Publications by authors named "Reena Doshi"

41 Publications

Zoonotic risk factors associated with seroprevalence of Ebola virus GP antibodies in the absence of diagnosed Ebola virus disease in the Democratic Republic of Congo.

PLoS Negl Trop Dis 2021 Aug 12;15(8):e0009566. Epub 2021 Aug 12.

UCLA Fielding School of Public Health, Los Angeles, California, United States of America.

Background: Ebola virus (EBOV) is a zoonotic filovirus spread through exposure to infected bodily fluids of a human or animal. Though EBOV is capable of causing severe disease, referred to as Ebola Virus Disease (EVD), individuals who have never been diagnosed with confirmed, probable or suspected EVD can have detectable EBOV antigen-specific antibodies in their blood. This study aims to identify risk factors associated with detectable antibody levels in the absence of an EVD diagnosis.

Methodology: Data was collected from September 2015 to August 2017 from 1,366 consenting individuals across four study sites in the DRC (Boende, Kabondo-Dianda, Kikwit, and Yambuku). Seroreactivity was determined to EBOV GP IgG using Zaire Ebola Virus Glycoprotein (EBOV GP antigen) ELISA kits (Alpha Diagnostic International, Inc.) in Kinshasa, DRC; any result above 4.7 units/mL was considered seroreactive. Among the respondents, 113 (8.3%) were considered seroreactive. Several zoonotic exposures were associated with EBOV seroreactivity after controlling for age, sex, healthcare worker status, location, and history of contact with an EVD case, namely: ever having contact with bats, ever having contact with rodents, and ever eating non-human primate meat. Contact with monkeys or non-human primates was not associated with seroreactivity.

Conclusions: This analysis suggests that some zoonotic exposures that have been linked to EVD outbreaks can also be associated with EBOV GP seroreactivity in the absence of diagnosed EVD. Future investigations should seek to clarify the relationships between zoonotic exposures, seroreactivity, asymptomatic infection, and EVD.
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http://dx.doi.org/10.1371/journal.pntd.0009566DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8384205PMC
August 2021

Rapid Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 in Detention Facility, Louisiana, USA, May-June, 2020.

Emerg Infect Dis 2021 Feb 4;27(2):421-429. Epub 2021 Jan 4.

To assess transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a detention facility experiencing a coronavirus disease outbreak and evaluate testing strategies, we conducted a prospective cohort investigation in a facility in Louisiana, USA. We conducted SARS-CoV-2 testing for detained persons in 6 quarantined dormitories at various time points. Of 143 persons, 53 were positive at the initial test, and an additional 58 persons were positive at later time points (cumulative incidence 78%). In 1 dormitory, all 45 detained persons initially were negative; 18 days later, 40 (89%) were positive. Among persons who were SARS-CoV-2 positive, 47% (52/111) were asymptomatic at the time of specimen collection; 14 had replication-competent virus isolated. Serial SARS-CoV-2 testing might help interrupt transmission through medical isolation and quarantine. Testing in correctional and detention facilities will be most effective when initiated early in an outbreak, inclusive of all exposed persons, and paired with infection prevention and control.
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http://dx.doi.org/10.3201/eid2702.204158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853536PMC
February 2021

Identification of Presymptomatic and Asymptomatic Cases Using Cohort-Based Testing Approaches at a Large Correctional Facility-Chicago, Illinois, USA, May 2020.

Clin Infect Dis 2021 03;72(5):e128-e135

Cermak Health Services, Chicago, Illinois, USA.

Background: Coronavirus disease 2019 (COVID-19) continues to cause significant morbidity and mortality worldwide. Correctional and detention facilities are at high risk of experiencing outbreaks. We aimed to evaluate cohort-based testing among detained persons exposed to laboratory-confirmed cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in order to identify presymptomatic and asymptomatic cases.

Methods: During 1-19 May 2020, 2 testing strategies were implemented in 12 tiers or housing units of the Cook County Jail, Chicago, Illinois. Detained persons were approached to participate in serial testing (n = 137) and offered tests at 3 time points over 14 days (day 1, days 3-5, and days 13-14). The second group was offered a single test and interview at the end of a 14-day quarantine period (day 14 group) (n = 87).

Results: 224 detained persons were approached for participation and, of these, 194 (87%) participated in ≥1 interview and 172 (77%) had ≥1 test. Of the 172 tested, 19 were positive for SARS-CoV-2. In the serial testing group, 17 (89%) new cases were detected, 16 (84%) on day 1, 1 (5%) on days 3-5, and none on days 13-14; in the day 14 group, 2 (11%) cases were identified. More than half (12/19; 63%) of the newly identified cases were presymptomatic or asymptomatic.

Conclusions: Our findings highlight the utility of cohort-based testing promptly after initiating quarantine within a housing tier. Cohort-based testing efforts identified new SARS-CoV-2 asymptomatic and presymptomatic infections that may have been missed by symptom screening alone.
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http://dx.doi.org/10.1093/cid/ciaa1802DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7799274PMC
March 2021

Risk factors for Ebola exposure in healthcare workers in Boende, Tshuapa Province, Democratic Republic of the Congo.

J Infect Dis 2020 Dec 3. Epub 2020 Dec 3.

Department of Epidemiology, University of California, Los Angeles, Fielding School of Public Health, Los Angeles, CA, USA.

Healthcare workers (HCW) are more likely to be exposed to Ebola virus (EBOV) during an outbreak compared to people in the general population due to close physical contact with patients and potential exposure to infectious fluids. However, not all will fall ill. Despite evidence of subclinical and paucisymptomatic Ebola Virus Disease (EVD), the prevalence and associated risk factors remains unknown. We conducted a serosurvey among healthcare workers in the town of Boende in Tshuapa Province, Democratic Republic of Congo (DRC). Human anti-EBOV Glycoprotein (GP) IgG titers were measured using a commercially available ELISA kit. We assessed associations between anti-EBOV IgG seroreactivity, defined as ≥2.5 units/mL and risk factors using univariable and multivariable logistic regression. Sensitivity analyses explored a more conservative cutoff >5 units/mL. Overall, 22.5% of HCWs were seroreactive for EBOV. In multivariable analyses, using any form of personal protective equipment (PPE) when interacting with a confirmed, probable, or suspect EVD case was negatively associated with seroreactivity [0.23 (95% CI: 0.07, 0.73)]. Our results suggest high exposure to EBOV among HCWs and provide additional evidence for asymptomatic or minimally symptomatic EVD. Further studies should be conducted to determine the probability of onward transmission and if seroreactivity is associated with immunity.
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http://dx.doi.org/10.1093/infdis/jiaa747DOI Listing
December 2020

Serial Laboratory Testing for SARS-CoV-2 Infection Among Incarcerated and Detained Persons in a Correctional and Detention Facility - Louisiana, April-May 2020.

MMWR Morb Mortal Wkly Rep 2020 Jul 3;69(26):836-840. Epub 2020 Jul 3.

Transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), by asymptomatic and presymptomatic persons poses important challenges to controlling spread of the disease, particularly in congregate settings such as correctional and detention facilities (1). On March 29, 2020, a staff member in a correctional and detention facility in Louisiana developed symptoms and later had a positive test result for SARS-CoV-2. During April 2-May 7, two additional cases were detected among staff members, and 36 cases were detected among incarcerated and detained persons at the facility; these persons were removed from dormitories and isolated, and the five dormitories that they had resided in before diagnosis were quarantined. On May 7, CDC and the Louisiana Department of Health initiated an investigation to assess the prevalence of SARS-CoV-2 infection among incarcerated and detained persons residing in quarantined dormitories. Goals of this investigation included evaluating COVID-19 symptoms in this setting and assessing the effectiveness of serial testing to identify additional persons with SARS-CoV-2 infection as part of efforts to mitigate transmission. During May 7-21, testing of 98 incarcerated and detained persons residing in the five quarantined dormitories (A-E) identified an additional 71 cases of SARS-CoV-2 infection; 32 (45%) were among persons who reported no symptoms at the time of testing, including three who were presymptomatic. Eighteen cases (25%) were identified in persons who had received negative test results during previous testing rounds. Serial testing of contacts from shared living quarters identified persons with SARS-CoV-2 infection who would not have been detected by symptom screening alone or by testing at a single time point. Prompt identification and isolation of infected persons is important to reduce further transmission in congregate settings such as correctional and detention facilities and the communities to which persons return when released.
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http://dx.doi.org/10.15585/mmwr.mm6926e2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7332096PMC
July 2020

Correction: Estimating the Size of Key Populations in Kampala, Uganda: 3-Source Capture-Recapture Study.

JMIR Public Health Surveill 2020 05 12;6(2):e19893. Epub 2020 May 12.

Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV and TB, Atlanta, GA, United States.

[This corrects the article DOI: 10.2196/12118.].
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http://dx.doi.org/10.2196/19893DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7351262PMC
May 2020

Measles antibody levels among vaccinated and unvaccinated children 6-59 months of age in the Democratic Republic of the Congo, 2013-2014.

Vaccine 2020 02;38(9):2258-2265

Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA 90095, United States. Electronic address:

Background: Measles is endemic in the Democratic Republic of the Congo (DRC), and 89-94% herd immunity is required to halt its transmission. Much of the World Health Organization African Region, including the DRC, has vaccination coverage below the 95% level required to eliminate measles, heightening concern of inadequate measles immunity.

Methods: We assessed 6706 children aged 6-59 months whose mothers were selected for interview in the 2013-2014 DRC Demographic and Health Survey. History of measles was obtained by maternal report, and classification of children who had measles was completed using maternal recall and measles immunoglobulin G serostatus obtained from a multiplex chemiluminescent automated immunoassay dried blood spot analysis. A logistic regression model was used to identify associations of covariates with measles and seroprotection, and vaccine effectiveness (VE) was calculated.

Results: Out of our sample, 64% of children were seroprotected. Measles vaccination was associated with protection against measles (OR: 0.15, 95% CI: 0.03, 0.81) when administered to children 12 months of age or older. Vaccination was predictive of seroprotection at all ages. VE was highest (88%) among children 12-24 months of age.

Conclusion: Our results demonstrated lower than expected seroprotection against measles among vaccinated children. Understanding the factors that affect host immunity to measles will aid in developing more efficient and effective immunization programs in DRC.
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http://dx.doi.org/10.1016/j.vaccine.2019.09.047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7026690PMC
February 2020

Monkeypox Rash Severity and Animal Exposures in the Democratic Republic of the Congo.

Ecohealth 2020 03 24;17(1):64-73. Epub 2019 Dec 24.

Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, USA.

Experimental studies have suggested a larger inoculum of monkeypox virus may be associated with increased rash severity; however, little data are available on the relationship between specific animal exposures and rash severity in endemic regions. Using cross-sectional data from an active surveillance program conducted between 2005 and 2007 in the Sankuru Province of the Democratic Republic of the Congo, we explored the possible relationship between rash severity and exposures to rodents and non-human primates among confirmed MPX cases. Among the 223 PCR-confirmed MPX cases identified during active surveillance, the majority of cases (n = 149) presented with mild rash (5-100 lesions) and 33% had a more serious presentation (> 100 lesions). No association between exposure to rodents and rash severity was found in the multivariable analysis. Those that self-reported hunting NHP 3 weeks prior to onset of MPX symptoms had 2.78 times the odds of severe rash than those that did not report such exposure (95% CI: 1.18, 6.58). This study provides a preliminary step in understanding the association between animal exposure and rash severity and demonstrates correlation with exposure to NHPs and human MPX presentation. Additional research exploring the relationship between rash severity and NHPs is warranted.
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http://dx.doi.org/10.1007/s10393-019-01459-7DOI Listing
March 2020

Do Monkeypox Exposures Vary by Ethnicity? Comparison of Aka and Bantu Suspected Monkeypox Cases.

Am J Trop Med Hyg 2020 01;102(1):202-205

Poxvirus and Rabies Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.

In 2017, a monkeypox outbreak occurred in Likouala Department, Republic of the Congo. Many of the affected individuals were of Aka ethnicity, hunter-gatherers indigenous to Central Africa who have worse health outcomes in comparison with other forest-dwelling peoples. To test the hypothesis that Aka people have different risk factors for monkeypox, we analyzed questionnaire data for 39 suspected cases, comparing Aka and Bantu groups. Aka people were more likely to touch animal urine/feces, find dead animals in/around the home, eat an animal that was found dead, or to have been scratched or bitten by an animal ( < 0.05, all variables). They were also more likely to visit the forest ≥ once/week, sleep outside, or sleep on the ground ( < 0.001, all variables), providing opportunities for contact with monkeypox reservoirs during the night. The Aka and possibly other vulnerable groups may warrant special attention during educational and health promotion programs.
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http://dx.doi.org/10.4269/ajtmh.19-0457DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947767PMC
January 2020

Field Test and Validation of the Multiplier Measles, Mumps, Rubella, and Varicella-Zoster Multiplexed Assay System in the Democratic Republic of the Congo by Using Dried Blood Spots.

mSphere 2019 08 14;4(4). Epub 2019 Aug 14.

Department of Epidemiology, University of California, Los Angeles, Fielding School of Public Health, Los Angeles, California, USA.

Here we describe baseline validation studies and field performance of a research-use-only chemiluminescent multiplex serology panel for measles, mumps, rubella, and varicella-zoster virus used with dried blood spots in support of the 2013-2014 Democratic Republic of the Congo Demographic and Health Survey. Characterization of the panel using U.S. FDA-cleared commercial kits shows good concordance for measles, mumps, rubella, and varicella-zoster with average sensitivity across assays of 94.9% and an average specificity of 91.4%. As expected, performance versus available standards validated for plaque-reduction assays does not provide a 1:1 correspondence with international units and yet demonstrates excellent linearity (average Hill's slope = 1.02) and ∼4 logs of dynamic range. In addition, for the four assays, the multiplexed format allowed for inclusion of three positive and two negative controls for each sample. A prototype Dynex Multiplier chemiluminescent automated immunoassay instrument with a charge-coupled device camera provided a rugged and robust processing and data acquisition platform. Performance of a multiplex instrument for serological testing in a substantially resource-limited environment shows excellent reproducibility, minimal cross-reactivity, and a clear discrimination between specific assays and should be considered a viable option for future serosurveys. The critical evaluation of immunization programs is key to identifying areas of suboptimal vaccination coverage, monitoring activities, and aiding development of public health policy. For evaluation of vaccine effectiveness, direct antibody binding assay methods, including enzyme immunoassay, enzyme-linked fluorescence assays, and indirect immunofluorescence assay, are most commonly used for detection of IgG antibodies. However, despite their well-demonstrated, reliable performance, they can be labor-intensive and time-consuming and require separate assays for each individual marker. This necessitates increased sample volumes, processing time, and personnel, which may limit assessment to a few key targets in resource-limited settings, that is, low- and middle-income locations where funding for public health or general infrastructure that directly impacts public health is restricted, limiting access to equipment, infrastructure, and trained personnel. One solution is a multiplexed immunoassay, which allows for the detection of multiple analytes in a single reaction for increased efficiency and rapid surveillance of infectious diseases in limited-resource settings. Thus, the scope of the project precluded a full validation, and here we present abbreviated validation studies demonstrating adequate sensitivity, specificity, and reproducibility.
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http://dx.doi.org/10.1128/mSphere.00112-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6695516PMC
August 2019

Estimating the Size of Key Populations in Kampala, Uganda: 3-Source Capture-Recapture Study.

JMIR Public Health Surveill 2019 Aug 12;5(3):e12118. Epub 2019 Aug 12.

Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV and TB, Atlanta, GA, United States.

Background: Key populations, including people who inject drugs (PWID), men who have sex with men (MSM), and female sex workers (FSW), are disproportionately affected by the HIV epidemic. Understanding the magnitude of, and informing the public health response to, the HIV epidemic among these populations requires accurate size estimates. However, low social visibility poses challenges to these efforts.

Objective: The objective of this study was to derive population size estimates of PWID, MSM, and FSW in Kampala using capture-recapture.

Methods: Between June and October 2017, unique objects were distributed to the PWID, MSM, and FSW populations in Kampala. PWID, MSM, and FSW were each sampled during 3 independent captures; unique objects were offered in captures 1 and 2. PWID, MSM, and FSW sampled during captures 2 and 3 were asked if they had received either or both of the distributed objects. All captures were completed 1 week apart. The numbers of PWID, MSM, and FSW receiving one or both objects were determined. Population size estimates were derived using the Lincoln-Petersen method for 2-source capture-recapture (PWID) and Bayesian nonparametric latent-class model for 3-source capture-recapture (MSM and FSW).

Results: We sampled 467 PWID in capture 1 and 450 in capture 2; a total of 54 PWID were captured in both. We sampled 542, 574, and 598 MSM in captures 1, 2, and 3, respectively. There were 70 recaptures between captures 1 and 2, 103 recaptures between captures 2 and 3, and 155 recaptures between captures 1 and 3. There were 57 MSM captured in all 3 captures. We sampled 962, 965, and 1417 FSW in captures 1, 2, and 3, respectively. There were 316 recaptures between captures 1 and 2, 214 recaptures between captures 2 and 3, and 235 recaptures between captures 1 and 3. There were 109 FSW captured in all 3 rounds. The estimated number of PWID was 3892 (3090-5126), the estimated number of MSM was 14,019 (95% credible interval (CI) 4995-40,949), and the estimated number of FSW was 8848 (95% CI 6337-17,470).

Conclusions: Our population size estimates for PWID, MSM, and FSW in Kampala provide critical population denominator data to inform HIV prevention and treatment programs. The 3-source capture-recapture is a feasible method to advance key population size estimation.
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http://dx.doi.org/10.2196/12118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6771531PMC
August 2019

Urogenital Schistosomiasis and Sexually Transmitted Coinfections among Pregnant Women in a Schistosome-Endemic Region of the Democratic Republic of Congo.

Am J Trop Med Hyg 2019 10;101(4):828-836

Department of Epidemiology, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California.

Schistosomiasis afflicts an estimated 10 million pregnant women in Africa annually. With mounting evidence of adverse impacts to reproductive health resulting from urogenital schistosomiasis, including increased transmission of HIV, further research on prenatal disease epidemiology is warranted, with implications for maternal and fetal health. Between October 2016 and March 2017, we conducted a cross-sectional study examining the prevalence of urogenital schistosomiasis and its association with sexually transmitted infections (STIs) other than HIV among pregnant women visiting antenatal clinics in Kisantu health zone, Democratic Republic of Congo. An extensive sociodemographic and clinical survey was administered to consenting participants, with urine samples and vaginal swabs collected to deduce active schistosomiasis and STIs, respectively. In total, 17.4% of expectant mothers were infected with , 3.1% with (CT), 1.4% with (NG), and 14.6% with (TV). Women infected with urogenital schistosomiasis were at significantly increased odds of harboring a CT, NG, or TV infection (adjusted odds ratio = 3.0, 95% CI: 1.5, 6.0), but reports of clinical symptoms were low, ranging from 17.2% of schistosomiasis to 30.8% of TV cases. Laboratory confirmation of schistosomiasis and STIs provided objective evidence of disease in a cohort with low symptomology where syndromic management may not suffice. Shedding light on local risk factors and associated coinfections of urogenital schistosomiasis can identify unique intervention opportunities for prenatal care in trematode-endemic regions and aid in reducing adverse pregnancy outcomes.
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http://dx.doi.org/10.4269/ajtmh.19-0024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6779196PMC
October 2019

Changes in childhood vaccination coverage over time in the Democratic Republic of the Congo.

PLoS One 2019 24;14(5):e0217426. Epub 2019 May 24.

Department of Epidemiology, University of California Los Angeles, Los Angeles, California, United States of America.

Despite increased vaccination rates, the burden, morbidity and mortality associated with vaccine preventable diseases remains high. In the Democratic Republic of the Congo (DRC), potentially unreliable data and geographically varied program provision call for a better understanding of vaccination coverage and its changes over time at the country and province level. To assess changes in the proportion of children who were fully vaccinated over time in the DRC, vaccination histories for children 12-59 months of age were obtained from both the 2007 and 2013-2014 Demographic and Health Surveys (DHS). Changes were assessed, both at the country- and province-levels, to identify potential geographic variations. Vaccination coverage improved 70% between the DHS waves: 26% compared to 44% of 12-59 month-old children met full vaccination criteria in 2007 and 2013-2014, respectively (n2007 = 3032 and n2013-14 = 6619). Similarly, there was an overall trend across both DHS waves where as year of birth increased, so did vaccination coverage. There was geographic variation in immunization changes with most central and eastern provinces increasing in coverage and most northern, western and southern provinces having decreased vaccination coverage at the second time point. Using nationally representative data, we identified significant changes over time in vaccination coverage which may help to inform future policy, interventions and research to improve vaccination rates among children in the DRC. This study is the first of its kind for the population of DRC and provides an important initial step towards better understanding trends in vaccination coverage over time.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0217426PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6534301PMC
January 2020

Capture-Recapture Among Men Who Have Sex With Men and Among Female Sex Workers in 11 Towns in Uganda.

JMIR Public Health Surveill 2019 Apr 3;5(2):e12316. Epub 2019 Apr 3.

Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV and TB, Atlanta, GA, United States.

Background: Key populations at higher risk for HIV infection, including people who inject drugs, men who have sex with men (MSM), and female sex workers (FSWs), are disproportionately affected by the HIV/AIDS epidemic. Empirical estimates of their population sizes are necessary for HIV program planning and monitoring. Such estimates, however, are lacking for most of Uganda's urban centers.

Objective: The aim of this study was to estimate the number of FSWs and MSM in select locations in Uganda.

Methods: We utilized conventional 2-source capture-recapture (CRC) to estimate the population of FSWs in Mbale, Jinja, Wakiso, Mbarara, Gulu, Kabarole, Busia, Tororo, Masaka, and Kabale and the population of MSM in Mbale, Jinja, Wakiso, Mbarara, Gulu, Kabarole, and Mukono from June to August 2017. Hand mirrors and key chains were distributed to FSWs and MSM, respectively, by peers during capture 1. A week later, different FSWs and MSM distributors went to the same towns to collect data for the second capture. Population size estimates and 95% CIs were calculated using the CRC Simple Interactive Statistical Analysis.

Results: We estimated the population of FSWs and MSM using 2 different recapture definitions: those who could present the object or identify the object from a set of photos. The most credible (closer to global estimates of MSM; 3%-5%) estimates came from those who presented the objects only. The FSW population in Mbale was estimated to be 693 (95% CI 474-912). For Jinja, Mukono, Busia, and Tororo, we estimated the number of FSWs to be 802 (95% CI 534-1069), 322 (95% CI 300-343), 961 (95% CI 592-1330), and 2872 (95% CI 0-6005), respectively. For Masaka, Mbarara, Kabale, and Wakiso, we estimated the FSWs population to be 512 (95% CI 384-639), 1904 (95% CI 1058-2749), 377 (95% CI 247-506), and 828 (95% CI 502-1152), respectively. For Kabarole and Gulu, we estimated the FSWs population to be 397 (95% CI 325-469) and 1425 (95% CI 893-1958), respectively. MSM estimates were 381 (95% CI 299-462) for Mbale, 1100 (95% CI 351-1849) for Jinja, 368 (95% CI 281-455) for Wakiso, 322 (95% CI 253-390) for Mbarara, 180 (95% CI 170-189) for Gulu, 335 (95% CI 258-412) for Kabarole, and 264 (95% CI 228-301) for Mukono.

Conclusions: The CRC activity was one of the first to be carried out in Uganda to obtain small town-level population sizes for FSWs and MSM. We found that it is feasible to use FSW and MSM peers for this activity, but proper training and standardized data collection tools are essential to minimize bias.
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http://dx.doi.org/10.2196/12316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6468338PMC
April 2019

Epidemiologic and Ecologic Investigations of Monkeypox, Likouala Department, Republic of the Congo, 2017.

Emerg Infect Dis 2019 02;25(2):281-289

Monkeypox, caused by a zoonotic orthopoxvirus, is endemic in Central and West Africa. Monkeypox has been sporadically reported in the Republic of the Congo. During March 22-April 5, 2017, we investigated 43 suspected human monkeypox cases. We interviewed suspected case-patients and collected dried blood strips and vesicular and crust specimens (active lesions), which we tested for orthopoxvirus antibodies by ELISA and monkeypox virus and varicella zoster virus DNA by PCR. An ecologic investigation was conducted around Manfouété, and specimens from 105 small mammals were tested for anti-orthopoxvirus antibodies or DNA. Among the suspected human cases, 22 met the confirmed, probable, and possible case definitions. Only 18 patients had available dried blood strips; 100% were IgG positive, and 88.9% (16/18) were IgM positive. Among animals, only specimens from Cricetomys giant pouched rats showed presence of orthopoxvirus antibodies, adding evidence to this species' involvement in the transmission and maintenance of monkeypox virus in nature.
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http://dx.doi.org/10.3201/eid2502.181222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6346463PMC
February 2019

Association of Previous Measles Infection With Markers of Acute Infectious Disease Among 9- to 59-Month-Old Children in the Democratic Republic of the Congo.

J Pediatric Infect Dis Soc 2019 Dec;8(6):531-538

Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles.

Background: Transient immunosuppression and increased susceptibility to other infections after measles infection is well known, but recent studies have suggested the occurrence of an "immune amnesia" that could have long-term immunosuppressive effects.

Methods: We examined the association between past measles infection and acute episodes of fever, cough, and diarrhea among 2350 children aged 9 to 59 months whose mothers were selected for interview in the 2013-2014 Democratic Republic of the Congo (DRC) Demographic and Health Survey (DHS). Classification of children who had had measles was completed using maternal recall and measles immunoglobulin G serostatus obtained via dried-blood-spot analysis with a multiplex immunoassay. The association with time since measles infection and fever, cough, and diarrhea outcomes was also examined.

Results: The odds of fever in the previous 2 weeks were 1.80 (95% confidence interval [CI], 1.25-2.60) among children for whom measles was reported compared to children with no history of measles. Measles vaccination demonstrated a protective association against selected clinical markers of acute infectious diseases.

Conclusion: Our results suggest that measles might have a long-term effect on selected clinical markers of acute infectious diseases among children aged 9 to 59 months in the DRC. These findings support the immune-amnesia hypothesis suggested by others and underscore the need for continued evaluation and improvement of the DRC's measles vaccination program.
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http://dx.doi.org/10.1093/jpids/piy099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6933309PMC
December 2019

Serologic Markers for Ebolavirus Among Healthcare Workers in the Democratic Republic of the Congo.

J Infect Dis 2019 01;219(4):517-525

Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles.

Healthcare settings have played a major role in propagation of Ebola virus (EBOV) outbreaks. Healthcare workers (HCWs) have elevated risk of contact with EBOV-infected patients, particularly if safety precautions are not rigorously practiced. We conducted a serosurvey to determine seroprevalence against multiple EBOV antigens among HCWs of Boende Health Zone, Democratic Republic of the Congo, the site of a 2014 EBOV outbreak. Interviews and specimens were collected from 565 consenting HCWs. Overall, 234 (41.4%) of enrolled HCWs were reactive to at least 1 EBOV protein: 159 (28.1%) were seroreactive for anti-glycoprotein immunoglobulin G (IgG), 89 (15.8%) were seroreactive for anti-nucleoprotein IgG, and 54 (9.5%) were VP40 positive. Additionally, sera from 16 (2.8%) HCWs demonstrated neutralization capacity. These data demonstrate that a significant proportion of HCWs have the ability to neutralize virus, despite never having developed Ebola virus disease symptoms, highlighting an important and poorly documented aspect of EBOV infection and progression.
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http://dx.doi.org/10.1093/infdis/jiy499DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6350949PMC
January 2019

Progress toward UNAIDS 90-90-90 targets: A respondent-driven survey among female sex workers in Kampala, Uganda.

PLoS One 2018 19;13(9):e0201352. Epub 2018 Sep 19.

Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States of America.

Background: We investigated progress towards UNAIDS 90-90-90 targets among female sex workers in Kampala, Uganda, who bear a disproportionate burden of HIV.

Methods: Between April and December 2012, 1,487 female sex workers, defined as women, 15-49 years, residing in greater Kampala, and selling sex for money in the last 6 months, were recruited using respondent-driven sampling. Venous blood was collected for HIV and viral load testing [viral load suppression (VLS) defined as <1,000 copies/mL]. We collected data using audio computer-assisted self-interviews and calculated weighted population-level estimates.

Results: The median age was 27 years (interquartile range: 23 to 32). HIV seroprevalence was 31.4% (95% confidence interval [CI]: 29.0, 33.7%). Among all female sex workers who tested HIV-positive in the survey (population-level targets), 45.5% (95% CI: 40.1, 51.0) had knowledge of their serostatus (population-level target: 90%), 37.8% (95% CI: 32.2, 42.8) self-reported to be on ART (population-level target: 81%), and 35.2% (95% CI: 20.7, 30.4) were virally suppressed (population-level target: 73%).

Conclusions: HIV prevalence among Kampala female sex workers is high, whereas serostatus knowledge and VLS are far below UNAIDS targets. Kampala female sex workers are in need of intensified and targeted HIV prevention and control efforts.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0201352PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6145590PMC
February 2019

Pan-Filovirus Serum Neutralizing Antibodies in a Subset of Congolese Ebolavirus Infection Survivors.

J Infect Dis 2018 11;218(12):1929-1936

Department of Epidemiology, School of Public Health, University of California, Los Angeles.

One year after a Zaire ebolavirus (EBOV) outbreak occurred in the Boende Health Zone of the Democratic Republic of the Congo during 2014, we sought to determine the breadth of immune response against diverse filoviruses including EBOV, Bundibugyo (BDBV), Sudan (SUDV), and Marburg (MARV) viruses. After assessing the 15 survivors, 5 individuals demonstrated some degree of reactivity to multiple ebolavirus species and, in some instances, Marburg virus. All 5 of these survivors had immunoreactivity to EBOV glycoprotein (GP) and EBOV VP40, and 4 had reactivity to EBOV nucleoprotein (NP). Three of these survivors showed serologic responses to the 3 species of ebolavirus GPs tested (EBOV, BDBV, SUDV). All 5 samples also exhibited ability to neutralize EBOV using live virus, in a plaque reduction neutralization test. Remarkably, 3 of these EBOV survivors had plasma antibody responses to MARV GP. In pseudovirus neutralization assays, serum antibodies from a subset of these survivors also neutralized EBOV, BDBV, SUDV, and Taï Forest virus as well as MARV. Collectively, these findings suggest that some survivors of naturally acquired ebolavirus infection mount not only a pan-ebolavirus response, but also in less frequent cases, a pan-filovirus neutralizing response.
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http://dx.doi.org/10.1093/infdis/jiy453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6217721PMC
November 2018

Strengthening of Surveillance during Monkeypox Outbreak, Republic of the Congo, 2017.

Emerg Infect Dis 2018 06;24(6):1158-1160

Reports of 10 suspected cases of monkeypox in Likouala Department, Republic of the Congo, triggered an investigation and response in March 2017 that included community education and surveillance strengthening. Increasing numbers of outbreaks suggest that monkeypox virus is becoming a more prevalent human pathogen. Diverse approaches are necessary for disease control and prevention.
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http://dx.doi.org/10.3201/eid2406.180248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6004878PMC
June 2018

Serologic Evidence of Ebolavirus Infection in a Population With No History of Outbreaks in the Democratic Republic of the Congo.

J Infect Dis 2018 01;217(4):529-537

UCLA Fielding School of Public Health, Los Angeles, California.

Background: Previous studies suggest that cases of Ebola virus disease (EVD) may go unreported because they are asymptomatic or unrecognized, but evidence is limited by study designs and sample size.

Methods: A large population-based survey was conducted (n = 3415) to assess animal exposures and behaviors associated with Ebolavirus antibody prevalence in rural Kasai Oriental province of the Democratic Republic of Congo (DRC). Fourteen villages were randomly selected and all healthy individuals ≥1 year of age were eligible.

Results: Overall, 11% of subjects tested positive for Zaire Ebolavirus (EBOV) immunoglobulin G antibodies. Odds of seropositivity were higher for study participants older than 15 years of age and for males. Those residing in Kole (closer to the outbreak site) tested positive at a rate 1.6× higher than Lomela, with seropositivity peaking at a site located between Kole and Lomela. Multivariate analyses of behaviors and animal exposures showed that visits to the forest or hunting and exposure to rodents or duikers predicted a higher likelihood of EBOV seropositivity.

Conclusions: These results provide serologic evidence of Ebolavirus exposure in a population residing in non-EBOV outbreak locations in the DRC and define statistically significant activities and animal exposures that associate with EBOV seropositivity.
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http://dx.doi.org/10.1093/infdis/jix619DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5853806PMC
January 2018

Ebola Virus Neutralizing Antibodies Detectable in Survivors of theYambuku, Zaire Outbreak 40 Years after Infection.

J Infect Dis 2018 01;217(2):223-231

Blood Systems Research Institute, and Department of Laboratory Medicine, University of California, San Francisco.

The first reported outbreak of Ebola virus disease occurred in 1976 in Yambuku, Democratic Republic of Congo. Antibody responses in survivors 11 years after infection have been documented. However, this report is the first characterization of anti-Ebola virus antibody persistence and neutralization capacity 40 years after infection. Using ELISAs we measured survivor's immunological response to Ebola virus Zaire (EBOV) glycoprotein and nucleoprotein, and assessed VP40 reactivity. Neutralization of EBOV was measured using a pseudovirus approach and plaque reduction neutralization test with live EBOV. Some survivors from the original EBOV outbreak still harbor antibodies against all 3 measures. Interestingly, a subset of these survivors' serum antibodies could still neutralize live virus 40 years postinitial infection. These data provide the longest documentation of both anti-Ebola serological response and neutralization capacity within any survivor cohort, extending the known duration of response from 11 years postinfection to at least 40 years after symptomatic infection.
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http://dx.doi.org/10.1093/infdis/jix584DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5853670PMC
January 2018

Predictors of measles vaccination coverage among children 6-59 months of age in the Democratic Republic of the Congo.

Vaccine 2018 01 14;36(4):587-593. Epub 2017 Dec 14.

Fielding School of Public Health, University of California, Los Angeles, Department of Epidemiology, Los Angeles, CA 90095, United States. Electronic address:

Background: Measles is a significant contributor to child mortality in the Democratic Republic of the Congo (DRC), despite routine immunization programs and supplementary immunization activities (SIA). Further, national immunization coverage levels may hide disparities among certain groups of children, making effective measles control even more challenging. This study describes measles vaccination coverage and reporting methods and identifies predictors of vaccination among children participating in the 2013-2014 DRC Demographic and Health Survey (DHS).

Methods: We examined vaccination coverage of 6947 children aged 6-59 months. A multivariate logistic regression model was used to identify predictors of vaccination among children reporting vaccination via dated card in order to identify least reached children. We also assessed spatial distribution of vaccination report type by rural versus urban residence.

Results: Urban children with educated mothers were more likely to be vaccinated (OR = 4.1, 95% CI: 1.6, 10.7) versus children of mothers with no education, as were children in wealthier rural families (OR = 2.9, 95% CI: 1.9, 4.4). At the provincial level, urban areas more frequently reported vaccination via dated card than rural areas.

Conclusions: Results indicate that, while the overall coverage level of 70% is too low, socioeconomic and geographic disparities also exist which could make some children even less likely to be vaccinated. Dated records of measles vaccination must be increased, and groups of children with the greatest need should be targeted. As access to routine vaccination services is limited in DRC, identifying and targeting under-reached children should be a strategic means of increasing country-wide effective measles control.
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http://dx.doi.org/10.1016/j.vaccine.2017.11.049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5780300PMC
January 2018

Assessing the cost-effectiveness of different measles vaccination strategies for children in the Democratic Republic of Congo.

Vaccine 2017 10 28;35(45):6187-6194. Epub 2017 Sep 28.

Department of Epidemiology, UCLA Fielding School of Public Health, 650 S Charles E Young Drive, Los Angeles, CA 90095, USA. Electronic address:

Introduction: One of the goals of the Global Measles and Rubella Strategic Plan is the reduction in global measles mortality, with high measles vaccination coverage as one of its core components. While measles mortality has been reduced more than 79%, the disease remains a major cause of childhood vaccine preventable disease burden globally. Measles immunization requires a two-dose schedule and only countries with strong, stable immunization programs can rely on routine services to deliver the second dose. In the Democratic Republic of Congo (DRC), weak health infrastructure and lack of provision of the second dose of measles vaccine necessitates the use of supplementary immunization activities (SIAs) to administer the second dose.

Methods: We modeled three vaccination strategies using an age-structured SIR (Susceptible-Infectious-Recovered) model to simulate natural measles dynamics along with the effect of immunization. We compared the cost-effectiveness of two different strategies for the second dose of Measles Containing Vaccine (MCV) to one dose of MCV through routine immunization services over a 15-year time period for a hypothetical birth cohort of 3 million children.

Results: Compared to strategy 1 (MCV1 only), strategy 2 (MCV2 by SIA) would prevent a total of 5,808,750 measles cases, 156,836 measles-related deaths and save U.S. $199 million. Compared to strategy 1, strategy 3 (MCV2 by RI) would prevent a total of 13,232,250 measles cases, 166,475 measles-related deaths and save U.S. $408 million.

Discussion: Vaccination recommendations should be tailored to each country, offering a framework where countries can adapt to local epidemiological and economical circumstances in the context of other health priorities. Our results reflect the synergistic effect of two doses of MCV and demonstrate that the most cost-effective approach to measles vaccination in DRC is to incorporate the second dose of MCV in the RI schedule provided that high enough coverage can be achieved.
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http://dx.doi.org/10.1016/j.vaccine.2017.09.038DOI Listing
October 2017

Varicella Coinfection in Patients with Active Monkeypox in the Democratic Republic of the Congo.

Ecohealth 2017 09 11;14(3):564-574. Epub 2017 Sep 11.

UCLA Fielding School of Public Health, 41-275 CHS, 650 Charles E. Young Dr. South, Los Angeles, CA, 90095, USA.

From 2006 to 2007, an active surveillance program for human monkeypox (MPX) in the Democratic Republic of the Congo identified 151 cases of coinfection with monkeypox virus and varicella zoster virus from 1158 suspected cases of human MPX (13%). Using clinical and socio-demographic data collected with standardized instruments by trained, local nurse supervisors, we examined a variety of hypotheses to explain the unexpectedly high proportion of coinfections among the sample, including the hypothesis that the two viruses occur independently. The probabilities of disease incidence and selection necessary to yield the observed sample proportion of coinfections under an assumption of independence are plausible given what is known and assumed about human MPX incidence. Cases of human MPX are expected to be underreported, and more coinfections are expected with improved surveillance.
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http://dx.doi.org/10.1007/s10393-017-1266-5DOI Listing
September 2017

Polio immunity and the impact of mass immunization campaigns in the Democratic Republic of the Congo.

Vaccine 2017 10 4;35(42):5693-5699. Epub 2017 Sep 4.

Department of Epidemiology, University of California, Los Angeles 90095, USA. Electronic address:

Background: In order to prevent outbreaks from wild and vaccine-derived poliovirus, maintenance of population immunity in non-endemic countries is critical.

Methods: We estimated population seroprevalence using dried blood spots collected from 4893 children 6-59months olds in the 2013-2014 Demographic and Health Survey in the Democratic Republic of the Congo (DRC).

Results: Population immunity was 81%, 90%, and 70% for poliovirus types 1, 2, and 3, respectively. Among 6-59-month-old children, 78% reported at least one dose of polio in routine immunization, while only 15% had three doses documented on vaccination cards. All children in the study had been eligible for at least two trivalent oral polio vaccine campaigns at the time of enrollment; additional immunization campaigns seroconverted 5.0%, 14%, and 5.5% of non-immune children per-campaign for types 1, 2, and 3, respectively, averaged over relevant campaigns for each serotype.

Conclusions: Overall polio immunity was high at the time of the study, though pockets of low immunity cannot be ruled out. The DRC still relies on supplementary immunization campaigns, and this report stresses the importance of the quality and coverage of those campaigns over their quantity, as well as the importance of routine immunization.
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http://dx.doi.org/10.1016/j.vaccine.2017.08.063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628608PMC
October 2017

Low Varicella Zoster Virus Seroprevalence Among Young Children in the Democratic Republic of the Congo.

Pediatr Infect Dis J 2018 02;37(2):138-143

Background: Varicella zoster virus (VZV) causes both varicella (chickenpox) and herpes zoster (shingles) and is associated with significant global morbidity. Most epidemiological data on VZV come from high-income countries, and to date there are limited data on the burden of VZV in Africa.

Methods: We assessed the seroprevalence of VZV antibodies among children in the Democratic Republic of Congo in collaboration with the 2013-2014 Demographic and Health Survey. Dried blood spot samples collected from children 6-59 months of age were run on Dynex™ Technologies Multiplier FLEX® chemiluminescent immunoassay platform to assess serologic response. Multivariate logistic regression was then used to determine risk factors for VZV seropositivity.

Results: Serologic and survey data were matched for 7,195 children 6-59 months of age, among whom 8% were positive and 2% indeterminate for VZV antibodies in weighted analyses. In multivariate analyses, the odds of seropositivity increased with increasing age, increasing socioeconomic status, mother's education level, rural residence, and province (South Kivu, North Kivu, Bandundu, Bas Congo had the highest odds of a positive test result compared with Kinshasa).

Conclusion: Our data suggest that VZV is circulating in DRC, and seropositivity is low among children 6-59 months. Seropositivity increased with age and varied by other sociodemographic factors, such as geographic location. This study provides the first nationally representative estimates of VZV infection among children in the DRC.
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http://dx.doi.org/10.1097/INF.0000000000001750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5762406PMC
February 2018

Human Exposure to Wild Animals in the Sankuru Province of the Democratic Republic of the Congo.

Ecohealth 2017 09 22;14(3):552-563. Epub 2017 Aug 22.

National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.

Due to the high level of biological diversity in the Congo Basin and human population dependence on bushmeat, the DRC represents an ideal location for expanding knowledge on wild animal exposures and thus the potential for transmission of zoonotic pathogens. However, limited information exists on patterns and extent of contact with wildlife in such communities. Using a cross-sectional study, 14 villages in the Sankuru Province of the DRC were surveyed between August and September 2007. Villagers ≥ 1 year of age and at home of the time of the survey were eligible and enrolled to describe and assess factors associated with animal exposures (both activity and type of animal). Among respondents, 91% reported exposure to rodents, 89% to duikers, 78% to non-human primates (NHPs), and 32% reported contact with bats in the month prior to the survey. The most frequently reported activities included eating (95%), cooking (70%), and butchering or skinning of animals (55%). The activities and animals to which subjects had contact varied by sex and age. Moreover, we observed a high correlation of the same activities across animal types. In this and other populations that rely on bushmeat, there is a high frequency of exposure to multiple animal species through various modalities. In the event of future zoonotic disease outbreaks, effective public health interventions and campaigns that mitigate the risk of animal contact during outbreaks need to be broad to include various modes of contact and should be directed to both men and women across all age groups. As available information is limited, further studies are necessary to better understand the complex relationships and exposures individuals have with animals.
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http://dx.doi.org/10.1007/s10393-017-1262-9DOI Listing
September 2017

Prevalence of Rubella Antibodies Among Children in the Democratic Republic of the Congo.

Pediatr Infect Dis J 2018 Jan;37(1):28-34

Background: While generally mild in children, rubella infection in early pregnancy can lead to miscarriage, fetal death or congenital rubella syndrome. Rubella vaccination is not yet available as a part of routine immunization in the Democratic Republic of the Congo (DRC), and the burden of infection is unknown.

Methods: In collaboration with the 2013-2014 DRC Demographic and Health Survey, a serosurvey was carried out to assess population immunity to vaccine-preventable diseases. Dry blood spot samples collected from children 6-59 months of age were processed using the Dynex Technologies Multiplier FLEX chemiluminescent immunoassay platform (Dynex Technologies, Chantilly, VA).

Results: Among the 7195 6- to 59-month-old children, 33% were positive and <1% indeterminate for rubella antibodies in weighted analyses. Seroprevalence was positively associated with age of the child and province, with seropositivity highest in Bandundu (53%) and lowest in Kasai-Oriental (20%). In multivariate analyses, serologic evidence of infection was associated with age of the mother and child, socioeconomic status and geographic location.

Conclusions: Rubella infection is prevalent among children in the DRC, and while most seroconversion occurs in young children, a significant proportion of children remain at risk and may enter reproductive age susceptible to rubella infection. While not currently in place, implementation of a surveillance program will provide improved estimates of both rubella virus circulation and the burden of congenital rubella syndrome. Such information will play an important role in future policy decisions, vaccine delivery strategies and may provide a basis upon which the effectiveness of rubella antigen introduction may be assessed.
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http://dx.doi.org/10.1097/INF.0000000000001703DOI Listing
January 2018
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