How prepared are we for cross-border outbreaks? An exploratory analysis of cross-border response networks for outbreaks of multidrug resistant microorganisms in the Netherlands and Germany.
ABSTRACT: BACKGROUND:The emergence and spread of multidrug resistant microorganisms is a serious threat to transnational public health. Therefore, it is vital that cross-border outbreak response systems are constantly prepared for fast, rigorous, and efficient response. This research aims to improve transnational collaboration by identifying, visualizing, and exploring two cross-border response networks that are likely to unfold during outbreaks involving the Netherlands and Germany. METHODS:Quantitative methods were used to explore response networks during a cross-border outbreak of carbapenem resistant Enterobacteriaceae in healthcare settings. Eighty-six Dutch and German health professionals reflected on a fictive but realistic outbreak scenario (response rate ? 70%). Data were collected regarding collaborative relationships between stakeholders during outbreak response, prior working relationships, and trust in the networks. Network analysis techniques were used to analyze the networks on the network level (density, centralization, clique structures, and similarity of tie constellations between two networks) and node level (brokerage measures and degree centrality). RESULTS:Although stakeholders mainly collaborate with stakeholders belonging to the same country, transnational collaboration is present in a centralized manner. Integration of the network is reached, since several actors are beneficially positioned to coordinate transnational collaboration. However, levels of trust are moderately low and prior-existing cross-border working relationships are sparse. CONCLUSION:Given the explored network characteristics, we conclude that the system has a promising basis to achieve effective coordination. However, future research has to determine what kind of network governance form might be most effective and efficient in coordinating the necessary cross-border response activity. Furthermore, networks identified in this study are not only crucial in times of outbreak containment, but should also be fostered in times of non-crisis.
Project description:The Mekong Basin Disease Surveillance cooperation (MBDS) is one of several sub-regional disease surveillance networks that have emerged in recent years as an approach to transnational cooperation for infectious disease prevention and control. Since 2003 MBDS has pioneered a unique model for local cross-border cooperation. This study examines stakeholders' perspectives of these MBDS experiences, based on a survey of local managers and semi-structured interviews with MBDS leaders and the central coordinator.Fifteen managers from 12 of 20 paired cross-border sites completed a written survey. They all monitor most or all of the 17 diseases agreed upon for MBDS surveillance information sharing. Fourteen agreed or strongly agreed with statements about the core MBDS values of cooperation, mutual trust, and transparency, and their own contributions to national and regional disease control (average score of 4.4 of 5.0). Respondents felt they implemented well to very well activities related to surveillance reporting (average scores 3.4 to 3.9 of 4.0), using computers for their work (3.9/4.0), and using surveillance data for action (3.8/4.0). Respondents reported that they did worst in implementing research (2.1/4.0) and somewhat poorly for local laboratory testing (2.9/4.0) and local coordination with cross-border counterparts (2.9/4.0), although all 15 maintain a list with contact information for these counterparts and many know their counterparts. Implementation of specified activities within their collective regional action plan was uneven across the cross-border sites. Most respondents reported positive lessons learned about local cooperation, information sharing and joint problem solving, based on trusting relationships with their cross-border counterparts. They recommend expansion of cross-border sites within MBDS and consideration of the cross-border cooperation model by other sub-regional networks.MBDS has over a decade of experience with its model of local cross-border cooperation in disease surveillance and control. Frontline managers have documented success with this model, strongly support it and recommend its expansion within and beyond the MBDS network. The MBDS cross-border cooperation model is standing the test of time as a solid approach to building and sustaining the public health capabilities needed for disease surveillance and control from the local to national and global levels.
Project description:This report describes emergency response following an imported vaccine derived poliovirus (VDPV) case from Myanmar to Yunnan Province, China and the cross-border collaboration between China and Myanmar. Immediately after confirmation of the VDPV case, China disseminated related information to Myanmar with the assistance of the World Health Organization.A series of epidemiological investigations were conducted, both in China and Myanmar, including retrospective searches of acute flaccid paralysis (AFP) cases, oral poliovirus vaccine (OPV) coverage assessment, and investigation of contacts and healthy children.All children <2 years of age had not been vaccinated in the village where the VDPV case had lived in the past 2 years. Moreover, most areas were not covered for routine immunization in this township due to vaccine shortages and lack of operational funds for the past 2 years.Cross-border collaboration may have prevented a potential outbreak of VDPV in Myanmar. It is necessary to reinforce cross-border collaboration with neighboring countries in order to maximize the leverage of limited resources.
Project description:In 2013, the outbreak of wild poliovirus (WPV) in the Horn of Africa (HOA) triggered an aggressive, coordinated national and regional response to interrupt continued transmission. Kenya, Somalia, Ethiopia, South Sudan, and other HOA countries share a range of complex factors that enabled the outbreak: porous and sparsely populated borders, insecurity due to armed conflicts, and weak health systems with persistently under-resourced health facilities resulting in low-quality care and low levels of immunization coverage in mobile populations. Consequently, the continued risk of WPV importation demanded cross-border and intersectoral collaboration. Assessing and addressing persistent communication gaps at the subnational levels were necessary to gain traction for improved immunization coverage and surveillance activities. This article describes a systematic approach to institutionalizing processes of dialogue and facilitation that can provide for a sustainable and effective joint cross-border health platform between Kenya and Somalia. It examines an operational model called the Cross-Border Health Initiative (CBHI) to support joint intercountry collaboration and coordination efforts. To evaluate progress of the CBHI, the authors used data from population coverage surveys for routine immunization and supplemental immunization activities (for polio), from acute flaccid paralysis (AFP) surveillance, and from plans developed by border districts and border health facilities. The project-trained community health volunteers have been a critical link between the hard-to-reach communities and the health facilities as well as an excellent resource to support understaffed health facilities. The authors conclude that the CBHI has been effective in bolstering immunization coverage, disease surveillance, and rapid outbreak response in border areas. The CBHI has the potential to address other public health threats that transcend borders.
Project description:In April 2019, a cross-border outbreak of Yersinia entercolitica O3 was identified in Sweden and Denmark and confirmed using whole genome sequencing. Close cross-border collaboration with representatives from human and food authorities helped direct resources and investigations. Combined epidemiological and trace-back investigations pointed to imported fresh spinach as the outbreak vehicle and highlight that other vehicles of Y. enterocolitica outbreaks than pork should be considered.
Project description:INTRODUCTION:Cross-border cholera outbreaks are a major public health problem in Sub-Saharan Africa contributing to the high annual reported cholera cases and deaths. These outbreaks affect all categories of people and are challenging to prevent and control. This article describes lessons learnt during the cross-border cholera outbreak control in Eastern and Southern Africa sub-regions using the case of Uganda-DRC and Malawi-Mozambique borders and makes recommendations for future outbreak prevention and control. MATERIALS AND METHODS:We reviewed weekly surveillance data, outbreak response reports and documented experiences on the management of the most recent cross-border cholera outbreaks in Eastern and Southern Africa sub-regions, namely in Uganda and Malawi respectively. Uganda-Democratic Republic of Congo and Malawi-Mozambique borders were selected because the countries sharing these borders reported high cholera disease burden to WHO. RESULTS:A total of 603 cross-border cholera cases with 5 deaths were recorded in Malawi and Uganda in 2015. Uganda recorded 118 cases with 2 deaths and CFR of 1.7%. The under-fives and school going children were the most affected age groups contributing 24.2% and 36.4% of all patients seen along Malawi-Mozambique and Uganda-DRC borders, respectively. These outbreaks lasted for over 3 months and spread to new areas leading to 60 cases with 3 deaths, CRF of 5%, and 102 cases 0 deaths in Malawi and Uganda, respectively. Factors contributing to these outbreaks were: poor sanitation and hygiene, use of contaminated water, floods and rampant cross-border movements. The outbreak control efforts mainly involved unilateral measures implemented by only one of the affected countries. CONCLUSIONS:Cross-border cholera outbreaks contribute to the high annual reported cholera burden in Sub-Saharan Africa yet they remain silent, marginalized and poorly identified by cholera actors (governments and international agencies). The under-fives and the school going children were the most affected age groups. To successfully prevent and control these outbreaks, guidelines and strategies should be reviewed to assign clear roles and responsibilities to cholera actors on collaboration, prevention, detection, monitoring and control of these epidemics.
Project description:BACKGROUND:The likelihood of large-scale outbreaks of multidrug-resistant organisms (MDRO) is growing. MDRO outbreaks can affect a wide range of healthcare institutions. Control of such outbreaks requires structured collaboration between professionals from all involved healthcare institutions, but guidelines for cross-institutional procedures are, however, often missing. Literature indicates that such multi-actor collaboration is most promising when effective network brokers are present, and when the collaborative actors have clarity about the different roles and responsibilities in the outbreak response network, including collaborative structures and coordination roles. Studying these factors in an imaginary MDRO outbreak scenario, we gained insights into the expectations that health professionals in the Netherlands have in regard to the procedures required to best respond to any future cross-institutional MDRO outbreaks. METHODS:For exploration purpose, a focus group discussion with ten healthcare professionals was held. Subsequently, an online-survey was conducted among 56 healthcare professionals in two Dutch regions. The survey data was analysed using social network analyses (clique analysis and centrality analysis), which provided insights into the collaborative structures and potential brokers in the outbreak response networks. Additionally, respondents were asked which healthcare institutions and which professions they would prefer as coordinating actors in the collaborative network. RESULTS:Our results show a relatively high level of perceived clarity about the roles and responsibilities that healthcare professionals have during a joint outbreak response. The regional outbreak response networks which were studied appeared inclusive and integrated, with many overlapping groups of fully-connected healthcare actors. Social network analyses resulted in the identification of several central actors from different healthcare institutions with the potential to take on a brokerage role in the collaboration. Actors in the outbreak response networks also showed to prefer several healthcare professionals to take on the coordination roles. CONCLUSION:Expected collaborative structures during an imaginary regional MDRO outbreak response are relatively dense and integrated. In regard to the coordination of an MDRO outbreak response, based on both the network analysis results and the preferred coordination roles, our findings support a governance structure with several healthcare institutions involved in responding to future cross-institutional MDRO outbreaks.
Project description:BACKGROUND:There has been significant progress in eliminating malaria in Iran. The aim of this study is to investigate the structure of inter-organizational collaboration networks in the field of unauthorized immigrants and refugees access to services in order to eliminate malaria. METHODS:This study employed social network analysis, in which nodes represented stakeholders associated with providing access of immigrants and refugees to services in the field of malaria elimination, and ties indicated the level of collaboration. This study adopted socio-centric analysis and the whole network was studied. In this regard, 12 districts of the malaria-endemic area in Iran were selected. Participants included 360 individuals (30 representatives of the organization/group in each district). The data were gathered by interview, using the levels of collaboration scale. UCINET 6 was used for data analysis. The indices of density, centralization, reciprocity, and clustering were investigated for each twelve network and at each level of collaboration. RESULTS:The average density of the networks was 0.22 (SD: 0.04). In districts with a high incidence of imported malaria, the values of network density and centralization were high and the networks comprised of a larger connected component (less isolated clusters). There were significant correlations between density of network (r?=?0.66, P?=?0.02), degree centralization (r?=?0.65, P?=?0.02), betweenness centralization (r?=?0.76, P?=?0.004), and imported malaria cases. In general, the degree centrality and betweenness centrality of the organizations of health, district governor, and foreign immigrants' affairs were higher. In all networks, 60% of the relationships were bilateral. At a higher level of collaboration, the centralization declined and reciprocity increased. The average of betweenness centralization index was 22.76 (SD?=?3.88). CONCLUSIONS:Higher values of network indices in border districts and districts with more cases of imported malaria, in terms of density and centralization measures, can propose the hypothesis that higher preparedness against the issue and centralization of power can enable a better top-down outbreak management, which needs further investigations. Higher centrality of governmental organizations indicates the need for involving private, non-governmental organizations and representatives of immigrant and refugee groups. Recognition of the existing network structure can help the authorities increase access to malaria prevention, diagnosis, and treatment services among immigrants and refugees.
Project description:IntroductionSequence-based typing of hepatitis A virus (HAV) is important for outbreak detection, investigation and surveillance. In 2013, sequencing was central to resolving a large European Union (EU)-wide outbreak related to frozen berries. However, as the sequenced HAV genome regions were only partly comparable between countries, results were not always conclusive.AimThe objective was to gather information on HAV surveillance and sequencing in EU/European Economic Area (EEA) countries to find ways to harmonise their procedures, for improvement of cross-border outbreak responses.MethodsIn 2014, the European Centre for Disease Prevention and Control (ECDC) conducted a survey on HAV surveillance practices in EU/EEA countries. The survey enquired whether a referral system for confirming primary diagnostics of hepatitis A existed as well as a central collection/storage of hepatitis A cases' samples for typing. Questions on HAV sequencing procedures were also asked. Based on the results, an expert consultation proposed harmonised procedures for cross-border outbreak response, in particular regarding sequencing. In 2016, a follow-up survey assessed uptake of suggested methods.ResultsOf 31 EU/EEA countries, 23 (2014) and 27 (2016) participated. Numbers of countries with central collection and storage of HAV positive samples and of those performing sequencing increased from 12 to 15 and 12 to 14 respectively in 2016, with all countries typing an overlapping fragment of 218 nt. However, variation existed in the sequenced genomic regions and their lengths.ConclusionsWhile HAV sequences in EU/EEA countries are comparable for surveillance, collaboration in sharing and comparing these can be further strengthened.
Project description:Objectives: To analyze the current situation of cross-border access to clinical trials in the EU with an overview of stakeholders' real-life experience, and to identify the needs, challenges, and potential for facilitation of cross-border access. Methods: We employed a mixed methods design. Semi-structured interviews and an online survey were conducted with a wide range of stakeholders: patient representatives, investigators/physicians, policy and regulatory experts, academic and commercial sponsor representatives, ethics committee members. Interviews underwent a framework analysis. The survey was analyzed descriptively. Results: Three hundred ninety six individuals responded to the survey. The majority were investigators/physicians (46%) and patient representatives (33%). Thirty eight individuals were interviewed. The majority were investigators/physicians (29%) and patient representatives (29%). All European regions were represented in the study. The highest response rate was received from residents of Western European countries (38% of survey respondents, 45% of interviewees), the lowest from Eastern Europe (9% of survey respondents, 5% of interviewees). The study suggested that cross-border participation in clinical trials occurs in practice, however very rarely. Ninety two percentage of survey respondents and the majority of interviewees perceived as needed the possibility to access clinical trials abroad. However, most interviewees also opined that patients ideally should not have to travel in order to access experimental treatment. The lack of access to treatment in the home country of the patient was described as the main motivation to participate in a clinical trial in another country. The logistical and financial burden for patients was perceived as the biggest challenge. Different stakeholders expressed diverging opinions regarding the allocation of financial and organizational responsibility for enabling cross-border access to clinical trials. Participants provided a number of proposals for improving the current system, which were carefully evaluated by the research team and informed future recommendations. Conclusions: Participation in clinical trials abroad is happening rarely but should be facilitated. There was a consensus on the need for reliable and accessible information regarding practical aspects, as well as multi-stakeholder, multi-national recommendations on existing options and best practice on cross-border access to clinical trials. Broader interdisciplinary research is recommended before discussing options in the EU legislative framework to enable clearly defined conditions for cross-border access to clinical trials.
Project description:<h4>Aims</h4>The growing burden of cardiovascular disease requires growth in research and innovation. We examine world-wide participation and citation impact across the cardiovascular research landscape from 1992 to 2012; we investigate cross-fertilization between countries and examine whether cross-border collaboration affects impact.<h4>Methods and results</h4>State-of-the-art bibliometric methods and indicators are used to identify cardiovascular publications from the Web of Science, and to map trends over time in output, citation impact, and collaboration. The publication output in cardiovascular research has grown steadily from 1992 to 2012 with increased participation worldwide. China has the highest growth as relative share. The USA share initially predominated yet has reduced steadily. Over time, the EU-27 supra-national region has increased its participation above the USA, though on average it has not had greater citation impact than the USA. However, a number of European countries, as well as Australia and Canada, have improved their absolute and relative citation impact above that of the USA by 2006-2012. Europe is a hub of cross-fertilization with strengthening collaborations and strong citation links; the UK, Germany, and France remain central in this network. The USA has the highest number of strong citation links with other countries. All countries, but especially smaller, highly collaborative countries, have higher citation impact for their internationally collaborative research when compared with their domestic publications.<h4>Conclusion</h4>Participation in cardiovascular research is growing but growth and impact show wide variability between countries. Cross-border collaboration is increasing, in particular within the EU, and is associated with greater citation impact.