The West African Ebola emergency and reconstruction; lessons from Public Health England.

BACKGROUND: West African governments, the WHO and wider international community were caught unprepared for the world's largest Ebola outbreak of 2014-16. This was an unprecedented challenge to local services and international agencies, since the emergency required high-tech molecular diagnostic services operated by specialist staff and a coordinated emergency response in addition to humanitarian support, which was not available at the beginning of the outbreak. Public Health England (PHE), as a new national public health agency was well placed to provide support for these needs. After the outbreak, PHE supported reconstruction to ensure diagnostic and emergency planning capability remained in place in the immediate aftermath of the outbreak and build necessary public health infrastructure for the future. The article describes the role PHE played as a national public health agency supporting reconstruction and long-term development through the UK Government (Department for International Development) programme called 'Resilient Zero'. SOURCES OF DATA: Public Health England (PHE), UK Government's Department for International Development, WHO, US Centers for Communicable Diseases (CDC), China Centre for Communicable Diseases (China CDC). AREAS OF AGREEMENT: The need for reliable, sustainable, in country molecular diagnostics, together with a programme to strengthen in country Emergency Planning, Preparedness and Response (EPRR). AREAS OF CONTROVERSY: Providing high tech molecular capability in a resource-poor West African country with variable provision of basic diagnostic equipment, intermittent power supply, ineffective supply chains and maintaining training capacity for emergency planning in the long term. Emergency planning models from the West needed to be adapted for the countries' context. Short term aid projects as a model did not suite this development requirement. GROWING POINTS: PHE had strong local and international political support to reconstruct three Government regional laboratories and deploy molecular technology. Significant learning by PHE as a national public health agency and sharing this will be of benefit to other national public health agencies. UK staff reported increased levels of satisfaction and experience relevant to public health practice. The Sierra Leonean Government and officials requested long-term levels of commitment. It is important for agencies such as PHE to constantly learn, develop long-term institutional partnerships and play a bigger role with other similar agencies internationally. AREAS TIMELY FOR DEVELOPING RESEARCH: How best to support sustainable high-tech molecular technology in West Africa and modules for emergency planning relevant to the context; evidence for long term versus short-term support for highly complex diagnostic capabilities; relevance to maintaining individual country public health infrastructure to ensuring global health security; benefits of overseas work for employee of a national agency.

Association between the introduction of a national targeted intervention program and the incidence of surgical site infections in Swiss acute care hospitals.

BACKGROUND: In Switzerland, the national surgical site infection (SSI) surveillance program showed a modest decrease in SSI rates for different procedures over the last decade. The study aimed to determine whether a multimodal, targeted intervention program in addition to existing SSI surveillance is associated with decreased SSI rates in the participating hospitals. METHODS: Prospective multicenter pre- and postintervention study conducted in eight Swiss acute care hospitals between 2013 and 2020. All consecutive patients > 18 years undergoing cardiac, colon, or hip/knee replacement surgery were included. The follow-up period was 30 days and one year for implant-related surgery. Patients with at least one follow-up were included. The intervention was to optimize three elements of preoperative management: (i) hair removal; (ii) skin disinfection; and (iii) perioperative antimicrobial prophylaxis. We compared SSI incidence rates (main outcome measure) pre- and postintervention (three years each) adjusted for potential confounders. Poisson generalized linear mixed models fitted to quarter-yearly confirmed SSIs and adjusted for baseline differences between hospitals and procedures. Adherence was routinely monitored through on-site visits. RESULTS: A total of 10 151 patients were included, with a similar median age pre- and postintervention (69.6 and IQR 60.9, 76.8 years, vs 69.5 and IQR 60.4, 76.8 years, respectively; P = 0.55) and similar proportions of females (44.8% vs. 46.1%, respectively; P = 0.227). Preintervention, 309 SSIs occurred in 5 489 patients (5.6%), compared to 226 infections in 4 662 cases (4.8%, P = 0.09) postintervention. The adjusted incidence rate ratio (aIRR) for overall SSI after intervention implementation was 0.81 (95% CI, 0.68 to 0.96, P = 0.02). For cardiac surgery (n = 2 927), the aIRR of SSI was 0.48 (95% CI, 0.32 to 0.72, P < 0.001). For hip/knee replacement surgery (n = 4 522), the aIRR was 0.88 (95% CI, 0.52 to 1.48, P = 0.63), and for colon surgery (n = 2 702), the aIRR was 0.92 (95% CI, 0.75 to 1.14, P = 0.49). CONCLUSIONS: The SSI intervention bundle was associated with a statistically significant decrease in SSI cases. A significant association was observed for cardiac surgery. Adding a specific intervention program can add value compared to routine surveillance only. Further prevention modules might be necessary for colon and orthopedic surgery.

Providing care to patients in contact isolation: is the systematic use of gloves still indicated?

This article reviews the available evidence on the effectiveness of gloves in preventing infection during care provided to patients under contact precautions, and analyses the risks and benefits of their systematic use. Although hand hygiene with alcohol-based handrub was shown to be effective in preventing nosocomial infections, many publications put the effectiveness and usefulness of gloves into perspective. Instead, literature and various unpublished experiences point towards reduced hand hygiene compliance and increased risk of spreading pathogens with routine glove use. Therefore, hospitals should emphasise hand hygiene in their healthcare staff and, instead of the routine use of gloves when caring for patients under contact precautions, limit their use to the indications of standard precautions, i.e., mainly for contact with body fluids. Wide and easy access to alcohol-based handrub and continual teaching are essential. If such conditions are met and adherence to hand hygiene is excellent and regularly assessed, the routine use of gloves for patients under contact precautions seems no longer indicated.

High adherence to national IPC guidelines as key to sustainable VRE control in Swiss hospitals: a cross-sectional survey.

BACKGROUND: Vancomycin resistant enterococci (VRE) are on the rise in many European hospitals. In 2018, Switzerland experienced its largest nosocomial VRE outbreak. The national center for infection prevention (Swissnoso) elaborated recommendations for controlling this outbreak and published guidelines to prevent epidemic and endemic VRE spread. The primary goal of this study was to evaluate adherence to this new guideline and its potential impact on the VRE epidemiology in Swiss acute care hospitals. METHODS: In March 2020, Swissnoso distributed a survey among all Swiss acute care hospitals. The level of adherence as well as changes of infection prevention and control (IPC) strategies in the years 2018 and 2019 after publication of the national guidelines were asked along with an inventory on VRE surveillance and outbreaks. RESULTS: Data of 97/146 (66%) participants were available, representing 81.6% of all acute care beds operated in Switzerland in 2019. The vast majority-72/81 (88%) responding hospitals-have entirely or largely adopted our new national guideline. 38/51 (74.5%) hospitals which experienced VRE cases were significantly more likely to have changed their IPC strategies than those 19/38 (50%) hospitals without VRE cases p = 0.017). The new IPC guidelines included (1) introduction of targeted admission screening in 89.5%, (2) screening of close contacts of VRE cases in 56%, and (3) contact precaution for suspected VRE cases 58% of these hospitals. 52 (54%) hospitals reported 569 new VRE cases in 2018 including 14 bacteremia, and 472 new cases in 2019 with 10 bacteremia. The ten largest outbreaks encountered between 2018 and 2019 included 671 VRE cases, of which most (93.4%) consisted of colonization events, 29 (4.3%) infections and 15 (2.2%) bacteremia. CONCLUSION: Wide adoption of this VRE control guideline seemed to have a positive effect on VRE containment in Swiss acute care hospitals over two years, even if its long-term impact on the VRE epidemiology remains to be evaluated. Broad dissemination and strict implementation of a uniform national guideline may therefore serve as model for other countries to fight VRE epidemics on a national level.

Evaluation of existing and desired measures to monitor, prevent and control healthcare-associated infections in Swiss hospitals.

OBJECTIVES: Optimal surveillance and prevention of healthcare-associated infections (HAI) are crucial for a well-functioning health care system. With a view to establishing a national state-of-the-art programme for surveillance and prevention of HAIs, the Swiss National Center for Infection Control, Swissnoso, developed a survey to explore the options for expanding the existing Swiss HAI surveillance system. METHODS: An online survey was sent to all Swiss acute care hospitals. Local infection prevention and control (IPC) professionals were asked to answer on behalf of their institutions. The questions covered the structure and organisation of IPC programmes, current preventive measures, availability and capacity of electronic medical record (EMR) systems, and ability and willingness to establish and participate in the proposed new surveillance modules. An invitation was sent to the 156 acute care hospitals and hospital networks in June 2020. Responses were collected up to the end of August 2020. RESULTS: Ninety-four hospitals and hospital networks out of 156 (60%) completed the survey. Among 84 hospitals reporting the number of acute care beds, 61 (73%) were small (<200 beds), 16 (19%) medium (200–650 beds) and 7 (8%) large hospitals (>650 beds). Twenty-nine different EMR systems were used in the participating hospitals. Twenty-two hospitals were using a different EMR system in their intensive care unit. There were 17 hospitals (18%) without an EMR system but which planned to introduce one soon, and eight small hospitals (9%) neither had an EMR system nor were preparing to introduce one. Surveillance for central-line associated bloodstream infection, catheter-associated urinary tract infection and ventilator-associated pneumonia were already established in 26 (28%), 15 (16%) and 15 (16%) hospitals, respectively. Thirty hospitals (36%) would be willing to participate in the pilot phase of a new surveillance system. Of these, 15 stated that they wanted to be part of the pilot hospital network, 6 could provide hospital-wide surveillance denominators (such as catheter-days and patient-days) to compute incidence rates, and 8 indicated interest in doing both. Large hospitals interested in participating in the pilot phase reported more full-time equivalent staff available for surveillance activities than those who did not declare an interest. CONCLUSIONS: Baseline information on hospital IPC structure and process indicators are essential for the roll-out of national surveillance programmes and for improving surveillance activities. Having an EMR system in place and adequate personnel resources dedicated for surveillance activities are crucial prerequisites for developing and implementing an effective HAI surveillance system. The lack of an EMR system and the diversity and capacities of EMR solutions will be the main challenges for successful implementation of national HAI surveillance modules.

Transport of COVID-19 and other highly contagious patients by helicopter and fixed-wing air ambulance: a narrative review and experience of the Swiss air rescue Rega.

BACKGROUND: The current COVID-19 pandemic highlights the challenges air ambulance services are facing when transporting highly infectious patients for several hours in enclosed spaces. This overview provides an example of a standard operating procedure (SOP) for infection prevention measures in HEMS missions during the COVID-19 pandemic. Furthermore, we describe different methods used by several organizations in Europe and the experience of the Swiss air rescue organization Rega in transporting these patients. Possible benefits of the use of small patient isolation units (PIU) are discussed, including the fact that accompanying medical personnel do not need to wear personal protective equipment (PPE) during the transport but can still maintain full access to the patient. Rega has developed and patented its own PIU. This device allows spontaneously breathing or mechanically ventilated patients to be transported in pressurized jet cabins, small helicopters and ambulance vehicles, without the need to change between transport units. This PIU is unique, as it remains air-tight even when there is a sudden loss of cabin pressure. CONCLUSION: A wide variety of means are being used for the aeromedical transport of infectious patients. These involve isolating either the patient or the medical crew. One benefit of PIUs is that the means of transport can be easily changed without contaminating the surroundings and while still allowing access to the patient.

Scoping review on vector-borne diseases in urban areas: transmission dynamics, vectorial capacity and co-infection.

BACKGROUND: Transmission dynamics, vectorial capacity, and co-infections have substantial impacts on vector-borne diseases (VBDs) affecting urban and suburban populations. Reviewing key factors can provide insight into priority research areas and offer suggestions for potential interventions. MAIN BODY: Through a scoping review, we identify knowledge gaps on transmission dynamics, vectorial capacity, and co-infections regarding VBDs in urban areas. Peer-reviewed and grey literature published between 2000 and 2016 was searched. We screened abstracts and full texts to select studies. Using an extraction grid, we retrieved general data, results, lessons learned and recommendations, future research avenues, and practice implications. We classified studies by VBD and country/continent and identified relevant knowledge gaps. Of 773 articles selected for full-text screening, 50 were included in the review: 23 based on research in the Americas, 15 in Asia, 10 in Africa, and one each in Europe and Australia. The largest body of evidence concerning VBD epidemiology in urban areas concerned dengue and malaria. Other arboviruses covered included chikungunya and West Nile virus, other parasitic diseases such as leishmaniasis and trypanosomiasis, and bacterial rickettsiosis and plague. Most articles retrieved in our review combined transmission dynamics and vectorial capacity; only two combined transmission dynamics and co-infection. The review identified significant knowledge gaps on the role of asymptomatic individuals, the effects of co-infection and other host factors, and the impacts of climatic, environmental, and socioeconomic factors on VBD transmission in urban areas. Limitations included the trade-off from narrowing the search strategy (missing out on classical modelling studies), a lack of studies on co-infections, most studies being only descriptive, and few offering concrete public health recommendations. More research is needed on transmission risk in homes and workplaces, given increasingly dynamic and mobile populations. The lack of studies on co-infection hampers monitoring of infections transmitted by the same vector. CONCLUSIONS: Strengthening VBD surveillance and control, particularly in asymptomatic cases and mobile populations, as well as using early warning tools to predict increasing transmission, were key strategies identified for public health policy and practice.

Intravenous artesunate versus intravenous quinine in the treatment of severe falciparum malaria: a retrospective evaluation from a UK centre.

INTRODUCTION: Despite evidence from developing world trials that intravenous (IV) artesunate (AS) is superior to IV quinine (Q) in severe falciparum malaria (FM), IV AS remains unlicensed in the UK with national guidelines listing it as an acceptable alternative to IV Q as the drug of choice. We retrospectively evaluate the safety and effectiveness of IV AS in returning travellers with severe FM. METHODS: We identified adults admitted to the Infectious Diseases unit with severe FM and treated with IV Q (1991-2009) or IV AS (2009-2011). Outcomes included adverse events, mortality, length of stay, admission to intensive care and, where data were available, parasite/fever clearance time and hypoglycaemic events. RESULTS: Of 167 patients, 24 received IV AS and 143 IV Q. There was one potential AS-associated adverse event, a case of late onset haemolysis. Median length of stay (LOS) was significantly shorter for AS (3·5 versus 5 days, P = 0·017), even after adjusting for African ethnicity (for LOS ≥3 days, mhor = 0·33, P = 0·027; crude OR = 0·29, P = 0·013). In the AS group, there were no fatalities (versus five in Q group, NS) and fewer intensive care unit (ICU) admissions (NS). Median parasite clearance was significantly faster in AS (65 versus 85 hours in Q, P = 0·0045) with no hypoglycaemic episodes (versus five in Q). DISCUSSION: We found IV AS to be safe and effective, with shorter LOS, faster parasite and fever clearance, no fatalities or hypoglycaemic events, and fewer ICU admissions versus IV Q. This corroborates both developing world trials and smaller European case series (although these lacked comparison groups). As well as obvious benefits for patients, there are potential resource savings. A case of late-onset haemolysis may represent an adverse event, particularly as it has been documented elsewhere, warranting further investigation. Nonetheless, our experience suggests IV AS should be first-line for treating severe FM in the UK.

Normal ocular flora in newborns delivered in two hospital centers in Argentina and Paraguay.

PURPOSE: To determine the spectrum of normal conjunctival flora in newborns in two hospital centers in North Argentina and Paraguay. METHODS: In this prospective observational study, conjunctival specimens were obtained from the right eyes of newborns prior to the application of any topical medications. Culture samples were also obtained from the cervicovaginal secretions of the infants' mothers. All samples were directly inoculated into culture media and all growth were identified and quantified. RESULTS: Among the 190 newborns studied, 126 were delivered vaginally and 64 via caesarean section (C-section). A total of 180 different bacterial strains were acquired from the vaginally delivered infants and 77 from the C-section group (P=0.078, Student's t-test). Conjunctival cultures obtained within one hour of birth showed that 85 out of 101 samples (84%) from both the vaginal and C-section group had positive cultures, compared to 84 out of 89 samples (94%) obtained more than 1 h after birth (P<0.001). Among the vaginally delivered newborns, the most common bacteria isolated were coagulase-negative Staphylococcus (in 69 samples, 38%), Propionibacterium spp (36, 20%) and Corynebacterium spp (29, 16%). In the CES, the most common isolates were coagulase-negative Staphylococcus (39, 51%), Propionibacterium spp (22, 29%) and Staphylococcus aureus (6, 8%). There was a significantly higher proportion of gram-positive rods (P=0.017) isolated from infants delivered vaginally (16%) than from those delivered by C-section (5%). No Neisseria gonorrhoeae were isolated in conjunctival samples. Among the 130 organisms isolated from cervicovaginal secretions in 81 out of 189 mothers, the most common organisms were Lactobacillus spp. (47%), Corynebacterium spp (21%), Gardnerella vaginalis (15%), and Candida spp (14%). No Neisseria gonorrhoeae or Chlamydia trachomatis were found in cervicovaginal samples. CONCLUSION: The most common conjunctival bacteria in newborns delivered by either vaginal birth or C-section were coagulase-negative Staphylococcus. The proportion of positive conjunctival cultures was higher for infants delivered vaginally than for C-section delivery.