Chukwuma Mbaeyi

Hepatitis C Virus Screening and Management of Seroconversions in Hemodialysis Facilities

Over the past two decades, healthcare‐associated exposure has increasingly been proved to be a means of hepatitis C virus (HCV) transmission, especially in hemodialysis facilities. The prevalence of HCV among hemodialysis patients is known to be several times greater than that of the general population of the United States, and chronic HCV infection is associated with significant morbidity and mortality among these patients. During 2008–2011, HCV infection outbreaks were identified in multiple US hemodialysis facilities, resulting in at least 46 new HCV infections among hemodialysis patients. These outbreaks, linked to infection control breaches, also highlight the failure of some facilities to follow established guidelines for routine HCV antibody (anti‐HCV) screening and response to new HCV infection among hemodialysis patients. Current national guidelines recommend screening of hemodialysis patients for anti‐HCV on facility admission and, for susceptible patients, on a semiannual basis.

Polio Outbreak Investigation and Response in Somalia, 2013

BACKGROUND For >2 decades, conflicts and recurrent natural disasters have maintained Somalia in a chronic humanitarian crisis. For nearly 5 years, 1 million children <10 years have not had access to lifesaving health services, including vaccination, resulting in the accumulation by 2012 of the largest geographically concentrated cohort of unvaccinated children in the world. This article reviews the epidemiology, risk, and program response to what is now known as the 2013 wild poliovirus (WPV) outbreak in Somalia and highlights the challenges that the program will face in making Somalia free of polio once again. METHODS A case of acute flaccid paralysis (AFP) was defined as a child <15 years of age with sudden onset of fever and paralysis. Polio cases were defined as AFP cases with stool specimens positive for WPV. RESULTS From 9 May to 31 December 2013, 189 cases of WPV type 1 (WPV1) were reported from 46 districts of Somalia; 42% were from Banadir region (Mogadishu), 60% were males, and 93% were <5 years of age. All Somalian polio cases belonged to cluster N5A, which is known to have been circulating in northern Nigeria since 2011. In response to the outbreak, 8 supplementary immunization activities were conducted with oral polio vaccine (OPV; trivalent OPV was used initially, followed subsequently by bivalent OPV) targeting various age groups, including children aged <5 years, children aged <10 years, and individuals of any age. CONCLUSIONS The current polio outbreak erupted after a polio-free period of >6 years (the last case was reported in March 2007). Somalia interrupted indigenous WPV transmission in 2002, was removed from the list of polio-endemic countries a year later, and has since demonstrated its ability to control polio outbreaks resulting from importation. This outbreak reiterates that the threat of large polio outbreaks resulting from WPV importation will remain constant unless polio transmission is interrupted in the remaining polio-endemic countries.

Transmission of Balamuthia mandrillaris by Organ Transplantation.

BACKGROUND During 2009 and 2010, 2 clusters of organ transplant-transmitted Balamuthia mandrillaris, a free-living ameba, were detected by recognition of severe unexpected illness in multiple recipients from the same donor. METHODS We investigated all recipients and the 2 donors through interview, medical record review, and testing of available specimens retrospectively. Surviving recipients were tested and treated prospectively. RESULTS In the 2009 cluster of illness, 2 kidney recipients were infected and 1 died. The donor had Balamuthia encephalitis confirmed on autopsy. In the 2010 cluster, the liver and kidney-pancreas recipients developed Balamuthia encephalitis and died. The donor had a clinical syndrome consistent with Balamuthia infection and serologic evidence of infection. In both clusters, the 2 asymptomatic recipients were treated expectantly and survived; 1 asymptomatic recipient in each cluster had serologic evidence of exposure that decreased over time. Both donors had been presumptively diagnosed with other neurologic diseases prior to organ procurement. CONCLUSIONS Balamuthia can be transmitted through organ transplantation with an observed incubation time of 17-24 days. Clinicians should be aware of Balamuthia as a cause of encephalitis with high rate of fatality, and should notify public health departments and evaluate transplant recipients from donors with signs of possible encephalitis to facilitate early diagnosis and targeted treatment. Organ procurement organizations and transplant centers should be aware of the potential for Balamuthia infection in donors with possible encephalitis and also assess donors carefully for signs of neurologic infection that may have been misdiagnosed as stroke or as noninfectious forms of encephalitis.

Dialysis Event Surveillance Report: National Healthcare Safety Network data summary, January 2007 through April 2011.

A total of 24,092 adverse events in hemodialysis outpatients during January 2007 through April 2011 were reported to the National Healthcare Safety Network. Of 2,656 bloodstream infections, 67.3% were in patients with central venous catheters. For all events, rates associated with central venous catheters were higher than for other vascular access types.

Response to a Large Polio Outbreak in a Setting of Conflict — Middle East, 2013–2015

As the world advances toward the eradication of polio, outbreaks of wild poliovirus (WPV) in polio-free regions pose a substantial risk to the timeline for global eradication. Countries and regions experiencing active conflict, chronic insecurity, and large-scale displacement of persons are particularly vulnerable to outbreaks because of the disruption of health care and immunization services (1). A polio outbreak occurred in the Middle East, beginning in Syria in 2013 with subsequent spread to Iraq (2). The outbreak occurred 2 years after the onset of the Syrian civil war, resulted in 38 cases, and was the first time WPV was detected in Syria in approximately a decade (3,4). The national governments of eight countries designated the outbreak a public health emergency and collaborated with partners in the Global Polio Eradication Initiative (GPEI) to develop a multiphase outbreak response plan focused on improving the quality of acute flaccid paralysis (AFP) surveillance* and administering polio vaccines to >27 million children during multiple rounds of supplementary immunization activities (SIAs).† Successful implementation of the response plan led to containment and interruption of the outbreak within 6 months of its identification. The concerted approach adopted in response to this outbreak could serve as a model for responding to polio outbreaks in settings of conflict and political instability.

Progress Toward Polio Eradication—Somalia, 1998–2013

Since the 1988 resolution of the World Health Assembly to eradicate polio, significant progress has been made toward achieving this goal, with the result that only Afghanistan, Nigeria, and Pakistan have never successfully interrupted endemic transmission of wild poliovirus. However, one of the greatest challenges of the Global Polio Eradication Initiative has been that of maintaining the polio-free status of countries in unstable regions with weak healthcare infrastructure, a challenge exemplified by Somalia, a country in the Horn of Africa region. Somalia interrupted indigenous transmission of wild poliovirus in 2002, 4 years after the country established its national polio eradication program. But political instability and protracted armed conflict, with significant disruption of the healthcare system, have left Somalia vulnerable to 2 imported outbreaks of wild poliovirus. The first occurred during 2005-2007, resulting in >200 cases of paralytic polio, whereas the second, which began in 2013, is currently ongoing. Despite immense challenges, the country has a sensitive surveillance system that has facilitated prompt detection of outbreaks, but its weak routine immunization system means that supplementary immunization activities constitute the primary strategy for reaching children with polio vaccines. Conducting vaccination campaigns in a setting of conflict has been at times hazardous, but the countrys polio program has demonstrated resilience in overcoming many obstacles to ensure that children receive lifesaving polio vaccines. Regaining and maintaining Somalias polio-free status will depend on finding innovative and lasting solutions to the challenge of administering vaccines in a setting of ongoing conflict and instability.

Assessment of Management Policies and Practices for Occupational Exposure to Bloodborne Pathogens in Dialysis Facilities

BACKGROUND Occupational exposure management is an important element in preventing the transmission of bloodborne pathogens in health care settings. In 2008, the US Centers for Disease Control and Prevention conducted a survey to assess procedures for managing occupational bloodborne pathogen exposures in outpatient dialysis facilities in the United States. STUDY DESIGN A cross-sectional survey of randomly selected outpatient dialysis facilities. SETTING & PARTICIPANTS 339 outpatient dialysis facilities drawn from the 2006 US end-stage renal disease database. PREDICTORS Hospital affiliation (free-standing vs hospital-based facilities), profit status (for-profit vs not-for-profit facilities), and number of health care personnel (≥100 vs <100 health care personnel). OUTCOMES Exposures to hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV); provision of HBV and HIV postexposure prophylaxis. MEASUREMENTS We calculated the proportion of facilities reporting occupational bloodborne pathogen exposures and offering occupational exposure management services. We analyzed bloodborne pathogen exposures and provision of postexposure prophylaxis by facility type. RESULTS Nearly all respondents (99.7%) had written policies and 95% provided occupational exposure management services to health care personnel during the daytime on weekdays, but services were provided infrequently during other periods of the week. Approximately 10%-15% of facilities reported having HIV, HBV, or HCV exposures in health care personnel in the 12 months prior to the survey, but inconsistencies were noted in procedures for managing such exposures. Despite 86% of facilities providing HIV prophylaxis for exposed health care personnel, only 37% designated a primary HIV postexposure prophylaxis regimen. For-profit and free-standing facilities reported fewer exposures, but did not as reliably offer HBV prophylaxis or have a primary HIV postexposure prophylaxis regimen relative to not-for-profit and hospital-based facilities. LIMITATIONS The survey response rate was low (37%) and familiarity of individuals completing the survey with facility policies or national guidelines could not be ascertained. CONCLUSIONS Significant improvements are required in the implementation of guidelines for managing occupational exposures to bloodborne pathogens in outpatient dialysis facilities.

Routine Immunization Service Delivery Through the Basic Package of Health Services Program in Afghanistan: Gaps, Challenges, and Opportunities.

Abstract Background. The Basic Package of Health Services (BPHS) program has increased access to immunization services for children living in rural Afghanistan. However, multiple surveys have indicated persistent immunization coverage gaps. Hence, to identify gaps in implementation, an assessment of the BPHS program was undertaken, with specific focus on the routine immunization (RI) component. Methods. A cross-sectional survey was conducted in 2014 on a representative sample drawn from a sampling frame of 1858 BPHS health facilities. Basic descriptive analysis was performed, capturing general characteristics of survey respondents and assessing specific RI components, and χ2 tests were used to evaluate possible differences in service delivery by type of health facility. Results. Of 447 survey respondents, 27% were health subcenters (HSCs), 30% were basic health centers, 32% were comprehensive health centers, and 12% were district hospitals. Eighty-seven percent of all respondents offered RI services, though only 61% of HSCs did so. Compared with other facility types, HSCs were less likely to have adequate stock of vaccines, essential cold-chain equipment, or proper documentation of vaccination activities. Conclusions. There is an urgent need to address manpower and infrastructural deficits in RI service delivery through the BPHS program, especially at the HSC level.

Contribution of Contact Sampling in Increasing Sensitivity of Poliovirus Detection during a Polio Outbreak – Somalia, 2013

Background. In May 2013, a wild poliovirus type 1 (WPV1) outbreak reported in Somalia provided an opportunity to examine the contribution of testing contacts to WPV detection. Methods. We reviewed acute flaccid paralysis (AFP) case-patients and linked contacts reported in the Somalia Surveillance Database from May 9 to December 31, 2013. We restricted our analysis to AFP case-patients that had ≥3 contacts and calculated the contribution of each contact to case detection. Results. Among 546 AFP cases identified, 328 AFP cases had ≥3 contacts. Among the 328 AFP cases with ≥3 contacts, 93 WPV1 cases were detected: 58 cases (62%; 95% confidence interval [CI], 52%–72%) were detected through testing stool specimens from AFP case-patients; and 35 cases (38%; 95% CI, 28%–48%) were detected through testing stool specimens from contacts, including 19 cases (20%; 95% CI, 14%–30%) from the first contact, 11 cases (12%; 95% CI, 7%–20%) from the second contact, and 5 cases (5%; 95% CI, 2%–12%) from the third contact. Among the 103 AFP cases with ≥4 contacts, 3 (6%; 95% CI, 2%–16%) of 52 WPV1 cases were detected by testing the fourth contact. No additional WPV1 cases were detected by testing >4 contacts. Conclusions. Stool specimens from 3 to 4 contacts of persons with AFP during polio outbreaks are needed to maximize detection of WPV cases.

Strategic Response to an Outbreak of Circulating Vaccine-Derived Poliovirus Type 2 — Syria, 2017–2018

Since the 1988 inception of the Global Polio Eradication Initiative (GPEI), progress toward interruption of wild poliovirus (WPV) transmission has occurred mostly through extensive use of oral poliovirus vaccine (OPV) in mass vaccination campaigns and through routine immunization services (1,2). However, because OPV contains live, attenuated virus, it carries the rare risk for reversion to neurovirulence. In areas with very low OPV coverage, prolonged transmission of vaccine-associated viruses can lead to the emergence of vaccine-derived polioviruses (VDPVs), which can cause outbreaks of paralytic poliomyelitis. Although WPV type 2 has not been detected since 1999, and was declared eradicated in 2015,* most VDPV outbreaks have been attributable to VDPV serotype 2 (VDPV2) (3,4). After the synchronized global switch from trivalent OPV (tOPV) (containing vaccine virus types 1, 2, and 3) to bivalent OPV (bOPV) (types 1 and 3) in April 2016 (5), GPEI regards any VDPV2 emergence as a public health emergency (6,7). During May-June 2017, VDPV2 was isolated from stool specimens from two children with acute flaccid paralysis (AFP) in Deir-ez-Zor governorate, Syria. The first isolate differed from Sabin vaccine virus by 22 nucleotides in the VP1 coding region (903 nucleotides). Genetic sequence analysis linked the two cases, confirming an outbreak of circulating VDPV2 (cVDPV2). Poliovirus surveillance activities were intensified, and three rounds of vaccination campaigns, aimed at children aged <5 years, were conducted using monovalent OPV type 2 (mOPV2). During the outbreak, 74 cVDPV2 cases were identified; the most recent occurred in September 2017. Evidence indicates that enhanced surveillance measures coupled with vaccination activities using mOPV2 have interrupted cVDPV2 transmission in Syria.