A growing global network's role in outbreak response: AFHSC-GEIS 2008-2009

A cornerstone of effective disease surveillance programs comprises the early identification of infectious threats and the subsequent rapid response to prevent further spread. Effectively identifying, tracking and responding to these threats is often difficult and requires international cooperation due to the rapidity with which diseases cross national borders and spread throughout the global community as a result of travel and migration by humans and animals. From Oct.1, 2008 to Sept. 30, 2009, the United States Department of Defense's (DoD) Armed Forces Health Surveillance Center Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) identified 76 outbreaks in 53 countries. Emerging infectious disease outbreaks were identified by the global network and included a wide spectrum of support activities in collaboration with host country partners, several of which were in direct support of the World Health Organization's (WHO) International Health Regulations (IHR) (2005). The network also supported military forces around the world affected by the novel influenza A/H1N1 pandemic of 2009. With IHR (2005) as the guiding framework for action, the AFHSC-GEIS network of international partners and overseas research laboratories continues to develop into a far-reaching system for identifying, analyzing and responding to emerging disease threats.     

Mass Measles Rubella Immunization Campaign: Bhutan Experience

Background:

Bhutan has attained universal child immunization since 1991. Since then, immunization coverage is maintained at high level through routine immunization, periodic National Immunization Days, and mop up campaigns. Despite high immunization coverage, every year, significant numbers of clinically suspected measles cases were reported.

Objective:

To assess the cause of continuing high “suspected measles cases” and take appropriate public health measures.

Materials and Methods:

Febrile rash outbreaks occurred in several districts in 2003. These episodes were investigated. Simultaneously, a retrospective data search revealed evidence of congenital rubella syndrome (CRS) in the country.

Results:

Thirty five percent of the tested samples were positive for rubella but none for measles. There were evidences of the presence of CRS. This was discussed in the annual health conference 2004, amongst health policy makers and district heads who recommended that a possibility of inclusion of rubella as an antigen be looked into. A nationwide measles and rubella immunization campaign was conducted in 2006 followed by introduction of rubella vaccine in the immunization schedule.

Conclusion:

Febrile rash can be caused by a host of viral infections. Following universal measles immunization, it is pertinent that febrile rash be looked in the light of rubella infections. Following the introduction of rubella vaccination in the national immunization schedule, there has been significant reduction of febrile rash episodes, cases of rubella, and congenital rubella syndrome.     

Emergency Contraceptive Pills (ECP) Knowledge,Attitudes, and Practices Among Women Working in the Entertainment Industry and Men in the Trucking Industry,Bhutan

Emergency contraceptive pills (ECP) were recently made available over the counter in Bhutan. We evaluated knowledge, attitudes, and practices concerning ECP in 2 populations at risk for HIV and STI (sexually transmitted infections): entertainment women (drayang) and male truck drivers and helpers (truckers). Of 179 drayang and 437 truckers intercepted at venues, 73.7 and 21.1%, respectively, had heard of ECP; 47.0% of drayang had used them. Their concerns about ECP use included harm to the body, impact on future pregnancy, side effects, and HIV/STI risk. Education programs are needed in Bhutan to increase awareness of ECP for unplanned pregnancy and condoms to prevent HIV and STI.     

Vascular anastomoses in dichorionic diamniotic-fused placentas.

A case of fetal twin-to-twin cytomegalovirus infection through a dichorionic diamniotic (DiDi)-fused placenta prompted our search for possible vascular anastomoses in this type of placenta. This case and three additional DiDi-fused placentas were studied with gross (macro) sections and a three-dimensional (3D) stereomicroscopic technique. Two twins were dizygotic (they differed in gender and blood groups) and the other two were probably monozygotic. Macrosections and 3D-image analysis demonstrated side-to-side connections between small subchorionic vessels. These findings demonstrate that vascular anastomoses are present in DiDi-fused placentas.     

Scrub typhus in pregnancy presenting with permanent hearing loss: A case report

As clinicians, we need to be vigilant about these rare and atypical presentations given the endemic nature of scrub typhus in southern belt of the country. Timely diagnosis and appropriate treatment is the key aspect to prevent further complications.     

Beyond Standard Practice in Liquid Biopsy: Selective Venous Sampling

Liquid biopsy is a molecular diagnostic procedure that aims to provide readily accessible genetic profiling of tumors for primary diagnosis, detection of minimal residual or metastatic disease, and therapeutic decision-making, especially for molecularly targeted treatments. Cancers release various biological markers into the circulation, although the most widely used are cell-free tumor DNA and circulating tumor cells. The paucity of biological material means that laboratory methods mainly based on genetic sequencing expose this innovative diagnostic method to a considerable incidence of false negatives. The 3 cases presented here show how the sensitivity and specificity of liquid biopsy may be improved through selective venous sampling.     

Prevalence and mechanisms of quinolone resistance among selected nontyphoid Salmonella isolated from food animals and humans in Korea

The aim of this study was to investigate the prevalence and mechanism of quinolone resistance among selected nontyphoid Salmonella (NTS) isolates. A total of 1279 NTS isolated from food animals (n=692) and humans (n=587) between 1995 and 2009 were investigated by serotyping, antimicrobial susceptibility testing, screening for plasmid-mediated quinolone resistance (PMQR) genes qnr, aac(6')-Ib-cr, and qepA and mutations in the quinolone resistance-determining region (QRDR) of gyrA and parC by PCR, and DNA sequencing. Three hundred thirty (47.7%) of 692 animal isolates and 177 (30.2%) of 587 human isolates were resistant to nalidixic acid. Most animal (94.8%, 313/330) and human (99.4%, 176/177) NTS exhibited decreased ciprofloxacin susceptibility (minimum inhibitory concentration [MIC]: 0.125-2?mg/L). None of them carried qnr or qepA gene. However, aac(6')-Ib was identified in six animal isolates, of which four carried aac(6')-Ib-cr gene. Based on antimicrobial resistance profile, year of isolation, MIC for quinolones and fluoroquinolones, and isolation frequency of serotype, 114 animal and 83 human isolates were tested for QRDR mutations. All contained a single mutation within the QRDR of gyrA at either codon 87 or 83, and 41 of them contained an additional mutation in parC. The most prevalent mutation was Asp87-Tyr (n=107), followed by Asp87-Gly (n=28), Asp87-Asn (n=26), Ser83-Tyr (n=22), and Ser83-Phe (n=14). Point mutations in parC were observed outside the QRDR, which included 40 isolates with Thr57-Ser substitution and 1 Salmonella Typhimurium with a novel Glu51-Lys substitution. In conclusion, a point mutation within the QRDR of gyrA was primarily responsible for quinolone resistance and reduced susceptibility to fluoroquinolones in NTS in Korea. To our knowledge, this is the first report of occurrence of aac(6')-Ib-cr gene among NTS in Korea. The spread of NTS carrying aac(6')-Ib-cr is of serious concern and should be carefully monitored.     

Rabies virus strains circulating in Bhutan: implications for control

We report a molecular epidemiological study of rabies virus (RABV) strains circulating in animal populations in Bhutan, and investigate potential origins of these viruses. Twenty-three RABV isolates originating from dogs and other domestic animals were characterized by sequencing the partial nucleoprotein (N) gene (395 bp). Phylogenetic analysis was conducted and the Bhutanese isolates were compared with rabies viruses originating from other parts of the world. Phylogenetic analysis showed that Bhutanese isolates were highly similar and were closely related to Indian strains and South Asian Arctic-like-1 viruses. Our study suggests that the rabies viruses spreading in southern parts of Bhutan have originated from a common ancestor, perhaps from the Indian virus strain.