Amena Ahmad

Controlling SARS: a review on China’s response compared with other SARS-affected countries

Objective  To summarise the major control measures implemented by severe acute respiratory syndrome (SARS)‐affected countries and to compare distinctive features of the Chinese approach to other affected Asian countries and Canada.

Health service resource needs for pandemic influenza in developing countries: a linked transmission dynamics, interventions and resource demand model

We used a mathematical model to describe a regional outbreak and extrapolate the underlying health-service resource needs. This model was designed to (i) estimate resource gaps and quantities of resources needed, (ii) show the effect of resource gaps, and (iii) highlight which particular resources should be improved. We ran the model, parameterized with data from the 2009 H1N1v pandemic, for two provinces in Thailand. The predicted number of preventable deaths due to resource shortcomings and the actual resource needs are presented for two provinces and for Thailand as a whole. The model highlights the potentially huge impact of health-system resource availability and of resource gaps on health outcomes during a pandemic and provides a means to indicate where efforts should be concentrated to effectively improve pandemic response programmes.

Impact of public health interventions in controlling the spread of SARS: Modelling of intervention scenarios

A variety of intervention measures exist to prevent and control diseases with pandemic potential like SARS or pandemic influenza. They differ in their approach and effectiveness in reducing the number of cases getting infected. The effects of different intervention measures were investigated by a mathematical modelling approach, with comparisons based on the effective reproduction number (R(e)). The analysis showed that early case detection followed by strict isolation could control a SARS outbreak. Tracing close contacts of cases and contacts of exposed health care workers additionally reduces the R(e). Tracing casual contacts and measures aiming to decrease social interaction were less effective in reducing the number of SARS cases. The study emphasizes the importance of early identification and isolation of SARS cases to reduce the number of people getting infected. However, doing so transfers cases to health care facilities, making infection control measures in hospitals essential to avoid nosocomial spread. The modelling approach applied in this study is useful for analysing interactions of different intervention measures for reducing the R(e) of SARS.

Pandemic public health paradox: Time series analysis of the 2009/10 influenza A/H1N1 epidemiology, media attention, risk perception and public reactions in 5 European countries

In 2009, influenza A H1N1 caused the first pandemic of the 21st century. Although a vaccine against this influenza subtype was offered before or at the onset of the second epidemic wave that caused most of the fatal cases in Europe, vaccination rates for that season were lower than expected. We propose that the contradiction between high risk of infection and low use of available prevention measures represents a pandemic public health paradox. This research aims for a better understanding of this paradox by exploring the time-dependent interplay among changing influenza epidemiology, media attention, pandemic control measures, risk perception and public health behavior among five European countries (Czech Republic, Denmark, Germany, Spain and the UK). Findings suggest that asynchronicity between media curves and epidemiological curves may potentially explain the pandemic public health paradox; media attention for influenza A H1N1 in Europe declined long before the epidemic reached its peak, and public risk perceptions and behaviors may have followed media logic, rather than epidemiological logic.

Evaluation of national pandemic management policies—A hazard analysis of critical control points approach

Analyses of pandemic preparedness policies revealed weaknesses in control systems of European nations. This reinforces the need to support countries in their endeavours to prevent and contain pandemics. A Hazard Analysis and Critical Control Points (HACCP) was applied to a generic plan to identify weaknesses in pandemic management policies, in order to develop recommendations for improving national pandemic management systems. Policy components considered in our analysis are command and control, early case detection and disease surveillance, and community containment management. The main critical areas identified in national pandemic control were: communication systems among all institutions and levels involved in pandemic management, guidelines and regulations describing how key personal and institutions should operate during a pandemic, training and dissemination of information to health care personnel involved in outbreak management. The HACCP analysis highlighted the need for agreed communication structures, clear division of responsibilities and harmonised policy guidelines at all levels of pandemic management. Being prepared is the key to successfully coordinate and implement response measures when a pandemic emerges.

Limited access to hepatitis B/C treatment among vulnerable risk populations: an expert survey in six European countries

Abstract Background: To investigate access to treatment for chronic hepatitis B/C among six vulnerable patient/population groups at-risk of infection: undocumented migrants, asylum seekers, people without health insurance, people with state insurance, people who inject drugs (PWID) and people abusing alcohol. Methods: An online survey among experts in gastroenterology, hepatology and infectious diseases in 2012 in six EU countries: Germany, Hungary, Italy, the Netherlands, Spain and the UK. A four-point ordinal scale measured access to treatment (no, some, significant or complete restriction). Results: From 235 recipients, 64 responses were received (27%). Differences in access between and within countries were reported for all groups except people with state insurance. Most professionals, other than in Spain and Hungary, reported no or few restrictions for PWID. Significant/complete treatment restriction was reported for all groups by the majority in Hungary and Spain, while Italian respondents reported no/few restrictions. Significant/complete restriction was reported for undocumented migrants and people without health insurance in the UK and Spain. Opinion about undocumented migrants in Germany and the Netherlands was divergent. Conclusions: Although effective chronic hepatitis B/C treatment exists, limited access among vulnerable patient populations was seen in all study countries. Discordance of opinion about restrictions within countries is seen, especially for groups for whom the health care system determines treatment access, such as undocumented migrants, asylum seekers and people without health insurance. This suggests low awareness, or lack, of entitlement guidance among clinicians. Expanding treatment access among risk groups will contribute to reducing chronic viral hepatitis-associated avoidable morbidity and mortality.

Influenza—Insights from Mathematical Modelling

BACKGROUND When the first cases of a new infectious disease appear, questions arise about the further course of the epidemic and about the appropriate interventions to be taken to protect individuals and the public as a whole. Mathematical models can help answer these questions. In this article, the authors describe basic concepts in the mathematical modelling of infectious diseases, illustrate their use with a simple example, and present the results of influenza models. METHOD Description of the mathematical modelling of infectious diseases and selective review of the literature. RESULTS The two fundamental concepts of mathematical modelling of infectious diseases-the basic reproduction number and the generation time-allow a better understanding of the course of an epidemic. Modelling studies based on past influenza epidemics suggest that the rise of the epidemic curve can be slowed at the beginning of the epidemic by isolating ill persons and giving prophylactic medications to their contacts. Later on in the course of the epidemic, restricting the number of contacts (e.g., by closing schools) may mitigate the epidemic but will only have a limited effect on the total number of persons who contract the disease. CONCLUSION Mathematical modelling is a valuable tool for understanding the dynamics of an epidemic and for planning and evaluating interventions.

Evaluating health systems' preparedness for emerging infectious diseases: A novel conceptual and analytic framework

In this article we present a novel conceptual framework for systematically assessing the national health system capacity to respond to pandemic influenza. This framework helps to determine how health systems and pandemic programmes interact, whether, where and which weak points exist, and how and where pandemic response health programmes can be improved effectively. This new conceptual framework draws upon two existing approaches for assessment and evaluation, the Systemic Rapid Assessment Toolkit (SYSRA) and the Hazard Analysis of Critical Control Points (HACCP). SYSRA is a systematic approach to analyse the interplay between communicable disease programmes and the broader health systems context within which they operate and the HACCP methodology builds upon a systematic analysis of process steps within a programme in order to identify likely hazards and to develop control measures to address them. The analytical framework that we have developed from the novel conceptualisation is simple, can be applied rapidly, and should, we believe, be low cost to implement. Thus, this provides a means for developing a contextual understanding of the broader health system in which a pandemic infectious disease programme operates, and for identifying frailties in programmes that need to be responded to.

Referral of newly diagnosed chronic hepatitis B and C patients in six EU countries: results of the HEPscreen Project

BACKGROUND Effective linkage to specialist care following screening is crucial for secondary prevention of chronic viral hepatitis-related consequences. METHODS To explore the frequency of referral of patients to secondary care from the health services involved in screening and to gather information on the services responsible for the provision of post-test counselling and contact tracing, four online surveys were conducted among general practitioners (GP), and experts working in sexual health services (SHS), antenatal care (ANC) and specialist secondary care in Germany, Hungary, Italy, The Netherlands, Spain and the UK. RESULTS Overall, 60% of GPs report referring all patients to specialist care. Although 67% of specialists commonly receive patients referred by GPs, specialists in Germany rarely or never receive patients from ANC or from centres testing injecting drug users; and specialists in the Netherlands, Hungary and Germany rarely receive patients from SHS. Gastroenterologists/hepatologists are the professionals mainly responsible for the provision of counselling following a positive diagnosis of viral hepatitis according to two-thirds of specialists, 14% of SHS providers and 11% of ANC providers. Almost half of ANC providers (45%) stated that gynaecologists are the professionals responsible for the provision of counselling to positive pregnant women; among SHS providers, only 14% identified SHS as the services responsible. CONCLUSION Our findings suggest the existence of complex/ineffective referral practices or that opportunities to screen risk groups are missed. Recommendations clarifying the services responsible at each step of the referral pathway are needed in order to increase the success of screening programmes.

Hepatitis B: Are at-risk individuals vaccinated if screened and found negative for HBV? Results of an online survey conducted in six EU countries

INTRODUCTION Vaccination is the best way to prevent hepatitis B infection and its consequences. The aim of the present study is to analyze the current vaccination practices within various population subgroups who are offered screening for hepatitis B, when found negative, in Germany, Hungary, Italy, the Netherlands, Spain and the UK. METHODS Online surveys were conducted in the six countries. In total, 1181 experts from six different health professions were invited to participate. Descriptive analyses of data were performed. RESULTS Less than half of the respondents in the Netherlands, only about 1/4 in Germany and none in Hungary reported that the vaccine is commonly offered to people who inject drugs. Less than half of the respondents in Germany reported vaccinating sex workers or HIV positive patients against hepatitis B as common practice. None in Hungary stated that vaccinating sex workers is common practice, and only according to a minority (17%) HIV patients are commonly vaccinated. 1/4 to 1/3 of respondents in Germany, the Netherlands, Italy, Hungary and the UK, indicated that HCV positive patients are only sporadically immunized. Only in Spain almost half of the respondents reported that migrants from hepatitis B endemic areas who are screened negative are commonly vaccinated. Widespread uncertainty about vaccination practices for asylum seekers was reported. CONCLUSIONS By showing the gaps between current practices and policies in place, our findings can help to increase the success of future vaccination programmes. Implementation of training for health care professional, e.g. introducing vaccinology and vaccination policy courses in the medical and paramedical curriculum, could contribute to a more homogenous application of the recommendations regarding immunization against hepatitis B. Our results show, nonetheless, that the universal vaccination approach, coupled with targeted programmes for immigrants, represents the only way to make the elimination of hepatitis B a foreseeable, realistic objective.