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But scientists began sounding the alarm after multiple outbreaks were discovered in Pacific islands and south-east Asia.
Multiple outbreaks were found in 11 of the 12 pilot districts within the first 3 months of the program operation.
Indeed, during 2004 and 2007, years when multiple outbreaks were identified, many patients who sought treatment for symptoms of encephalitis in hospitals located near identified outbreak areas were tested for Nipah virus.
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This, despite multiple outbreaks being prevented by early detection thanks to the cost-efficient program.
If pathogen resistant strains evolve under drug pressure, multiple outbreaks are possible with variability in their characteristics, magnitude, and timing.
Additionally, it is possible that the multiple outbreaks are a result of multiple introductions likely through nomadic herds from neighboring endemic areas rather than through viral persistence.
However, multiple measles outbreaks were reported in recent years in countries where elimination has been achieved, such as the United States (8 ) and Australia (9 ), mainly because of transmission resulting from international travel and low vaccine coverage in some populations (10 ).
Specifically, whether these seasonal epidemics arise from a single clonal strain or reflect superimposition of multiple small outbreaks is not clear.
Because most outbreaks were multiple days, this study reports results only for a sequential test (Page's) applied to the forecast errors.
The timeliness of diagnostic confirmation and outbreak response was much improved over that during previous EHF outbreaks in Uganda (timeline shown in Figure 2), during which transmission of the virus occurred for multiple months before the outbreaks were detected (13 – 15 ).
Since it was first detected in 1930s, multiple outbreaks have been reported in different parts of Africa and the Middle East [ 16– 20].
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