Median Age Of Cases Research Articles

Failure of chronic hydroxychloroquine in preventing severe complications of COVID-19 in patients with rheumatic diseases.

ObjectiveTo compare baseline characteristics, clinical presentations and outcomes of patients with rheumatic conditions requiring hospitalization for coronavirus disease 2019 (COVID-19) who received chronic HCQ with those who did not receive chronic HCQ.MethodsWe identified all patients with a rheumatologic disease who were admitted with COVID-19 to two hospitals in New York City between 3 March 3 and 30 April 2020. Patients who received chronic HCQ prior to admission were matched 1:2 (±10 years of age) with patients who did not receive chronic HCQ. We compared demographics, comorbidities, HCQ dosages, concurrent medications, presentations and outcomes between the groups.ResultsThere were 14 patients receiving HCQ and 28 matched control subjects. The median age of cases was 63 years [interquartile range (IQR) 43–73) and 60 years (IQR 41–75) for controls. Control subjects had a higher prevalence of pulmonary diseases (42.8%), diabetes (35.7%) and obesity (35.7%) than their case counterparts (28.6%, 14.3% and 7.1%, respectively). A higher proportion of cases than control subjects (50% vs 25%) reported the use of prednisone for their rheumatic conditions prior to admission. Despite these differences in baseline characteristics, univariate logistic regression revealed no statistically significant differences in the need for mechanical ventilation [OR 1.5 (95% CI 0.34, 6.38)] or in-hospital mortality [OR 0.77 (95% CI 0.13, 4.56)].ConclusionHCQ therapy in individuals with rheumatic conditions was not associated with less severe presentations of COVID-19 among hospitalized patients compared with individuals with rheumatic conditions not receiving HCQ.

Dimethylarginines correlate to common carotid artery wall layer dimensions and cardiovascular risk factors in pregnant women with/without preeclampsia: A group comparative study

ObjectivesAsymmetric- and symmetric dimethylarginines (ADMA, SDMA) are elevated in cardiovascular disease (CVD). Preeclampsia is a pregnancy-specific syndrome and is an independent risk factor for subsequent CVD. Aims were to investigate whether ADMA, SDMA levels and l-arginine/ADMA and l-arginine/SDMA ratios during pregnancy and their changes from pregnancy to postpartum are associated to arterial wall layer dimensions and cardiovascular risk factors in women with and without preeclampsia. Study designDimethylarginines were analyzed by LC–MS, and the common-carotid-artery (CCA) intima and media thicknesses were estimated using 22-MHz non-invasive ultrasonography in women with preeclampsia (cases = 48) and normal pregnancies (controls = 58) in similar gestational age, with reassessment one-year postpartum. A thick intima, thin media and high intima/media ratio (I/M) indicates a less healthy arterial wall. ResultsThe median age of cases and controls was 30 years. During pregnancy, women with preeclampsia had higher plasma ADMA, SDMA and lower l-arginine/ADMA and l-arginine/SDMA (all p < 0.01) than women with normal pregnancies. Further, ADMA, SDMA, l-arginine/ADMA and l-arginine/SDMA correlated to intima thickness (rs = 0.33/0.33/−0.33/−0.35 and p < 0.01), I/M (rs = 0.26/0.28/−0.22/−0.26 and p < 0.05) and mean arterial pressure (MAP) (rs = 0.43/0.42/−0.39/−0.40 and p < 0.0001). Changes in ADMA, SDMA and l-arginine/SDMA from pregnancy to postpartum correlated to changes in intima thickness (rs = 0.22/0.32/-0.21 and p < 0.05/<0.01/<0.05), I/M (rs = 0.22/0.31/0.08 and p < 0.05/<0.01/=0.43) and MAP (rs = 0.31/0.53/-0.25 and p < 0.01/<0.001/<0.05). No correlations were found for conventional CCA intima-media-thickness. ConclusionsDimethylarginines were associated to signs of adverse effects on arterial wall layer dimensions and cardiovascular risk factors in women with and without preeclampsia, during pregnancy and to their changes from pregnancy up to one-year postpartum.

Autoimmune Sclerosing Cholangitis in Children: A Prospective Case-Control Study.

PurposeIn children overlap of autoimmune hepatitis (AIH) and primary sclerosing cholangitis is labelled as autoimmune sclerosing cholangitis (ASC). The only prospective pediatric study showed a high prevalence of ASC by using endoscopic retrograde cholangiopancreatography. Aims of our study were to find the prevalence of ASC by using magnetic resonance cholangiography (MRC) in AIH and in non-AIH cirrhosis and to compare clinical presentation and outcome of AIH and ASC.MethodsProspectively we did MRC in 38 children with AIH (cases) and 19 disease controls (Wilson disease). Multiple biliary strictures with proximal dilatation on MRC were taken as definitive changes of ASC. Detail clinical, laboratory parameters, liver histopathology and treatment outcome were recorded.ResultsThe median age of cases was 11.5 (3–18) years, 22 (57.9%) were girls and 28 (73.7%) were diagnosed as type 1 AIH. MRC was done in 11 children (28.9%) at the time of diagnosis and in 27 (71.1%) after a median follow-up of 2.5 (0.3–10) years. Abnormal MRC changes were seen in 14/38 (36.8%) of AIH and 8/19 (42.1%) of controls. However, definite changes of ASC were present in four (10.5%) children in AIH and none in controls. None of the clinical, laboratory, histological parameters and treatment response were significantly different between ASC and AIH groups.ConclusionThe prevalence of ASC in children with AIH was just 10.5%. We suggest MRC in select group with cholestatic features, inflammatory bowel disease and in those who showed poor response to immunosuppression instead of all children with AIH.

Epidemiological investigation of recurrent outbreaks of haemolytic uraemic syndrome caused by Shiga toxin-producing Escherichia coli serotype O55:H7 in England, 2014-2018.

Recurrent outbreaks of haemolytic uraemic syndrome (HUS) caused by Shiga toxin-producing Escherichia coli (STEC) serotype O55:H7 occurred in England between 2014 and 2018. We reviewed the epidemiological evidence to identify potential source(s) and transmission routes of the pathogen, and to assess the on-going risk to public health. Over the 5-year period, there were 43 confirmed and three probable cases of STEC O55:H7. The median age of cases was 4 years old (range 6 months to 69 years old) and over half of all cases were female (28/46, 61%). There were 36/46 (78.3%) symptomatic cases, and over half of all cases developed HUS (25/46, 54%), including two fatal cases. No common food or environmental exposures were identified, although the majority of cases lived in rural or semi-rural environments and reported contact with both wild and domestic animals. This investigation informed policy on the clinical and public health management of HUS caused by STEC other than serotype O157:H7 (non-O157 STEC) in England, including comprehensive testing of all household contacts and household pets and more widespread use of polymerase chain reaction assays for the rapid diagnosis of STEC-HUS.

Intussusception among infants in Tanzania: findings from prospective hospital-based surveillance, 2013-2016.

Introductionintussusception surveillance was initiated in Tanzania in 2013 after monovalent rotavirus vaccine was introduced, as part of the 7-country African evaluation to assess whether the vaccine was associated with an increased risk of intussusception. An increased risk from vaccine was not identified. Published data on intussusception in Tanzanian infants are limited.Methodsprospective intussusception surveillance was conducted at 7 referral hospitals during 2013-2016 to identify all infants with intussusception meeting Brighton Level 1 criteria. Demographic, household and clinical data were collected by hospital clinicians and analyzed.Resultsa total of 207 intussusception cases were identified. The median age of cases was 5.8 months and nearly three-quarters were aged 4-7 months. Median number of days from symptom onset to admission at treatment hospital was 3 (IQR 2-5). Seventy-eight percent (152/195) of cases had been admitted at another hospital before transfer to the treating hospital. Enema reduction was not available; all infants were treated surgically and 55% (114/207) had intestinal resection. The overall case-fatality rate was 30% (62/206). Compared with infants who survived, those who died had longer duration of symptoms before admission to treatment hospital (median 4 vs 3 days; p < 0.01), higher rate of intestinal resection (81% [60/82] vs 44% [64/144], p < 0.001), and from families with lower incomes (i.e., less likely to own a television [p < 0.01] and refrigerator [p < 0.05).ConclusionTanzanian infants who develop intussusception have a high case-fatality rate. Raising the index of suspicion among healthcare providers, allocating resources to allow wider availability of abdominal ultrasound for earlier diagnosis, and training teams in ultrasound-guided enema reduction techniques used in other African countries could reduce the fatality rate.

Epidemiological analysis of 3,219 COVID-19 outbreaks in the state of Baden-Wuerttemberg, Germany

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has emerged as an unprecedented global crisis challenging health systems. This paper aims to assess and characterise SARS-CoV-2 outbreaks in the state of Baden-Wuerttemberg to identify groups at greatest risk, to establish early measures to curb transmission. We analysed all mandatory notified (i.e. laboratory-confirmed) coronavirus disease (COVID-19) outbreaks with more than two cases in Baden-Wuerttemberg from calendar weeks 18-49 (from 27 April to 6 December 2020). We used the following classification for settings: asylum and refugee accommodation, care homes, care facilities, day care child centres, hobby-related, hospitality, hospitals, households, other, residence halls, schools, supported housing, training schools, transportation, treatment facilities and workplace (occupational). We used R program version 3.6.3 for analysis. In our analysis, 3219 outbreaks with 22 238 individuals were included. About 48% were in household and hobby-related settings. Care homes accounted for 9.5% of outbreaks and 21.6% of cases. The median age across all settings was 43 (interquartile range (IQR) 24-63). The median age of cases in care homes was 81 (IQR 56-88). Of all reported cases in care homes, 72.1% were women. Over 30% (466/1511) of hospitalisations were among cases in care homes compared to 17.7% (268/1511) in households. Overall, 70% (500/715) of all deceased persons in outbreaks in the study period were in care homes compared to 4.2% in household settings (30/715). We observed an exponential increase in the number of notified outbreaks starting around the 41st week with N = 291 outbreaks reported in week 49. The median number of cases in outbreaks in care homes and care facilities after the 40th week was 14 (IQR 5-29) and 11 (IQR 5-20), respectively, compared to 3 (IQR 3-5) in households. We observed an increase in hospitalisations, and mortality associated with COVID-19 outbreaks in care homes after the 40th week. We found the care home demographic to be at greatest risk after the 40th week, based on the exponential increase in outbreaks, the number of cases, hospitalisations and mortality trends. Our analysis highlights the necessity of targeted, setting-specific approaches to control transmission in this vulnerable population. Regular screening of staff members and visitors' using rapid antigen point-of-care-tests could be a game-changer in curbing transmission in this setting.

Rubella Outbreak Investigation at General Tadesse Biru Primary School, Addis Ababa, Ethiopia 2018

Background: In African countries, rubella is widely under-recognized public health problem, and information on its epidemiology is very limited. In Ethiopia, rubella is not prioritized disease under surveillance and its vaccine has not been introduced into infant vaccination schedule. Rumor of suspected rubella outbreak received on January 26/2018. The purpose of investigation was to establish rumor existence, describe cases epidemiologically, identify causative agent and source of the outbreak to support outbreak control activities. Methods: A1:2 unmatched case-control study conducted at General Tadesse Biru Primary School, Addis Ababa, Ethiopia from February 3-25/2018. Total of 41 cases and 82 controls included. Controls selected conveniently from same school and data collected using structured questioner. Data analysis done using Epi-info software version7.2.1.0. Result: Total of 41 rubella cases identified. Index case and source of outbreak were not identified. Rubella sample positivity rate was 20%. First case seen on 5th January and last case on 19th February/2018. Most 23 (56.1%) cases were females and 17 (41.46%) among grade 1 and 2 students. Median age of cases was 10 years (IQR=4). Overall attack rate in the school was 1.39% and case fatality rate zero. All cases were complaining rash and 80.49% had fever. Educational status of grade 5-6 and 7-8 had 0.13- and 0.12-time reduced risk of developing rubella disease than grade 1-2 at P-value less than 0.05, respectively. Conclusion: Although index case and source of infection not identified, the outbreak might be driven by contact and sharing transportation service. Late notification causes late investigation and control. Provision of health education at school and community increase people’s awareness on rubella that contribute to control the outbreak.

Determinants of scabies outbreak in Takusa district of Amhara Region, Northwest Ethiopia.

BackgroundHuman scabies is a highly contagious human dermatitis disease. As indicated by the national and regional reports, the epidemic of scabies became a major public health problem in Ethiopia since 2015.ObjectiveTo identify the determinant factors of scabies outbreak in Takusa district, Northwest Ethiopia, 2017.MethodsA community based unmatched case-control study among 188 participants (63 cases and 125 controls) was conducted in Takusa district from September to October 2017. Data were collected using a pretested structured questionnaire. Multivariable logistic regression analysis was computed using SPSS version 22 to identify factors associated with scabies. Odds ratio at 95% CI and p-value less than 0.05 were used to describe the strength of the association and statistical significance.ResultsThe median age of cases was 20 years (ranges1-61). Presence of person with itching in the family (AOR=7.7, 95% CI:1.9-30.5), sleeping with scabies patient (AOR=3.99, 95% CI:1.37-11.7), travel to scabies epidemic area in the last six weeks (AOR=3.79, 95%CI:1.28-11.1) and infrequent use of detergent for showering (AOR=4.85; 95% CI: 1.3-17.9)) were found to be determinant factors of scabies outbreak.ConclusionFrequent contact with people who develop scabies at home, not using detergents for washing, and mobility of people from non-epidemic to the epidemic areas were determinant factors. Giving special emphasis on regular awareness creation to the rural community is important to prevent scabies outbreak.

Unsterile injection equipment associated with HIV outbreak and an extremely high prevalence of HCV-A case-control investigation from Unnao, India.

The integrated counseling and testing center (ICTC) located in the district hospital, Unnao in the northern state of Uttar Pradesh (UP), India witnessed an increased detection of HIV among its attendees in July 2017. Subsequently, health camps were organized by the UP State AIDS Control Society in the villages and townships contributing to such detection. We conducted a case-control study to identify factors associated with this increased detection; 33 cases and 125 controls were enrolled. Cases were individuals, detected HIV sero-reactive during November 2017-April 2018 from three locations namely Premganj, Karimuddinpur and Chakmeerapur in the Bangarmau block of the district of Unnao. Controls hailed from the same geographical setting and tested HIV sero-nonreactive either in health camps or at ICTC centers from where the cases were detected. Misclassification bias was avoided by confirming HIV sero-status of both cases as well as controls prior to final analysis. Study participants were interviewed on various risk practices and invasive treatment procedures. They were also tested for HIV and other bio-markers reflecting unsafe injecting and sexual exposures such as hepatitis B surface antigen (HBsAg), anti-HCV antibody (HCV Ab), anti-herpes simplex-2 Immunoglobulin G (HSV-2 IgG) and rapid plasma regain (RPR) test for syphilis. Secondary data analysis on three time points during 2015 through 2018 revealed a rising trend of HIV among attendees of the ICTCs (ICTC-Hasanganj, ICTC-Unnao district hospital and ICTC- Nawabganj) catering to the entire district of Unnao. While there was a seven fold rise of HIV among ICTC attendees of Hasanganj (χ2 value for trend 23.83; p < 0.001), the rise in Unnao district hospital was twofold (χ2 value for trend 4.37; p < 0.05) and was tenfold at ICTC-Nawabganj (χ2 value for trend 5.23; p < 0.05) indicating risk of infection prevailing throughout the district. Primary data was generated through interviews and laboratory investigations as mentioned above. The median age of cases and controls was 50 year (minimum 18 -maximum 68; IQR 31-57) and 38 year (minimum 18 -maximum 78; IQR 29-50) respectively. Thirty six percent of the cases and 47% of controls were male. A significantly higher proportion of cases (85%) had HCV Ab compared to controls (56%; OR 4.4, 95% CI 1.5-12.1); none reported injection drug use. However, cases and controls did not differ significantly regarding presence of HSV-2 IgG (6% versus 8% respectively). Neither any significant difference existed between cases and controls in terms of receiving blood transfusion, undergoing invasive surgical procedures, tattooing, tonsuring of head or skin piercing. In multivariate logistic regression model, 'unsafe injection exposure during treatment-seeking'(AOR 6.61, 95% CI 1.80-24.18) and 'receipt of intramuscular injection in last five years' (AOR 7.20, 95% CI 1.48-34.88) were independently associated with HIV sero-reactive status. The monophyletic clustering of HIV sequences from 14 cases (HIV-1 pol gene amplified) indicated a common ancestry. Availability of auto-disabled syringes and needles, empowerment of the local communities and effective regulatory practices across care settings would serve as important intervention measures in this context.

Clinical characteristics of SARS-CoV-2 infection in children with cystic fibrosis: An international observational study

BackgroundThe presence of co-morbidities, including underlying respiratory problems, has been identified as a risk factor for severe COVID-19 disease. Information on the clinical course of SARS-CoV-2 infection in children with cystic fibrosis (CF) is limited, yet vital to provide accurate advice for children with CF, their families, caregivers and clinical teams. MethodsCases of SARS-CoV-2 infection in children with CF aged less than 18 years were collated by the CF Registry Global Harmonization Group across 13 countries between 1 February and 7 August 2020. ResultsData on 105 children were collated and analysed. Median age of cases was ten years (interquartile range 6–15), 54% were male and median percentage predicted forced expiratory volume in one second was 94% (interquartile range 79–104). The majority (71%) of children were managed in the community during their COVID-19 illness. Out of 24 children admitted to hospital, six required supplementary oxygen and two non-invasive ventilation. Around half were prescribed antibiotics, five children received antiviral treatments, four azithromycin and one additional corticosteroids. Children that were hospitalised had lower lung function and reduced body mass index Z-scores. One child died six weeks after testing positive for SARS-CoV-2 following a deterioration that was not attributed to COVID-19 disease. ConclusionsSARS-CoV-2 infection in children with CF is usually associated with a mild illness in those who do not have pre-existing severe lung disease.

Risk factors associated with cholera outbreak in Mubi Adamawa state – Nigeria, 2018

Background: Cholera is associated with high morbidity and mortality. On 16th May, 2018 an outbreak of suspected cholera was reported in Mubi North and Mubi South Local Government Areas of Adamawa State, Nigeria. We investigated the outbreak to characterize it, determine its associated factors and control it. Methods and materials: We defined a case as any person aged ≥ 2 years presenting with acute watery diarrhea, severe dehydration ± vomiting; while a control was any person aged ≥ 2 years without acute watery diarrhea, severe dehydration ± vomiting. We reviewed the linelist and conducted active case search in health facilities and neighbouring communities. We conducted a 1:1 unmatched case-control study. Rapid diagnostic testing and bacterial culture were conducted on stool and water samples to confirm diagnosis. We calculated frequencies, rates, Adjusted Odds Ratios (AOR) and 95% Confidence intervals (CI). Results: There were 1,545 cases (attack rate: 13.6/ 10,000 population) and a case fatality rate of 1.7%. Median age of cases was 11 years (range: 2 months–80 years). Independent risk factors associated with the outbreak were storing water in uncovered container (AOR = 2.3; 95% CI = 1.1–4.8), not washing hand after toilet use (AOR = 17.6; 95% CI = 7.0–44.1), using water from truck water vendors (AOR = 4.8; 95% CI = 2.1–11.1) and contact with persons having diarrhea (AOR = 10.0; 95% CI = 2.6–33.3). 73 samples were positive to RDT while 35 yielded a growth of Vibrio cholerae. Conclusion: Cholera outbreak was confirmed in Mubi associated with poor sanitary conditions and lack of potable water. We performed chlorination of water sources, household disinfection, sensitized communities and strengthened case management. We recommended strengthening surveillance system and notification, sustained treatment of public water sources and health promotion in the communities.

Rapid response and epidemic preparedness led to control of dengue outbreak in rural areas of Namakkal district, Tamilnadu, India, 2017 and 2018.

Background: Tamilnadu state, India reported 11,744 dengue cases in 2017. Dengue cases started increasing in rural parts of Namakkal district, Tamilnadu in 2017. Following the epidemic, public health department took control measures. We analysed the dengue epidemic to measure the impact of control measures. Methods and materials: We did a quasi-experimental study. We included rural residents of Namakkal district in the study. We defined a confirmed case of dengue as any patient with fever for more than 2 days and positive for IgM antibody or NS1 antigen by ELISA method. Rapid response team (RRT) did active surveillance, collected clinical samples and sent to district public health laboratory. RRT conducted special medical camps, chlorinated all sources of stored water and did mass cleaning of affected areas. RRT conducted anti-larval works and fogging activities in affected areas. They also created awareness among community through meetings. We collected line list of confirmed dengue cases from district public health laboratory and identified private laboratories for the year 2017. We included cases which were cross notified from other districts. We collected dengue linelist for 2018 for comparing with baseline. We calculated proportions for attack rate per 1 million population in all rural health blocks of Namakkal. We calculated paired t test for comparing mean dengue cases reported in each health blocks in 2017 and 2018 to measure the effect of control measures. Results: There were 15 rural health blocks in Namakkal district. There were 982 cases(Attack rate = 696/million) in 2017. Median age of cases were 17 years (Range: 4 months to 80 years). Attack rate among females was 685/million (471/686718) and among males was 706/ million(511/723313) in 2017. Dengue cases decreased to 78 cases (Attack rate = 55/million) in 2018. Attack rate was 48/million among females (n = 33) and 62/million among males (n = 45). Outbreak was controlled with decreased incidence of cases in all 15 blocks in 2018. (Mean difference was 60, with standard deviation of 28). Paired t test was significant at p < 0.05 (t = 8.3). Conclusion: Dengue epidemic was effectively controlled in rural areas of Namakkal by rapid response team. We recommend to implement similar control measures in other areas with dengue epidemic.

Determinants of HIV-malaria co-infection among people living with HIV on anti-retroviral therapy in Northeast Ethiopia: unmatched case control study

BackgroundHIV and malaria are the leading causes of morbidity and mortality in the developing world including Ethiopia. Globally, HIV-malaria co-infection causes approximately 3 million deaths per year. However, both these infections are preventable if measures are taken on determinant factors. The objective of the study was therefore to assess factors associated with HIV-malaria co-infection among HIV-positive people who lived in Shewarobit district, northeast Ethiopia.MethodsUnmatched case-control study was conducted among people living with HIV (PLWHA) in Shewarobit district from February 28, 2018, to April 30, 2018. The sample size was determined taking the assumption of 95% CI, 85% power, 3:1 control to case ratio, the proportion of PLWHA-malaria coinfection of 22.7%, OR 2.73, and 10% non-response rate. The final sample size was 262 (66 cases and 196 controls). Cases were adults on anti-retroviral therapy and diagnosed positive for malaria by microscopy while controls were adults on anti-retroviral therapy and diagnosed negative for malaria by microscopy in the previous 6 months before the survey.ResultThe median age of cases and controls in years was 35 (IQR = 19) and 38 (IQR = 19) respectively. Variables that had a significant association with HIV-malaria co-infection were non-in-door residual spraying (adjusted odds ratio (AOR) = 4.91; 95% CI 4.03, 15.13), poor perception on the health risk of HIV-malaria co-infections (AOR = 4.11; 95% CI 1.28, 10.17), non-use of insecticidal treated bed nets (AOR = 6.21; 95%CI 2.74, 14.11), non-use of cotrimoxazole prophylaxis (AOR = 2.42; 95% CI 1.11, 5.28), and not received health education on the risk of HIV-malaria interaction (AOR = 4.11; 95% CI 1.24, 4.84).ConclusionProvision of cotrimoxazole prophylaxis, sleeping under an insecticidal treated bed net, and indoor residual spraying help to reduce HIV-malaria co-infection-associated morbidity/mortality.

Source attribution of community-acquired cases of Legionnaires' disease-results from the German LeTriWa study; Berlin, 2016-2019.

IntroductionSources of infection of most cases of community-acquired Legionnaires’ disease (CALD) are unknown.ObjectiveIdentification of sources of infection of CALD.SettingBerlin; December 2016–May 2019.ParticipantsAdult cases of CALD reported to district health authorities and consenting to the study; age and hospital matched controls.Main outcome measurePercentage of cases of CALD with attributed source of infection.MethodsAnalysis of secondary patient samples for monoclonal antibody (MAb) type (and sequence type); questionnaire-based interviews, analysis of standard household water samples for Legionella concentration followed by MAb (and sequence) typing of Legionella pneumophila serogroup 1 (Lp1) isolates; among cases taking of additional water samples to identify the infectious source as appropriate; recruitment of control persons for comparison of exposure history and Legionella in standard household water samples. For each case an appraisal matrix was filled in to attribute any of three source types (external (non-residence) source, residential non-drinking water (RnDW) source (not directly from drinking water outlet), residential drinking water (RDW) as source) using three evidence types (microbiological results, cluster evidence, analytical-comparative evidence (using added information from controls)).ResultsInclusion of 111 study cases and 202 controls. Median age of cases was 67 years (range 25–93 years), 74 (67%) were male. Among 65 patients with urine typable for MAb type we found a MAb 3/1-positive strain in all of them. Compared to controls being a case was not associated with a higher Legionella concentration in standard household water samples, however, the presence of a MAb 3/1-positive strain was significantly associated (odds ratio (OR) = 4.9, 95% confidence interval (CI) 1.7 to 11). Thus, a source was attributed by microbiological evidence if it contained a MAb 3/1-positive strain. A source was attributed by cluster evidence if at least two cases were exposed to the same source. Statistically significant general source types were attributed by calculating the population attributable risk (analytical-comparative evidence). We identified an external source in 16 (14%) cases, and RDW as source in 28 (25%). Wearing inadequately disinfected dentures was the only RnDW source significantly associated with cases (OR = 3.2, 95% CI 1.3 to 7.8) and led to an additional 8% of cases with source attribution, for a total of 48% of cases attributed.ConclusionUsing the appraisal matrix we attributed almost half of all cases of CALD to an infectious source, predominantly RDW. Risk for LD seems to be conferred primarily by the type of Legionella rather than the amount. Dentures as a new infectious source needs further, in particular, integrated microbiological, molecular and epidemiological confirmation.

Use of specific pesticides is associated with increased risk of developing shingles in the Agricultural Health Study

BACKGROUND: Some pesticides are immunotoxic and may increase risk of immune-mediated diseases. Risk of shingles, the clinical reactivation of varicella zoster virus (VZV), increases with aging and immunosuppression; little is known about associations with pesticides. OBJECTIVE: We evaluated pesticide use in relation to incident shingles among licensed pesticide applicators in the Agricultural Health Study, a prospective cohort in Iowa and North Carolina. METHODS: We identified 590 incident shingles cases among 12,820 applicators (97% male farmers) enrolled in 1993-7 and followed for a median of 12 years (IQR 11,13). We evaluated associations with ever-use of 48 pesticides reported at enrollment and examined exposure-response trends for cumulative intensity-weighted lifetime days of use. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox proportional hazard models, adjusting for state and correlated pesticides, and allowing estimates to vary by median age of cases (60 years). RESULTS: Shingles risk was associated with ever-use of 14 pesticides (5 insecticides, 2 fumigants, 2 fungicides, and 5 herbicides (HRs 1.22 to 1.94). Increasing exposure-response trends (p&lt;0.01) were seen for four insecticides (coumaphos, carbaryl, diazinon, permethrin on crops), two fumigants (methyl bromide, carbon tetrachloride), and two herbicides (trifluralin, and 2,4-D). In older participants, shingles was associated with self-reported history of a high pesticide exposure event (HR 1.89; 95%CI 1.45, 2.45). Findings were similar after excluding those with a history of leukemia/lymphoma or autoimmune diseases. CONCLUSIONS: Specific pesticides were related to shingles risk in farmers, with several demonstrating exposure-response trends. These novel findings support further investigation of pesticides in relation to shingles risk and VZV immunity. Some pesticides may compromise cell-mediated immune responses to VZV, as seen with aging and immunosuppressant medications, which may have broader implications for vaccine efficacy and susceptibility to other infections.

High COVID-19 attack rate among attendees of wedding events in Bali, Indonesia, March 2020.

Large gatherings are associated with the spread of coronavirus 2019 disease (COVID-19); however, transmission dynamics are not well understood. We investigated a cluster of COVID-19 cases in returning Australian residents who attended wedding events in Bali, Indonesia, during 15- 21 March 2020. Attendees participated in various social events and were in close proximity, providing multiple opportunities for transmission. We conducted a retrospective cohort study of the 41 attendees, of whom 17 participated in a structured interview that included history of illness, risk exposures and event attendance. We obtained data for the remaining 24 participants through corroborative histories and public health unit case investigations. COVID-19 was identified in 56% of attendees (23/41), with illness onset between 21 March and 2 April 2020. One secondary case was identified in a household contact of an attendee. The median age of cases was 31 years (range 3-64). One case was hospitalised and did not require critical care. There were no deaths. No cases occurred among six attendees who left prior to the actual wedding day. Guests attended multiple events and participated in high-risk transmission behaviours such as shaking hands, kissing, dancing, sharing drinks and sharing shisha (water pipes). Attack rates ranged from 64% to 87% for different exposures. We could not identify a single risk exposure that accounted for all cases; it is therefore likely there were multiple episodes of transmission. Our investigation identified a high attack rate of COVID-19 among a cohort of wedding event attendees. Attendees engaged in close physical contact, shared drinks and shisha, and were in close proximity during the wedding events, which may have contributed to the high attack rate. This outbreak highlights the significant role social events can play in transmission of COVID-19 and underscores why it is important to limit gatherings and close physical contact to control the spread of the virus.

Who is at risk for measles in Italy? Continued measles outbreaks in 2019 and barriers to elimination

Abstract Background Measles is a highly contagious vaccine preventable disease that can lead to serious complications, including death. All five regions of the World Health Organization have set targets to eliminate measles. In Italy, measles vaccination was introduced in 1976, with sustained low uptake in the 1980s and 1990s. Uptake improved in subsequent years but never reached 95% coverage required for elimination. Two doses of measles-mumps-rubella (MMR) vaccine are recommended (at 12-15 months and 5-6 years respectively). Since July 2017, MMR vaccine has become mandatory for all children up to 16 years of age. Large outbreaks continue to occur, with over 8.000 cases reported in 2017-2018. Methods We analysed measles cases reported to the national integrated measles and rubella surveillance system during January 1 - December 31, 2019. Results From 1 January to 31 December 2019, 1,627 cases (87% laboratory-confirmed), were reported from all 21 administrative regions. National incidence was 27 cases/million. Overall, 86% of cases were unvaccinated. Median age was 30 years but the highest incidence was in infants below one year of age. Ninety-six cases were reported amongst healthcare workers and transmission in the healthcare setting was frequent. Overall, 31% of cases reported complications, including three cases of encephalitis (in two adults and one child) and one death in an adult patient. Complications were more frequent in cases ≥20 years of age compared to younger patients. Forty-six percent of cases were hospitalised. Conclusions The median age of cases has increased further in 2019 compared to 2017 (27 years) and 2018 (28 years). The proportions of complicated and hospitalised cases are high, this may be due to the high median age of cases but also to underreporting from general practitioners who are likely to see milder cases. Wide immunity gaps among adults (including healthcare workers) and nosocomial transmission are major challenges to measles elimination in Italy. Key messages Measles is still endemic in Italy and large outbreaks continue to occur, with a significant public health impact. Wide immunity gaps among adults (including healthcare workers) and nosocomial transmission are major challenges to measles elimination in Italy.

Puerperal Sepsis Caused by Clostridium Innocuum in a Patient with Placenta Accreta and Literature Review

Puerperal Sepsis Caused by Clostridium Innocuum in a Patient with Placenta Accreta and Literature Review

Geospatial clustering of meningitis: an early warning system (hotspot) for potential meningitis outbreak in upper east region of Ghana.

We mapped and generated hot spots for potential meningitis outbreak from existing data in Upper East region, Ghana. This was a cross-sectional study conducted in 2017. Meningitis data in the Upper East Region from January 2007, to December 2016. We used spatial tools in Quantum Geographic Information System (QGIS) and Geoda to draw choropleth map of meningitis incidence, case fatality and hotspot for potential meningitis outbreak. A total of 2312 meningitis cases (suspected and confirmed) were recorded from 2016-2017 with median incidence of 15.0cases/100,000 population (min 6.3, max 47.8). Median age of cases was 15 years (IQR: 6-31 years). Most (44.2%) of those affected were 10 years and below. Females (51.2%) constituted the highest proportion. Median incidence from 2007-2011 was 20cases/100,000 population (Min 11.3, Max 39.9) whilst from 2012-2016 was 11.1cases/100,000 populations (Min 6.3, Max 47.8). A total of 28 significant hotspot sub-districts clusters (p=0.024) were identified with 7 High-high risk areas as potential meningitis outbreak spots. The occurrence of meningitis is not random, spatial cluster with high -high-risk exist in some sub-districts. Overall meningitis incidence and fatality rate have declined in the region with district variations. Districts with high meningitis incidence and fatality rates should be targeted for intervention. Author EA was supported by the West Africa Health Organization (Ref.: Prog/A17IEpidemSurveillN°57212014/mcrt).

Measles outbreak investigation in Ginnir district of Bale zone, Oromia region, Southeast Ethiopia, May 2019.

IntroductionMeasles is a vaccine-preventable viral infection of humans, primarily affecting children <5 years. During early 2019, outbreak of measles occurred in Ginnir district of Bale zone, Southeast Ethiopia. We investigated to describe the outbreak and identify risk factors.MethodsWe conducted a descriptive and 1:2 unmatched case-control study in Ginnir district from March 18 to April 29, 2019. Fifty-six cases and 112 controls were recruited. For descriptive study, we identified 1043 cases recorded on the line-list and for case-control study, cases were identified using national standard case-definition. Mothers of case-patients and controls were interviewed using structured questionnaire. We estimated vaccine efficacy (VE) from case-control study. We conducted bivariate and multivariable logistic regression.ResultsIn four-months period, a total of 1,043 suspected measles cases epidemiologically linked to five laboratory confirmed cases reported. Of which, 555 (53.2%) were males and 714 (68.5%) were <5 years. The median age of cases was 36 months (IQR=12-60 months). The overall attack rate (AR) was 63/10,000 population with case fatality ratio of 0.5% (5 deaths/1043). Infant <9 months were the most affected age groups (AR=31/1000). Majority (79%) of measles cases were not vaccinated against measles. Last-year (2017/18) administrative measle vaccine coverage of the district was 76.7%. Being unvaccinated against measles (AOR=5.4, 95%CI=2.2-13.4), travel history (AOR=4.02, 95%CI=1.2-13.6), contact with measles case-patient (AOR=5.6, 95%CI=2.12-14.4) and mothers knowledge of measles transmission (AOR=0.36, 95%CI=0.15-0.87) were associated with measles infection. VE in children aged 9-59 months was 90% (95%CI=69-97%).ConclusionThis confirmed measles outbreak was caused by failure to vaccinate, as indicated by the high VE, low administrative coverage, and 79% unvaccinated cases. Strengthening routine and supplementary immunization are required.