Modellings of Infectious Diseases and Cancers under Wars and Pollution Impacts in Iraq with Reference to a Novel Mathematical Model and Literature Review

Microbial pathogens include bacteria, viruses, fungi, and parasites and together account for a significant percentage of acute and chronic human diseases. In addition to understanding the mechanisms by which various pathogens cause human disease, research in microbial pathogenesis also addresses mechanisms of antimicrobial resistance and the development of new antimicrobial agents and vaccines. Answering fundamental questions regarding host-microbe interactions requires an interdisciplinary approach, including microbiology, genomics, informatics, molecular and cellular biology, biochemistry, immunology, epidemiology, environment and interaction between host and microbe. Studies investigating the direct effects of pollutants on respiratory tract infections are very vast, but those interested in the role of a pre-existing disease and effects of the exposure on the response to secondary stresses are few. In an experimental study at concentrations of air pollutants found in urban environments, frank toxicological responses are rarely observed, however, exposure to secondary stress like the respiratory challenge with infectious bacteria can exacerbate the response of the experimental host. The models like experimental, mechanical, and mathematical are the most abstract, but they allow analysis and logical proofs in a way that other approaches do not permit. The present review is mostly concerned with these model representations particularly with a novel mathematical model explaining the interaction between pathogen and immunity including the equivalence point.

Fear can be more harmful than the severe acute respiratory syndrome coronavirus 2 in controlling the corona virus disease 2019 epidemic

The current corona virus disease 2019 outbreak caused by severe acute respiratory syndrome coronavirus 2 started in Wuhan,China in December 2019 and has put the world on alert.To safeguard Chinese citizens and to strengthen global health security,China has made great efforts to control the epidemic.Many in the global community have joined China to limit the epidemic.However,discrimination and prejudice driven by fear or misinformation have been flowing globally,superseding evidence and jeopardizing the anti-severe acute respiratory syndrome coronavirus 2 efforts.We analyze this phenomenon and its underlying causes and suggest practical solutions.

Nursing ethics for prevention and control of major infectious disease outbreaks:Chinese expert consensus

Background Major infectious disease has become a serious threat to people’s health worldwide.As the world’s largest healthcare workforce and the core forces fighting against the epidemic,nurses are on the frontline of this battle.A number of ethical issues have given rise to numerous concerns that have largely affected nurses in different ways as they respond to the epidemic.In addition,excessive expectations from people can exert undue pressure,which can easily lead to burnout in nurses.Methods In this consensus,the expert panel method was used to develop and reach a consensus.The members involved in the formation of the consensus included an expert discussion panel and a consensus writing expert group,a methodologist,and four secretaries.After 16 rounds of online expert consultation and two rounds of expert panel meetings,the writing team analyzed and reviewed the 78 amendments suggested by the experts to develop a consensus on nursing ethics for prevention and control of major infectious disease outbreaks based on the ethical vision of life care.Results This expert consensus focuses on five essential domains:the responsibilities and rights of nurses,the nurse-patient relationship,the doctor-nurse relationship,and the relationship between society and nurses throughout the epidemic.Conclusions We hope this consensus can help nurses better understand and respond to the ethical issues and challenges in public health emergencies,and raise reasonable public expectations of the roles and responsibilities of nurses in these situations.

The difficulties of early detection for infectious disease outbreak in China:A qualitative investigation

Objective： To make intensified analysis upon the existing difficulties in early detection for the infectious diseases outbreak in China and put forward some effective measures to improve it. Methods： Field investigation and in-depth interview were applied in 23 interviewees from different-level CDC. Results：The study findings suggest that although the timeliness of outbreak detection has been improved since SARS epidemic in China, some problems still exist, such as： ① lacking syndrome surveillance; ② report quality of infectious disease should be improved; ③ difficulties of identifying the cases at lower social economic status; ④a definite financial compensation mechanism for the operation of web-based report system is absent; ⑤insufficient information exchange among different branches. Conclusion：Some effective measures must be taken including developing syndrome surveillance system; affording more education and txaining for related staff; increasing payout on surveillance and establishing an information exchange platform for early detection of disease outbreak.

Measles outbreaks in the Kyeongin area of the Republic of Korea,2013-2014:A single-center experience in a country of measles elimination

Objective: To identify the source of infection and determine the clinical features and laboratory finding of measles infection,Methods: In 27 measles patients,except for 3 adult patients,the rest of 24 pediatric measles cases were analyzed with regard to age,sex,immunization status,transmission routes and molecular genotyping of measles virus,Eighteen measles patients who admitted in isolation ward were set apart to investigate clinical findings and its correlation with laboratory characteristics,Retrospective analysis of cases was conducted in this study,Results: Of the 24 pediatric patients,23(95.8%) had not received any measles-containing vaccine(MCV),Sixteen of the patients(66.7%) were aged <12 months,The suspicious index case of a girl aged 34 months was not vaccinated with MCV1 and got measles after a trip to Philippines,and molecular genotype was revealed as B3,Measles outbreaks in the community such as a restaurant were followed by this one imported case,According to analysis of 18 patients admitted in isolation ward,the median level of C-reactive protein(CRP) was 0.38 mg/d L and that of lactate dehydrogenase(LDH) was 1 200 IU/L,All of the 18 patients had LDH levels above the normal range,Age correlated with CRP(ρ = 0.528,P = 0.024) and LDH(ρ = 0.501,P = 0.034),The duration of fever was correlated with the duration of fever before rash(ρ = 0.898,P < 0.01),The duration of hospitalization was correlated with CRP(ρ = 0.586,P = 0.011),The white blood cell counts were correlated with the levels of LDH(ρ = 0.505,P = 0.033),aspartate aminotransferase(ρ = 0.507,P = 0.032),and alanine aminotransferase(ρ = 0.481,P = 0.043),Conclusions: Early weaning of maternally derived measles antibodies therefore vaccination of MCV1 at a young age from 9 months to 12 months should be considered in situations of early exposure,Furthermore there is a call for consideration of scheduling an earlier age for the first dose of MMR vaccine in Europe,It is necessary for Korea to investigate the duration of the presence and quantitative analysis of maternal measles antibodies in infants and to reconsider the timing of MCV1.

Epidemic Outbreaks in Plovdiv Region (Bulgaria) of Vaccine-Preventable Diseases: Measles, Mumps, Hepatitis A

Aim: To analyze the reasons for epidemic outbreaks of measles, mumps and viral hepatitis A and to propose measures to prevent them in future. Materials and methods: Тhe incidence of measles, mumps and hepatitis A in Plovdiv region was studied for the period 2006-2010. An analysis of the age structure of the patients was made, while taking into account the time for routine immunization performed against measles and mumps (first and second dose). Results: In 2006-2009 single cases of measles were found occasionally, but in 2010 they were 2787 (incidence 395/100,000). Most of them (51%) were for ages 13 months-12years, 27%-0-13 months and 11%-13 to 18 years. The incidence of mumps for 2006-2010 varied widely, and has increased significantly in 2007 (130/100,000) and 2008 (169/100,000). The majority of patients (over 34%) during the epidemics were aged 13 months-12years, and over 26% of them-13-19 years. For the period 2006-2010 the incidence of hepatitis A ranged from 2.98/100, 000 (2009) to 426/100,000 (2006). Over 50% of the cases involved children aged up to 9 years. For the three diseases over 80% of patients were individuals of Roma origin. Conclusions: 1. Epidemic spread of measles in 2010 was mainly due to shortcomings in the routine immunization carried as a prevention of the disease. 2. There are two reasons for the outbreak of mumps: А) Failure to administer the second vaccine dose at 12 years in Bulgaria until 2001. B) Shortcomings in routinely performed immunization. 3. The extremely high incidence of hepatitis A in 2006 (and in the rest of the years) is due to the lack of routine immunization. 4. Essential for the outbreaks in all three diseases are the poor hygienic living conditions, the low social status and the lack of health promotion of the population at risk 5. To prevent future outbreaks of the diseases hereby in question, we suggest it is appropriate: А) To introduce compulsory immunization against hepatitis A;B) To carry out periodic catch-up vaccination campaigns against measles and mumps.

Epidemiological Descriptive Analysis of Disease Outbreaks in 2019 in Sudan

Background: Sudan has often faced outbreaks of malaria, the life-threatening waterborne disease. In 2019, the country experienced an outbreak of six different infectious diseases, i.e., cholera, chikungunya, dengue fever, diphtheria, malaria, and Rift Valley fever. Objectives: The aim of this study was to perform an epidemiological descriptive analysis of data of these disease outbreaks to determine the spatial and temporal patterns of outbreaks and to estimate the magnitude of the diseases. Methods: The data consisted of the number of cases and deaths due to disease outbreaks of cholera, chikungunya, dengue fever, diphtheria, malaria, and Rift Valley fever. We analyzed the reports of an investigation conducted by the World Health Organization and the Federal Ministry of Health, Sudan. Descriptive statistics and case fatality rate (CFR) were used in this study. Results: The frequency of disease occurrence was as follows: cholera (344 cases), chikungunya (308 cases), dengue fever (4236 cases), diphtheria (105 cases), malaria (5,188,135 cases) and River Valley fever (567 cases). The CFRs for cholera, chikungunya, are diphtheria were 4.3%, 2.05%, and 9.5%, respectively. The mortality rate of malaria was 0.0013. The states most affected by outbreaks of these diseases in Sudan were the western states. Women were at a higher risk for all diseases, except River Valley fever. Conclusions: This study highlights the patterns of the outbreak of these diseases in Sudan and provides a basis for future scientific research.

Ebola virus disease: From epidemiology to prophylaxis

The outbreak of Ebola virus disease(EVD) continues to spread through West Africa. Since the first reported EVD in March 2014, the number of cases has increased rapidly, with the fatality rate of >50%. The most prevalent Ebola virus belongs to the species of Zaire ebolavirus, with a mortality rate as high as 90%. Although there were introduced cases in other continents, Africa is the endemic area where fruit bats and apes are suspected to be Ebola virus carriers. The virus might be transmitted from the host animals to humans if humans consume relative raw and contaminated meats; however, human-to-human transmission via close contact is the major route of current outbreaks. EVD happens at any seasons and affected people of any race in any age groups. Direct contact with body fluids of EVD patients and living in the contaminated environment greatly increase the risk of being infected. Transmission viaaerosol is less possible but the transmission via droplet is possible in humans. Thus, health care providers are facing danger of getting Ebola virus infection. So far, there are limited vaccines, drugs and/or therapies to prevent Ebola virus infection or treat EVD. Medical workers should follow the current standard prophylactic procedures. Military forces can orchestrate efficient care to mass EVD casualties. Although it is necessary to speed up the pace of developing effective vaccine and therapeutics for the prevention and treatment of EVD, public health prophylaxis is the most important issue at present to control the spread of this disease cost-effectively.

Emergency management of nursing human resources and supplies to respond to coronavirus disease 2019 epidemic

Objective:To introduce the emergency management of nursing human resources and supplies of a large general hospital when facing the outbreak of coronavirus disease 2019(COVID-19).Method:The Nursing Department of the hospital fully executed its functional authority to establish a three-level echelon of sustainable support,allocate human recourses dynamically,organize pre-service training,supervise the key working steps,formulate positive incentive methods,and deploy medical supplies scientifically.Result:By taking these strategies,the hospital effectively improved the coping capacity of the nursing team and played a positive role in the prevention and treatment of COVID-19.Conclusion:The emergency management of nursing human resources and material resources for COVID-19 of the hospital is successful.But several deficiencies were identified as well,which indicated that the hospital needs to establish an efficient emergency management system,and pay attention to the practice of nursing emergency plans to enhance coping capacities in public health emergencies.

Viral outbreaks and communicable health hazards due to devastating floods in Pakistan

Pakistan is a developing country that has a population of 190 million people and faces a huge burden of viral diseases. Every year during monsoon season heavy rain fall and lack of disaster management skills potentially increase the transmission of waterborne diseases, vector borne diseases and viral outbreaks. Due to severe flooding, thousands of people lose their lives and millions are displaced each year. In most of the cases the children who lose their family members are forced into illegal professions of begging, child labor and prostitution which make them prone to sexually transmitted infections. Up to date, no scientific study has been conducted nationwide to illustrate epidemiological patterns of waterborne diseases, vector borne diseases and viral epidemics during flash flood. Mosquito sprays would not be a sufficient approach for dengue eradication; mass awareness, larvicide and biological control by Guppy fishes are also effective strategies to overcome dengue problem. International health bodies and non-governmental organizations must take note of this alerting situation and take adequate steps such as financial/medical aid in order to defeat the after-effects of flood.

Patterns of biomass,carbon,and nitrogen storage distribution dynamics after the invasion of pine forests by Bursaphelenchus xylophilus (Nematoda: Aphelenchoididae) in the three Gorges Reservoir Region

Masson pine stands infected by Pine wilt disease(PWD) in the Three Gorges Reservoir Region of central China were surveyed to quantify the immediate responses and subsequent trajectories of biomass,carbon(C),and nitrogen(N) in stand-level major ecosystem compartments.The biomasses of above-and belowground tree components,as well as of the understory,forest floor,and mineral soil(0–40 cm),were determined within each stand.C and N storage were also estimated for each ecosystem compartment.Overstory biomass decreased steadily with the extent of PWD infection.Understory biomass ranged from1.97 to 4.16 Mg ha,and the observed value for forest floor biomass was 12.89–22.59 Mg ha.The highest mean C and N concentrations were found in the stem bark and needles of Masson pine,respectively,while the lowest were found in the semi-to fully decomposed layer of the forest floor and stem wood of Masson pine,respectively.The C and N storage of aboveground trees,tree roots,and the aboveground ecosystem decreased with the extent ofPWD infection.However,the C and N contents of the understory,forest floor,and total mineral soil initially declined after PWD infection before recovering over the following several years.Those result concluded that the biomass,C,and N storage of different forest ecosystem compartments have experienced certain variations following the PWD epidemic.This is vital to understand the shifts in stand-level C and N allocation in PWD-damaged forest stands,as well as for predicting the responses of regional and global C and N cycling.

A reflection on the anti-epidemic response of COVID-19 from the perspective of disaster management

The outbreak of coronavirus disease 2019(COVID-19)shocked the world as it spread rapidly from continent to continent,and finally,it became a pandemic resulting in many infected patients,with an increasing number of deaths,and a devastating effect on worldwide economics.People only know that epidemic or pandemic is a rapid spread of infection,but in fact it can also be regarded as a biological disaster,which can be managed from a perspective of disaster management.This article discusses the current situation of the anti-epidemic response of COVID-19,and suggests using a disaster management approach to better handle this pandemic situation through mitigation,preparedness,response and recovery.

Providing Infectious Disease Information to Child-Rearing Families and Its Evaluation

Background: Earlier study without actual trial indicated that caregivers needed delivery of information about outbreak situations independently of their job status. This report describes, for about two months in winter, actual delivery outbreak information to families with preschool children. The study objective was to confirm the usefulness of this information delivery. Method: Participants receiving outbreak information were recruited from the Child Care Support Service in a ward in Tokyo, Japan. Outbreak information was obtained from the Nursery School Absenteeism Surveillance System (NSASSy) covering approximately 40% of all nursery schools in Japan, prescription surveillance and other resources. Delivery of outbreak information started in December 2017 and ceased at the end of February in 2018. After the delivery period, a questionnaire survey was administered to participants. Results: For this area, NSASSy showed the most dominant disease was influenza, with 707 patients, followed by group A streptococcal pharyngitis with 98 patients. The outbreak peak was inferred to be as Monday, 22 January, and it was announced by e-mail on 23 January. Of the 202 persons joined this trial, 60 participants responded to the questionnaire survey after the delivery period. Of those respondents, 98% wanted delivery of that information to continue. Conclusion: We found that almost all respondents confirmed usefulness of the information about infectious diseases which was delivered.

‘Outbreak Gold Standard’Selection to Provide Optimized Threshold for Infectious Diseases Early-alert Based on China Infectious Disease Automated-alert and Response System

The China Infectious Disease Automated-alert and Response System（CIDARS） was successfully implemented and became operational nationwide in 2008. The CIDARS plays an important role in and has been integrated into the routine outbreak monitoring efforts of the Center for Disease Control（CDC） at all levels in China. In the CIDARS, thresholds are determined using the ？Mean＋2SD？ in the early stage which have limitations. This study compared the performance of optimized thresholds defined using the ？Mean ＋2SD？ method to the performance of 5 novel algorithms to select optimal ？Outbreak Gold Standard（OGS）？ and corresponding thresholds for outbreak detection. Data for infectious disease were organized by calendar week and year. The ？Mean＋2 SD？, C1, C2, moving average（MA）, seasonal model（SM）, and cumulative sum（CUSUM） algorithms were applied. Outbreak signals for the predicted value（Px） were calculated using a percentile-based moving window. When the outbreak signals generated by an algorithm were in line with a Px generated outbreak signal for each week, this Px was then defined as the optimized threshold for that algorithm. In this study, six infectious diseases were selected and classified into TYPE A（chickenpox and mumps）, TYPE B（influenza and rubella） and TYPE C [hand foot and mouth disease（HFMD） and scarlet fever]. Optimized thresholds for chickenpox（P_（55））, mumps（P_（50））, influenza（P_（40）, P_（55）, and P_（75））, rubella（P_（45） and P_（75））, HFMD（P_（65） and P_（70））, and scarlet fever（P_（75） and P_（80）） were identified. The C1, C2, CUSUM, SM, and MA algorithms were appropriate for TYPE A. All 6 algorithms were appropriate for TYPE B. C1 and CUSUM algorithms were appropriate for TYPE C. It is critical to incorporate more flexible algorithms as OGS into the CIDRAS and to identify the proper OGS and corresponding recommended optimized threshold by different infectious disease types.

Does Family with Children Need Information about Infectious Disease?

This paper reports a study of the necessity of providing information that is of the most concern of caregivers: health management, responses to sudden onset, and outbreaks of infectious diseases. We asked users and providers of Child Care Support Service in ward A of Tokyo, as respondents, whether they would like to receive information related to infectious diseases. Of questionnaires sent by mail to 383 providers and 3101 users, we received 18 responses from providers and 88 responses from users. All providers and users were required to provide information related to infectious diseases. The most often reported responses were “straight-out hand washing, mask wearing, gargling, and disinfection”, followed by “voluntary restraint of outside activities”, and “measures for illnesses of the family or children.” Results show that caregivers would like to receive information about infectious diseases because they have many health management concerns about their children.

Prevalence and intensity of soil-transmitted helminth infections among school-age children in the Cagayan Valley, the Philippines

Objective:To identify the prevalence of soil-transmitted helminthiasis(STH)among school-age children in the Cagayan Valley,the Philippines,assess their level of awareness on the disease,and determine predisposing factors of the disease.Methods:A total of 478 GradesⅢ-Ⅴschool-age children in Pamplona and Sanchez-Mira School Districts in the Cagayan Valley answered the questionnaire assessing their knowledge,attitude,and practices on STH,subjected to anthropometric measurements,and provided faecal samples for parasitologic assessment(direct smear,Kato-Katz,and formol-ether concentration techniques).Results:The participants of the study,with 55.86%females,were 8 to 14 years old.Their nutritional status was assessed‘normal’(84.31%),‘severely wasted’(6.49%),‘wasted’(5.23%),‘overweight’(2.72%),and‘obese’(1.26%).The prevalence of infection with at least 1 STH species was 25.99%in Pamplona and 19.40%in SanchezMira.Overall,the prevalence of heavy intensity was 7.11%for Ascaris lumbricoides and 1.67%for Trichuris trichiura.All hookworm infections had light intensities.The majority of the school-age children had a low score in the KAP test.In knowledge of STH,‘stunted growth as a symptom of infection’was associated with a lower risk of Ascaris lumbricoides infection(OR 0.448;95%CI 0.212,0.945;P=0.035)while‘playing with soil as a mode of transmission’was associated with an increased risk of Ascaris lumbricoides infection(OR 2.067;95%CI 1.014,4.212;P=0.046).In attitude towards STH,‘I think I have intestinal worm now’was associated with a higher risk of Ascaris lumbricoides infection(OR 1.681;95%CI 1.061,2.662;P=0.027).Conclusions:The prevalence rate of Ascaris lumbricoides among the school-age children in the Cagayan Valley shows the need to further intensify intervention in the area to meet the threshold set by the World Health Organization.The identified predictors of infection,which concerns the school-age children’s knowledge and attitude toward STH,can be used in augmenting intervention programs in the future.

Other Possible Causes of a Well-Publicized Outbreak of <i>Pseudomonas aeruginosa</i>Following Arthroscopy in Texas

Background: Seven patients at a hospital in Houston, TX, were diagnosed during a two-week period in 2009 with joint space infection of pansusceptible P. aeruginosa following arthroscopic procedures of the knee or shoulder. Tosh et al. (2011), who investigated and published the principal report discussing this bacterial outbreak, conclude that its most likely cause was the improper reprocessing of certain reusable, physically-complex, heat-stable arthroscopic instruments used during these arthroscopic procedures. These reusable instruments reportedly remained contaminated with remnant tissue, despite diligent efforts by the hospital to clean their internal structures. This retained bioburden presumably shielded the outbreak’s strain of embedded P. aeruginosa from contact with the pressurized steam, reportedly resulting in ineffective sterilization of these arthroscopic instruments and bacterial transmission. Objectives: First, to clarify which specific sterilization methods, in addition to steam sterilization, Methodist Hospital employed to process its reusable arthroscopic instrumentation at the time of its outbreak, in 2009;second, to evaluate Tosh et al.’s (2011) conclusion that ineffective steam sterilization due to inadequate cleaning was the most likely cause of this hospital’s outbreak;third, to consider whether any other hitherto unrecognized factors could have plausibly contributed to this outbreak;and, fourth, to assess whether any additional recommendations might be warranted to prevent disease transmission following arthroscopic procedures. Methods: The medical literature was reviewed;some of the principles of quality assurance, engineering and a root-cause analysis were employed;and Tosh et al.’s (2011) findings and conclusions were reviewed and compared with those of other published reports that evaluated the risk of disease transmission associated with the steam sterilization of physically-complex, heat-stable, soiled surgical instruments. Results and Conclusion: Reports documenting outbreaks of P. aeruginosa or another vegetative bacterium associated with the steam sterilization of inadequately cleaned surgical or arthroscopic instruments are scant. This finding—coupled with a number of published studies demonstrating the effective steam sterilization of complex instruments contaminated with vegetative bacteria mixed with organic debris, or, in one published series of tests, with resistant bacterial endospores coated with hydraulic fluid—raises for discussion whether Methodist Hospital’s outbreak might have been due to one or more factors other than, or in addition to, that which Tosh et al. (2011) conclude was its most likely cause. An example of such a factor not ruled out by Tosh et al. (2011) findings would be the re-contamination of the implicated arthroscopic instruments after sterilization. The specific methods that Methodist Hospital employed at the time of its outbreak to sterilize some of its arthroscopic instrumentation remain unclear. A number of additional recommendations are provided to prevent disease transmission following arthroscopic procedures.

Establishment of an early warning system for cutaneous leishmaniasis in Fars province, Iran

Objective:To establish an early warning system for cutaneous leishmaniasis in Fars province,Iran in 2016.Methods:Time-series data were recorded from 29 201 cutaneous leishmaniasis cases in 25 cities of Fars province from 2010 to 2015 and were used to fit and predict the cases using time-series models.Different models were compared via Akaike information criterion/Bayesian information criterion statistics,residual analysis,autocorrelation function,and partial autocorrelation function sample/model.To decide on an outbreak,four endemic scores were evaluated including mean,median,mean+ 2 standard deviations,and median+ interquartile range of the past five years.Patients whose symptoms of cutaneous leishmaniasis began from 1 January 2010 to 31 December 2015 were included,and there were no exclusion criteria.Results:Regarding four statistically significant endemic values,four different cutaneous leishmaniasis space-time outbreaks were detected in 2016.The accuracy of all four endemic values was statistically significant(P<0.05).Conclusions:This study presents a protocol to set early warning systems regarding time and space features of cutaneous leishmaniasis in four steps:(i)to define endemic values based on which we could verify if there is an outbreak,(ii)to set different time-series models to forecast cutaneous leishmaniasis in future,(iii)to compare the forecasts with endemic values and decide on space-time outbreaks,and(iv)to set an alarm to health managers.

Clostridium difficile infection in the community:Are proton pump inhibitors to blame?

Once a nosocomial disease,Clostridium difficile infection(CDI)now appears frequently in the community in the absence of exposure to antibiotics.Prior studies have shown that patients with community-acquired CDI are younger,more likely to be female,and have fewer comorbidities compared to patients with hospital-associated CDI.Because most studies of CDI are hospitalbased,comparatively little is known about communityacquired CDI.The recent study by Chitnis has received widespread attention because it used active surveillance to capture all cases of community-acquired CDI within a large population and assessed key risk factors.The authors found that low-level healthcare exposure and proton pump inhibitor use were common among those with non-antibiotics associated,community-acquired CDI.In this commentary,we discuss the changing epidemiology of community-acquired CDI and the evidence basis for the controversial association between proton pump inhibitors and community-acquired CDI.

Modelling Pathways for Outbreaks in Field Occupational Epidemiology

Background: The investigation of an occupational outbreak, once the index case has been identified, triggers a stress situation to epidemiologists. Modelling occupational outbreaks will be useful to guide the field investigation. Objective: To identify standard pathways for occupational epidemic outbreaks. Methods: In-depth critical appraisal of 57 occupational outbreaks. Standard pathways of occupational outbreaks were identified by analysing the similarity between out-breaks. The model’s accuracy and homogeneity were established through Fisher’s exact test and the Kappa Index. Results: The analysis allowed synthesizing the occupational outbreaks variability in 4 pathways. 92.98% of the analysed outbreaks could be allocated to one of those 4 types. The theoretical patterns showed a good adjustment with the analysed out-breaks: Type I (Kappa = 0.94 - 0.60), Type II (Kappa = 1.00), Type III (Kappa = 1.00 - 0.68) and Type IV (Kappa = 0.94 - 0.87). The probability of a given outbreak fitting with its three components in any of the theoretical pathways was 0.83. Conclusions: The incorporation of those pathways to the field occupational epidemiology will allow: 1) to provide early guidance to epidemiological, clinical and environmental studies focused on specific hypothesis of causality;2) to anticipate preventive measures;3) to contribute to an earlier and more efficient outbreak resolution.