Background: Since the start of the 2009 influenza A pandemic (H1N1pdm), the World Health Organization and its member states have gathered information to characterize the clinical severity of H1N1pdm infection and to assist policy makers to determine risk groups for targeted control measures. Methods and Findings: Data were collected on approximately 70,000 laboratory-confirmed hospitalized H1N1pdm patients, 9,700 patients admitted to intensive care units (ICUs), and 2,500 deaths reported between 1 April 2009 and 1 January 2010 from 19 countries or administrative regions—Argentina, Australia, Canada, Chile, China, France, Germany, Hong Kong SAR, Japan, Madagascar, Mexico, the Netherlands, New Zealand, Singapore, South Africa, Spain, Thailand, the United States, and the United Kingdom—to characterize and compare the distribution of risk factors among H1N1pdm patients at three levels of severity: hospitalizations, ICU admissions, and deaths. The median age of patients increased with severity of disease. The highest per capita risk of hospitalization was among patients ,5 y and 5–14 y (relative risk [RR] = 3.3 and 3.2, respectively, compared to the general population), whereas the highest risk of death per capita was in the age groups 50–64 y and $65 y (RR = 1.5 and 1.6, respectively, compared to the general population). Similarly, the ratio of H1N1pdm deaths to hospitalizations increased with age and was the highest in the $65-y-old age group, indicating that while infection rates have been observed to be very low in the oldest age group, risk of death in those over the age of 64 y who became infected was higher than in younger groups. The proportion of H1N1pdm patients with one or more reported chronic conditions increased with severity (median = 31.1%, 52.3%, and 61.8% of hospitalized, ICU-admitted, and fatal H1N1pdm cases, respectively). With the exception of the risk factors asthma, pregnancy, and obesity, the proportion of patients with each risk factor increased with severity level. For all levels of severity, pregnant women in their third trimester consistently accounted for the majority of the total of pregnant women. Our findings suggest that morbid obesity might be a risk factor for ICU admission and fatal outcome (RR = 36.3). Conclusions: Our results demonstrate that risk factors for severe H1N1pdm infection are similar to those for seasonal influenza, with some notable differences, such as younger age groups and obesity, and reinforce the need to identify and protect groups at highest risk of severe outcomes. Please see later in the article for the Editors’ Summary.

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Risk Factors for Severe Outcomes following 2009 Influenza A (H1N1) Infection: A Global Pooled Analysis

The acknowledged potential of using mobile phones for improving healthcare in low-resource environments of developing countries has yet to translate into significant mHealth policy investment. The low uptake of mHealth in policy agendas may stem from a lack of evidence of the scalable, sustainable impact on health indicators. The mHealth literature in low- and middle-income countries reveals a burgeoning body of knowledge; yet, existing reviews suggest that the projects yield mixed results. This article adopts a stage-based approach to understand the varied contributions to mHealth research. The heuristic of inputs-mechanism-outputs is proposed as a tool to categorize mHealth studies. This review (63 articles comprising 53 studies) reveals that mHealth studies in developing countries tend to concentrate on specific stages, principally on pilot projects that adopt a deterministic approach to technological inputs (n = 32), namely introduction and implementation. Somewhat less studied were research designs that demonstrate evidence of outputs (n = 15), such as improvements in healthcare processes and public health indicators. The review finds a lack of emphasis on studies that provide theoretical understanding (n = 6) of adoption and appropriation of technological introduction that produces measurable health outcomes. As a result, there is a lack of dominant theory, or measures of outputs relevant to making policy decisions. Future work needs to aim for establishing theoretical and measurement standards, particularly from social scientific perspectives, in collaboration with researchers from the domains of information technology and public health. Priorities should be set for investments and guidance in evaluation disseminated by the scientific community to practitioners and policymakers.

https://dr.ntu.edu.sg/bitstream/10356/102310/2/mHealth%20Adoption%20in%20Low-Resource%20Environments%20A%20Review%20of%20the%20Use%20of%20Mobile%20Healthcare%20in%20Developing%20Countries.pdf

mHealth Adoption in Low-Resource Environments: A Review of the Use of Mobile Healthcare in Developing Countries

Bacterial diversity of field-caught mosquitoes, Aedes albopictus and Aedes aegypti, from different geographic regions of Madagascar.

Parasitic infections are ubiquitous in wildlife, livestock and human populations, and healthy ecosystems are often parasite rich. Yet, their negative impacts can be extreme. Understanding how both anticipated and cryptic changes in a system might affect parasite transmission at an individual, local and global level, is critical for sustainable control in humans and livestock. Here we highlight and synthesise evidence regarding potential effects of ‘system changes’ (both climatic and anthropogenic) on parasite transmission from wild host-parasite systems. Such information could inform more efficient and sustainable parasite control programmes in domestic animals or humans. Many examples from diverse terrestrial and aquatic natural systems show how abiotic and biotic factors affected by system changes can interact additively, multiplicatively or antagonistically to influence parasite transmission, including through altered habitat structure, biodiversity, host demographics and evolution. Despite this, few studies of managed systems explicitly consider these higher-order interactions, or the subsequent effects of parasite evolution, which can conceal or exaggerate measured impacts of control actions. We call for a more integrated approach to investigating transmission dynamics, which recognizes these complexities and makes use of new technologies for data capture and monitoring, and to support robust predictions of altered parasite dynamics in a rapidly changing world.

https://royalsocietypublishing.org/doi/pdf/10.1098/rstb.2016.0088

Global change, parasite transmission and disease control: lessons from ecology

Monitoring, evaluation, and surveillance measure how well public health programs operate over time and achieve their goals. As countries approach malaria elimination, these activities will need to shift from measuring reductions in morbidity and mortality, to detecting infections (with or without symptoms) and measuring transmission. Thus, the monitoring and evaluation and surveillance research and development agenda needs to develop the tools and strategies that will replace passive surveillance of morbidity with active and prompt detection of infection, including confirmation of interruption of transmission by detecting present and past infections, particularly in mobile populations. The capacity to assess trends and respond without delay will need to be developed, so that surveillance itself becomes an intervention. Research is also needed to develop sensitive field tests that can detect low levels of parasitaemia, together with strategies for their implementation. Other areas to explore include the rigorous evaluation of the utility of more detailed maps of disease and infection incidence and prevalence, the development of new maps to inform programmatic responses and the use of surveillance technologies based on cell phone or real-time internet Web-based reporting. Because any new strategies for monitoring and evaluation and surveillance for eradication have major implications for program implementation, research is also needed to test systems of delivery for acceptability, feasibility, efficiency, cost-effectiveness, and community engagement. Finally, there is a clear need to systematically review the information from past elimination efforts for malaria and other infectious diseases.

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A research agenda for malaria eradication: monitoring, evaluation, and surveillance.

Following the outbreak of chikungunya in the Indian Ocean, the Ministry of Health directed the necessary development of an early outbreak detection system. A disease surveillance team including the Institut Pasteur in Madagascar (IPM) was organized to establish a sentinel syndromic-based surveillance system. The system, which was set up in March 2007, transmits patient data on a daily basis from the various voluntary general practitioners throughout the six provinces of the country to the IPM. We describe the challenges and steps involved in developing a sentinel surveillance system and the well-timed information it provides for improving public health decision-making. Surveillance was based on data collected from sentinel general practitioners (SGP). The SGPs report the sex, age, visit date and time, and symptoms of each new patient weekly, using forms addressed to the management team. However, the system is original in that SGPs also report data at least once a day, from Monday to Friday (number of fever cases, rapid test confirmed malaria, influenza, arboviral syndromes or diarrhoeal disease), by cellular telephone (encrypted message SMS). Information can also be validated by the management team, by mobile phone. This data transmission costs 120 ariary per day, less than US$1 per month. In 2008, the sentinel surveillance system included 13 health centers, and identified 5 outbreaks. Of the 218,849 visits to SGPs, 12.2% were related to fever syndromes. Of these 26,669 fever cases, 12.3% were related to Dengue-like fever, 11.1% to Influenza-like illness and 9.7% to malaria cases confirmed by a specific rapid diagnostic test. The sentinel surveillance system represents the first nationwide real-time-like surveillance system ever established in Madagascar. Our findings should encourage other African countries to develop their own syndromic surveillance systems. Prompt detection of an outbreak of infectious disease may lead to control measures that limit its impact and help prevent future outbreaks.

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Sentinel surveillance system for early outbreak detection in Madagascar

PROBLEM: The revision of the International Health Regulations (IHR) and the threat of influenza pandemics and other disease outbreaks with a major impact on developing countries have prompted bolstered surveillance capacity, particularly in low-resource settings. APPROACH: Surveillance tools with well-timed, validated data are necessary to strengthen disease surveillance. In 2007 Madagascar implemented a sentinel surveillance system for influenza-like illness (ILI) based on data collected from sentinel general practitioners. SETTING: Before 2007, Madagascar's disease surveillance was based on the passive collection and reporting of data aggregated weekly or monthly. The system did not allow for the early identification of outbreaks or unexpected increases in disease incidence. RELEVANT CHANGES: An innovative case reporting system based on the use of cell phones was launched in March 2007. Encrypted short message service, which costs less than 2 United States dollars per month per health centre, is now being used by sentinel general practitioners for the daily reporting of cases of fever and ILI seen in their practices. To validate the daily data, practitioners also report epidemiological and clinical data (e.g. new febrile patient's sex, age, visit date, symptoms) weekly to the epidemiologists on the research team using special patient forms. LESSONS LEARNT: Madagascar's sentinel ILI surveillance system represents the country's first nationwide "real-time" surveillance system. It has proved the feasibility of improving disease surveillance capacity through innovative systems despite resource constraints. This type of syndromic surveillance can detect unexpected increases in the incidence of ILI and other syndromic illnesses.

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Robinson Ramanjato

Papers

Sentinel surveillance system for early outbreak detection in Madagascar

Short message service sentinel surveillance of influenza-like illness in Madagascar, 2008-2012