Assessment of knowledge, attitudes and perceptions regarding Ebola disease in healthcare workers from a tertiary care hospital in Romania.

OBJECTIVES: The National Institute for Infectious Diseases 'Prof. Dr. Matei Balș' was the designated centre for managing Ebola alerts in Romania during the 2014 African outbreak. We surveyed Ebola knowledge, attitudes and perceptions (KAP) among the institute's healthcare workers. STUDY DESIGN: This was a cross-sectional survey. METHODS: The study consisted of a self-administered paper-based anonymous questionnaire that included 24 closed-item questions and two scales of personal concern. RESULTS: Respondents were generally well informed; compared to nurses, doctors recorded a 1.9-fold higher rate of correct responses regarding Ebola transmission (P < 0.001), but both nurses and doctors correctly identified Ebola's aetiological agent. Nurses perceived higher personal (P = 0.008) and family (P < 0.001) risk than doctors. Respondents reporting high perceived risks were more likely to be less informed about Ebola (P = 0.019) and its prevention options (P = 0.033). Males were 6.7-fold more likely to volunteer than females (P = 0.001) and so were graduates of higher rather than lower education (1.5-fold more likely, P = 0.017) and doctors than nurses (1.7-fold more likely, P = 0.018). The institute ranked first among sources of information on Ebola; respondents who had received Ebola training in the institute 2 years previously were 1.2-1.3 times more likely to correctly identify transmission routes. CONCLUSIONS: We have characterised KAP on Ebola disease among Romanian healthcare workers from a tertiary care hospital in Bucharest. Nurses, specialist physicians and laboratory personnel may need more frequent retraining than residents and senior physicians.

CORRELATION BETWEEN THE WAIST CIRCUMFERENCE, DIASTOLIC BLOOD PRESSURE AND INSULIN RESISTANCE IN NON-OBESE YOUNG ADULTS.

CONTEXT: The metabolic syndrome is a profound, systemic impairment of the metabolism of lipids, carbohydrates and branched amino-acids, affecting specially obese people. Recently, many studies outlined the presence of the metabolic syndrome, also in non obese persons. OBJECTIVE AND DESIGN: To assess the relationship between insulin resistance and the cardiovascular component of the metabolic syndrome in a group of young, non obese subjects using a cross sectional study. SUBJECTS AND METHODS: We enrolled 103 subjects with body mass index < 30 Kg/m2, without metabolic syndrome to whom fasting glucose, triglycerides, high density lipoprotein cholesterol, insulinemia, waist circumference and arterial pressure were recorded in a cross-sectional approach. Insulin resistance was evaluated using the homeostasis model assessment for insulin (HOMA-IR) index. Statistic data processing included Pearson relation and multiple regression (backward method), using the SPSS version 21 software. RESULTS: A significant relationship between waist circumference, diastolic blood pressure and HOMA-IR is found. High value of HOMA-IR (>2.6) was more frequently in men (p=0.011). The incidence of the 2 metabolic components mentioned above was higher in the high value HOMA-IR group: 33% vs. 7% in women and 50% vs. 4% in men. Multiple regression showed a strong correlation between HOMA-IR and waist circumference (p<0.001) and diastolic blood pressure (p=0.008) that was maintained inside the women group (p=0.016 and p=0.032, respectively). In men, HOMA-IR correlated with waist circumference (p=0.031). CONCLUSION: We found a significant interdepen-dence between waist circumference, diastolic blood pressure and HOMA-IR. Based on our results, we consider that lifestyle intervention should start as soon as abnormal waist circumference is recorded.

The clinical and epidemiological evolution of varicella in Romania during 2004 and 2013.

INTRODUCTION: Varicella, a vaccine preventable disease (VPD) is one of the most common communicable diseases in Romania. The objectives of our study were to describe the epidemiological evolution of varicella in Romania between 2004 and 2013 and the clinical characteristics of the cases admitted to NIID between 2011 and 2013. MATERIALS AND METHODS: An epidemiological retrospective study was conducted by using the information reported quarterly by general practitioners and hospitals at the national level. There is no system for the surveillance of severe cases in Romania, so, to describe the clinical characteristics of varicella cases, a second retrospective study was developed, in which the patients hospitalized in the NIID, within the period 2011-2013, were included. Questionnaires were completed by using data from the clinical observation forms. Collected information included demographic, clinical and laboratory data, complications, date of onset and admission, length of stay, admission and discharge diagnosis. Data were processed and analyzed by using Microsoft Excel program. RESULTS: A total of 504,844 cases were reported of at the national level between 2004 and 2013, with a mean incidence of 238.2/ 100,000 inhabitants. The most affected age group was 5-9 years old (incidence 1362.7/ 100,000 inhabitants). The study conducted in NIID, registered 353 patients hospitalized with varicella between 2011 and 2013. Most of the hospitalized cases (88.8%) were under 10 years old and many (72.6 %) attended a community. The majority of cases had rash (98.6%) and fever (79.9%). The main complications were pneumonia (46.2%), bacterial infection (16.1%) and encephalitis (2.5%). DISCUSSIONS: Varicella is a very common disease in Romania, which may develop complications. A specific surveillance system should be introduced in order to provide accurate epidemiological, clinical and laboratory information to assess whether varicella is a public health problem in Romania and if the introduction of vaccination in NIP is recommended. However, given the large number of current cases in Romania, a solution may be a sentinel surveillance system type.

Influenza vaccine effectiveness estimates in Europe in a season with three influenza type/subtypes circulating: the I-MOVE multicentre case-control study, influenza season 2012/13.

In the fifth season of Influenza Monitoring Vaccine Effectiveness in Europe (I-MOVE), we undertook a multicentre case-control study (MCCS) in seven European Union (EU) Member States to measure 2012/13 influenza vaccine effectiveness against medically attended influenza-like illness (ILI) laboratory confirmed as influenza. The season was characterised by substantial co-circulation of influenza B, A(H1N1)pdm09 and A(H3N2) viruses. Practitioners systematically selected ILI patients to swab ≤7 days of symptom onset. We compared influenza-positive by type/subtype to influenza-negative patients among those who met the EU ILI case definition. We conducted a complete case analysis using logistic regression with study as fixed effect and calculated adjusted vaccine effectiveness (AVE), controlling for potential confounders (age, sex, symptom onset week and presence of chronic conditions). We calculated AVE by type/subtype. Study sites sent 7,954 ILI/acute respiratory infection records for analysis. After applying exclusion criteria, we included 4,627 ILI patients in the analysis of VE against influenza B (1,937 cases), 3,516 for A(H1N1)pdm09 (1,068 cases) and 3,340 for influenza A(H3N2) (730 cases). AVE was 49.3% (95% confidence interval (CI): 32.4 to 62.0) against influenza B, 50.4% (95% CI: 28.4 to 65.6) against A(H1N1)pdm09 and 42.2% (95% CI: 14.9 to 60.7) against A(H3N2). Our results suggest an overall low to moderate AVE against influenza B, A(H1N1)pdm09 and A(H3N2), between 42 and 50%. In this season with many co-circulating viruses, the high sample size enabled stratified AVE by type/subtype. The low estimates indicate seasonal influenza vaccines should be improved to achieve acceptable protection levels.

Low and decreasing vaccine effectiveness against influenza A(H3) in 2011/12 among vaccination target groups in Europe: results from the I-MOVE multicentre case-control study.

Within the Influenza Monitoring Vaccine Effectiveness in Europe (I-MOVE) project we conducted a multicentre case­control study in eight European Union (EU) Member States to estimate the 2011/12 influenza vaccine effectiveness against medically attended influenza-like illness (ILI) laboratory-confirmed as influenza A(H3) among the vaccination target groups. Practitioners systematically selected ILI / acute respiratory infection patients to swab within seven days of symptom onset. We restricted the study population to those meeting the EU ILI case definition and compared influenza A(H3) positive to influenza laboratory-negative patients. We used logistic regression with study site as fixed effect and calculated adjusted influenza vaccine effectiveness (IVE), controlling for potential confounders (age group, sex, month of symptom onset, chronic diseases and related hospitalisations, number of practitioner visits in the previous year). Adjusted IVE was 25% (95% confidence intervals (CI): -6 to 47) among all ages (n=1,014), 63% (95% CI: 26 to 82) in adults aged between 15 and 59 years and 15% (95% CI: -33 to 46) among those aged 60 years and above. Adjusted IVE was 38% (95%CI: -8 to 65) in the early influenza season (up to week 6 of 2012) and -1% (95% CI: -60 to 37) in the late phase. The results suggested a low adjusted IVE in 2011/12. The lower IVE in the late season could be due to virus changes through the season or waning immunity. Virological surveillance should be enhanced to quantify change over time and understand its relation with duration of immunological protection. Seasonal influenza vaccines should be improved to achieve acceptable levels of protection.

[An experimental model of transgastric ooforectomy using a porcine model]. / Stabilirea modelului experimental de ooforectomie transgastrica pe model suin.

INTRODUCTION: Transabdominal routes for surgery entail general anaesthesia with its inherent risks and complications (prolonged hospital stay, abdominal incisions that may be difficult in obese patients). Minimally invasive procedures require shorter hospitalization, have shorter recovery periods, less postoperative discomfort, and lower morbidity and complications. The purpose of this study was to use a porcine model to determine the feasibility and the safety of organ resection (oophorectomy and tubectomy). MATERIALS AND METHODS: 10 Big White pigs between 25-30 kg underwent transgastric ooforectomy. The first 5 cases were performed in a hybrid procedure (laparoscopic-NOTES) in order to have a better control and supervise the maneuvers done by the mobile endoscope and to guide in the abdominal cavity. RESULTS: Adnexectomy was possible in all ten experiments. Full operative time (from starting endoscopy to complete gastrectomy closing) was 180 min to 270 min. The gastric defect closing was the most difficult manoever lasting from 10 min with OTSC clips to 100 using endoloops and clips. The animals have tolerated well the experiments and there have been no remarkable incidents during our 10 experments. In only one case a bleeding from gastotomy required electric coagulation. CONCLUSION: Transgastric ooforectomy in an experimental model is a procedure that requires advanced laparoscopical and endoscopical skills. Our early results are promissing. Its application in humans needs further confirmation of the method.

"I-MOVE" towards monitoring seasonal and pandemic influenza vaccine effectiveness: lessons learnt from a pilot multi-centric case-control study in Europe, 2008-9.

Within I-MOVE (European programme to monitor seasonal and pandemic influenza vaccine effectiveness (IVE)) five countries conducted IVE pilot case-control studies in 2008-9. One hundred and sixty sentinel general practitioners (GP) swabbed all elderly consulting for influenza-like illness (ILI). Influenza confirmed cases were compared to influenza negative controls. We conducted a pooled analysis to obtain a summary IVE in the age group of >or=65 years. We measured IVE in each study and assessed heterogeneity between studies qualitatively and using the I2 index. We used a one-stage pooled model with study as a fixed effect. We adjusted estimates for age-group, sex, chronic diseases, smoking, functional status, previous influenza vaccinations and previous hospitalisations. The pooled analysis included 138 cases and 189 test-negative controls. There was no statistical heterogeneity (I2=0) between studies but ILI case definition, previous hospitalisations and functional status were slightly different. The adjusted IVE was 59.1% (95% CI: 15.3-80.3%). IVE was 65.4% (95% CI: 15.6-85.8%) in the 65-74, 59.6% (95% CI: -72.6 -90.6%) in the age group of >or=75 and 56.4% (95% CI: -0.2-81.3%) for A(H3). Pooled analysis is feasible among European studies. The variables definitions need further standardisation. Larger sample sizes are needed to achieve greater precision for subgroup analysis. For 2009-10, I-MOVE will extend the study to obtain early IVE estimates in groups targeted for pandemic H1N1 influenza vaccination.

Circulation of a type 1 recombinant vaccine-derived poliovirus strain in a limited area in Romania.

After intensive immunisation campaigns with the oral polio vaccine (OPV) as part of the Global Polio Eradication Initiative, poliomyelitis due to wild viruses has disappeared from most parts of the world, including Europe. Here, we report the characterization of a serotype 1 vaccine-derived poliovirus (VDPV) isolated from one acute flaccid paralysis (AFP) case with tetraplegia and eight healthy contacts belonging to the same small socio-cultural group having a low vaccine coverage living in a small town in Romania. The genomes of the isolated strains appeared to be tripartite type 1/type 2/type 1 vaccine intertypic recombinant genomes derived from a common ancestor strain. The presence of 1.2% nucleotide substitutions in the VP1 capsid protein coding region of most of the strains indicated a circulation time of about 14 months. These VDPVs were thermoresistant and, in transgenic mice expressing the human poliovirus receptor, appeared to have lost the attenuated phenotype. These results suggest that small populations with low vaccine coverage living in globally well-vaccinated countries can be the origin of VDPV emergence and circulation. These results reaffirm the importance of active surveillance for acute flaccid paralysis and poliovirus in both polio-free and polio-endemic countries.

West nile virus surveillance in Romania: 1997-2000.

In response to the 1996 West Nile (WN) fever epidemic that occurred in Bucharest and southeastern Romania, a surveillance program was established. The surveillance system detected 39 clinical human WN fever cases during the period 1997-2000: 14 cases in 1997, 5 cases in 1998, 7 cases in 1999, and 13 cases in 2000. Thirty-eight of the 39 case-patients lived in the greater Danube Valley of southern Romania, and 1 case-patient resided in the district of Vaslui, located on the Moldavian plateau. The estimated annual case incidence rate for the surveillance area during the period 1997-2000 was 0.95 cases per million residents. Thirty-four cases were serologically confirmed, and 5 cases were classified as probable. Twenty-four case-patients presented with clinical symptoms of meningitis (62%), 12 with meningoencephalitis (31%), 1 with encephalitis (3%), and 2 with febrile exanthema (5%). Five of the 39 cases were fatal (13%). Fourteen case-patients resided in rural areas, and 25 in urban and suburban areas, including 7 case-patients who resided in Bucharest. The ages of case-patients ranged from 8 to 76 years with a median age of 45 years. Twenty-four case-patients were males and 15 were females. Dates of onset of illness occurred from May 24 through September 25, with 82% of onset dates occurring in August and September. Limited entomological surveillance failed to detect WN virus. Retrospective sampling of domestic fowl in the vicinity of case-patient residences during the years 1997-2000 demonstrated seroprevalence rates of 7.8%-29%. Limited wild bird surveillance demonstrated seroprevalence rates of 5%-8%. The surveillance data suggest that WN virus persists focally for several years in poorly understood transmission cycles after sporadic introductions or that WN virus is introduced into Romania at relatively high rates, and persists seasonally in small foci.

[Acute infectious diarrheal disease in Romania: 1993-1998]. / Boala diareica acuta infectioasa în Romania: 1993-1998.

The decrease of morbidity-mortality caused by gastroenteritis is in relation to the factors largely responsible for the fall in infant mortality and mortality from communicable diseases in developing countries. Nevertheless, diarrhea is still a considerable public health problem in these countries, especially among children under 5 years old. 98% of all deaths in children younger than 15 years are in the developing world. Five of the ten leading killers are communicable, perinatal, and nutritional disorders largely affecting children. The knowledge of the etiology and epidemiology of childhood diarrhea in a given area is needed to plan any measure designed to prevent or ameliorate diarrheal illness and to develop practical guidelines for the most appropriate examination procedures. In Romania, although the real data of morbidity by acute diarrhea are not known, the reports show a significant decrease in the past 10 years. In 1993, 420.2 cases at 100,000 inhabitants were reported, the most commonly affected being the children age 0-4 years. The incidence decreased to 338.5 cases at 100,000 inhabitants in 1997 (and a quite similar incidence for the first 11 month of 1998). Between 1993-1998, 527,977 cases were reported (58.1% in urban area), with a higher frequency in spring-autumn season. Antibiotics are not required in case of acute diarrhea with little or no fever. Antibiotics could be discussed for cholera-like diarrhea and are required in case of invasive bacterial diarrhea, shigellosis, cholera, and Clostridium difficile as well as diarrhea with fever and sanguinolent stools in infants or salmonella-induced diarrhea with signs of extradigestive complications. Importance of oral rehydration solution in the treatment of diarrhoeal diseases is well known. It can be applied to all types of diarrhoea, practically, without any side effects, complications, such aas hypernatraemia is avoidable. It has proved to be effective for dehydration caused by diarrhoea and for diarrhoea, too. There is a need for effective infection control policies, which include appropriate training of staff; simple surveillance systems and readily available expert advice to ensure that outbreaks are rapidly controlled. Approaches to prevention include education about risk factors, which often fails to lead to modification of risky behavior. Further regional epidemiological studies are necessary to develop more appropriate management guidelines.

[The epidemiological process of West Nile viral infection]. / Procesul epidemiologic al infectiei cu virusul West Nile.

An important number of arboviruses are known to produce clinical or subclinical infections in humans. Most of these viruses are maintained in zoonotic cycles and are transmitted by mosquitoes or ticks. Viruses believed to be associated with human disease are classified according to the type of vector, the main clinical sign and the geographic distribution. The arboviruses are classified in families and genera, of which Togaviridae, Flaviviridae and Bunyaviridae are the best known. West Nile virus is present in Egypt, Israel, India and is widespread in parts of Africa, the northern Mediterranean area and Western Asia. The first major West Nile fever epidemic in Europe occurred in Romania, in 1996, with a high rate of neurological infections. 393 patients with serologically confirmed or probable West Nile fever infection (352 had acute central-nervous-system infections) were identified. The number of mild cases could not be estimated. WN virus was recovered from Culex pipiens mosquitoes. The virus is not transmitted through direct human contact, probably the infected mosquitoes transmit the virus throughout their life. Viremia is essential for vector infection and occurs during early clinical illness in humans. Susceptibility appears to be general, in both males and females, throughout life. Inapparent infections and mild disease are common.