MethodsBased on the French national cancer cohort, which extracts data from the French National Health Data System (SNDS), all adult patients who underwent a total thyroidectomy for cancer in France between 2011 and 2015 were identified, and their healthcare resource use during the first postoperative year was compared according to whether they were treated postoperatively with calcium and/or vitamin D or not. Univariate and multivariate cost analyses were performed with the non-parametric Wilcoxon test and generalized linear model (gamma distribution and log link), respectively.ResultsAmong the 31,175 patients analyzed (75% female, median age: 52y), 13,247 (42%) started calcium and/or vitamin D supplementation within the first postoperative month, and 2,855 patients (9.1%) were still treated at 1 year. Over the first postoperative year, mean overall and specific health expenditures were significantly higher for treated patients than for untreated patients: €7,233 vs €6,934 per patient (p<0.0001) and €478.6 vs €332.7 per patient (p<0.0001), respectively. After adjusting for age, gender, Charlson Comorbidity index, ecological deprivation index, types of thyroid resection, lymph node dissection and complications, year and region, the incremental cost of overall health care utilization was €142 (p<0.004).ConclusionOur study found a significant additional cost in respect of health expenditures for patients who had hypoparathyroidism after thyroidectomy for cancer, over the first postoperative year. Five-year follow-up is planned to assess the impact of more severe long-term complications on costs

Geographical and temporal distribution of human giardiasis in Ontario, Canada

BACKGROUND: Giardia is the most frequently identified intestinal parasite in North America. Although information on geographical distribution of giardiasis is critical in identifying communities at high risk, little has been done in this area. Therefore, the objective of this study was to investigate the geographical and temporal distribution of human giardiasis in Ontario in order to identify possible high risk areas and seasons. Two spatial scales of analyses and two disease measures were used with a view to identifying the best of each in assessing geographical patterns of giardiasis in Ontario. Global Moran's I and Moran Local Indicators of Spatial Associations were used to test for evidence of global and local spatial clustering, respectively. RESULTS: There were seasonal patterns with summer peaks and a significant (P < 0.001) decreasing temporal trend. Significant (P < 0.05) global spatial clustering of high rates was observed at the Census Sub-division spatial scale but not at the Census Division scale. The Census Sub-division scale was a better scale of analyses but required spatial empirical Bayesian smoothing of the rates. A number of areas with significant local clustering of giardiasis rates were identified. CONCLUSIONS: The study identified spatial and temporal patterns in giardiasis distribution. This information is important in guiding decisions on disease control strategies. The study also showed that there is benefit in performing spatial analyses at more than one spatial scale to assess geographical patterns in disease distribution and that smoothing of disease rates for mapping in small areas enhances visualization of spatial patterns

Whole genome sequence of Vibrio cholerae directly from dried spotted filter paper.

BACKGROUND: Global estimates for cholera annually approximate 4 million cases worldwide with 95,000 deaths. Recent outbreaks, including Haiti and Yemen, are reminders that cholera is still a global health concern. Cholera outbreaks can rapidly induce high death tolls by overwhelming the capacity of health facilities, especially in remote areas or areas of civil unrest. Recent studies demonstrated that stool specimens preserved on filter paper facilitate molecular analysis of Vibrio cholerae in resource limited settings. Specimens preserved in a rapid, low-cost, safe and sustainable manner for sequencing provides previously unavailable data about circulating cholera strains. This may ultimately contribute new information to shape public policy response on cholera control and elimination. METHODOLOGY/PRINCIPAL FINDINGS: Whole genome sequencing (WGS) recovered close to a complete sequence of the V. cholerae O1 genome with satisfactory genome coverage from stool specimens enriched in alkaline peptone water (APW) and V. cholerae culture isolates, both spotted on filter paper. The minimum concentration of V. cholerae DNA sufficient to produce quality genomic information was 0.02 ng/μL. The genomic data confirmed the presence or absence of genes of epidemiological interest, including cholera toxin and pilus loci. WGS identified a variety of diarrheal pathogens from APW-enriched specimen spotted filter paper, highlighting the potential for this technique to explore the gut microbiome, potentially identifying co-infections, which may impact the severity of disease. WGS demonstrated that these specimens fit within the current global cholera phylogenetic tree, identifying the strains as the 7th pandemic El Tor. CONCLUSIONS: WGS results allowed for mapping of short reads from APW-enriched specimen and culture isolate spotted filter papers. This provided valuable molecular epidemiological sequence information on V. cholerae strains from remote, low-resource settings. These results identified the presence of co-infecting pathogens while providing rare insight into the specific V. cholerae strains causing outbreaks in cholera-endemic areas

Genetic Structure of Plasmodium falciparum and Elimination of Malaria, Comoros Archipelago

Elimination interventions should be implemented simultaneously throughout the entire archipelago

COVID-19 symptoms at hospital admission vary with age and sex: results from the ISARIC prospective multinational observational study

Background: The ISARIC prospective multinational observational study is the largest cohort of hospitalized patients with COVID-19. We present relationships of age, sex, and nationality to presenting symptoms. Methods: International, prospective observational study of 60 109 hospitalized symptomatic patients with laboratory-confirmed COVID-19 recruited from 43 countries between 30 January and 3 August 2020. Logistic regression was performed to evaluate relationships of age and sex to published COVID-19 case definitions and the most commonly reported symptoms. Results: ‘Typical’ symptoms of fever (69%), cough (68%) and shortness of breath (66%) were the most commonly reported. 92% of patients experienced at least one of these. Prevalence of typical symptoms was greatest in 30- to 60-year-olds (respectively 80, 79, 69%; at least one 95%). They were reported less frequently in children (≤ 18 years: 69, 48, 23; 85%), older adults (≥ 70 years: 61, 62, 65; 90%), and women (66, 66, 64; 90%; vs. men 71, 70, 67; 93%, each P &lt; 0.001). The most common atypical presentations under 60 years of age were nausea and vomiting and abdominal pain, and over 60 years was confusion. Regression models showed significant differences in symptoms with sex, age and country. Interpretation: This international collaboration has allowed us to report reliable symptom data from the largest cohort of patients admitted to hospital with COVID-19. Adults over 60 and children admitted to hospital with COVID-19 are less likely to present with typical symptoms. Nausea and vomiting are common atypical presentations under 30 years. Confusion is a frequent atypical presentation of COVID-19 in adults over 60 years. Women are less likely to experience typical symptoms than men

Dynamic study of cholera epidemics in Africa and in Haiti and application to the implementation of elimination strategies

Le choléra est une diarrhée hydrique sévère volontiers épidémique causée par des Vibrio cholerae O1 toxinogènes. Ses déterminants environnementaux ont donné naissance à un paradigme influent sur les stratégies de lutte, qui sont se sont avérées peu efficientes en Afrique comme en Haïti. Elles pourraient être améliorées par une meilleure compréhension de la dynamique des épidémies. La synthèse bibliographique des influences de l'environnement sur les épidémies de choléra en Afrique y montre les limites du paradigme environnemental. L'étude multidisciplinaire des origines de l'épidémie de choléra en Guinée en 2012 suggère fortement qu'elle fut importée par voie humaine depuis la Sierra Leone voisine. Une description spatio-temporelle du choléra au Mozambique démontre l'hétérogénéité de sa transmission et amène à questionner le concept d'endémicité du choléra. Depuis son importation en Haïti en octobre 2010, l'épidémie de choléra présente également une répartition spatiale et temporelle très hétérogène. Son importante rétractation en saison sèche et son absence d'enracinement significatif dans l'environnement laissent espérer la possibilité d'une élimination rapide à condition d'apporter une réponse ciblée à tous les foyers épidémiques du pays. Une stratégie d'élimination basée sur nos recommandations y est actuellement menée par le Ministère de la Santé, l'UNICEF et leurs partenaires. Après des résultats spectaculaires en 2013 et au premier semestre 2014, la situation s'est à nouveau dégradée pendant la saison des pluies. Une élimination du choléra dans saison sèche à venir demeure cependant réaliste si nous parvenons à convaincre et remobiliser les acteurs de terrain.Cholera is an epidemic acute watery diarrhea caused by toxigenic bacteria Vibrio cholerae O1. Its environment determinants have been at the source of a popular paradigm. Many recent control strategies have shown little efficiency in Africa or in Haiti, but they could be improved by a better comprehension of the epidemics dynamic. The bibliographic synthesis of environment influences on cholera in Africa highlights the limits of the environmental paradigm on this continent. A multidisciplinary study of the origin of cholera epidemic in Guinea in 2012 strongly suggests it was humanly imported from nearby Sierra Leone. A space-time description of cholera in Mozambique demonstrates heterogeneous transmission patterns and challenges the concept of cholera endemicity. Since its importation in Haiti in October 2010, cholera transmission also exhibits a marked spatio-temporal heterogeneity. Cholera important retraction during the dry season and its absence of significant establishment in the Haitian environment suggest it may be possible to rapidly eliminate cholera in the country, provided that every outbreak focus receives a targeted response. An elimination strategy based on our recommendations is currently implemented by Haitian Ministry of Health, UNICEF and their partners. After spectacular results in 2013 and during the first half of 2014, the situation has slowly deteriorated during the rainy season. However, cholera elimination during the coming dry season remains realistic provided that we succeed in persuading and remobilizing the partners present on the field

Epidémiologie moléculaire et génétique des populations de Plasmodium falciparum dans l'archipel des Comores. Implications pour la lutte antipaludique.

Plasmodium falciparum malaria is the main health problem in Comoro archipelago. The present work proposes a synthesis of its available epidemiological data, and an application of the recent molecular epidemiology and population genetics tools to the comoran malaria situation. This appears contrasted on the archipelago. Malaria morbidity is important on Grande Comore, Moheli and Anjouan islands, and their P. falciparum populations are quite homogeneous. Conversely, morbidity is limited in Mayotte, where cases are half imported from nearby islands, and half autochthonous and concentrated in Bandraboua, a residual and genetically isolated transmission focus where malaria is epidemic. Chemoresistance levels are globally high on the archipelago, but also contrasted because of different drug selective pressures. These data suggest : (1) the need to organize a separated surveillance of drug resistance in each of the four islands, (2) the theoretic possibility of a malaria elimination from the 4 islands at the same time but not from a sole one, and (3) the need to strengthen efforts for preventing malaria epidemics in Bandraboua. Arrival of artemisininbased treatments in Comoros, the large distribution of treated bednets and the recent mass treatment on Moheli, should rapidly reshape this epidemiologic situation. They should also raise the relevance of a distant chemoresistance surveillance from Marseille, where genetical representativeness of imported parasites has been limited.Le paludisme à P. falciparum constitue le problème de santé publique principal sur l'archipel des Comores. Le présent travail propose une synthèse des informations relatives à son épidémiologie, associée à une application des méthodes récentes d'épidémiologie moléculaire et de génétique des populations plasmodiales à la situation comorienne. Celle-ci apparaît contrastée. Ainsi, Grande Comore, Mohéli et Anjouan sont des îles marquées par une morbidité palustre importante, et leur population plasmodiale est globalement homogène. La morbidité est en revanche beaucoup plus faible à Mayotte, où les cas sont pour moitié d'origine importée depuis les îles voisines, et pour moitié autochtones et concentrés dans le foyer résiduel et génétiquement isolé de Bandraboua selon une distribution microépidémique. Les niveaux de chimiorésistance, globalement élevés, sont également contrastés, du fait de pressions médicamenteuses différentes. En complément des stratégies actuelles de lutte antipaludique, ces informations conduisent donc à recommander : (1) la nécessité d'une surveillance de la chimiorésistance séparée pour chaque île, (2) le principe d'une élimination du paludisme sur les 4 îles à la fois et non pas sur une seule, et (3) un renforcement de la prévention des épidémies sur la commune de Bandraboua. Mais l'arrivée des ACT, la large distribution des moustiquaires imprégnées et le récent traitement de masse sur Mohéli devraient modifier à court terme cette situation épidémiologique. Ils devraient également relancer la pertinence d'une surveillance de la chimiorésistance excentrée à Marseille, où la représentativité génétique des parasites importés est pour l'instant limitée

[The surprising disappearance of cholera in Haiti].

International audienceNo abstract provided