[Effective management of an outbreak with multiresistent Klebsiella pneumoniae in a neurorehabilitation unit]. / Effektives Management eines Ausbruchs mit multiresistenten Klebsiella pneumoniae in der Neurorehabilitation.

BACKGROUND: In addition to acute care hospitals, rehabilitation centres are increasingly confronted with multi-resistant pathogens. Long durations of stay and intensive treatments impose special hygienic challenges. MATERIAL AND METHODS: We investigated an extended spectrum beta-lactamase-Klebsiella pneumoniae (ESBL-K. pneumoniae) outbreak in a neurorehabilitation centre. We defined confirmed cases as patients who stayed in the centre during the outbreak period and from whom ESBL-K. pneumoniae was isolated with the outbreak sequence type. Probable cases had an epidemiological link to at least one confirmed case but no isolate for typing. Next generation sequencing (NGS) was performed on 53 isolates from patients. Environmental sampling was performed. Systematic microbiological screening was implemented and ESBL-K. pneumoniae-positive patients were cohorted in a designated ward. RESULTS: We identified 30 confirmed and 6 probable cases. NGS revealed three genetic clusters: Cluster 1 - the outbreak cluster - with isolates of 30 cases (sequence type ST15), Cluster 2 with 7 patients (ST405) and Cluster 3 with 8 patients (ST414). In two patients, the outbreak strain developed further antibiotic resistance, one with colistin resistance and the other carbapenem resistance. The outbreak ceased after strict isolation measures. DISCUSSION: Epidemiology and NGS results paired with the effectiveness of cohorting suggest that transmission occurred mainly from person to person in this outbreak. There was an apparent association of the probability to acquire ESBL-K. pneumoniae and treatment intensity, whereas infection rate was related to morbidity. The identification of the outbreak clone and additional clusters plus the development of additional antibiotic resistance shows the relevance of NGS and highlights the need for timely and efficient outbreak management.

Ongoing outbreaks of hepatitis A among men who have sex with men (MSM), Berlin, November 2016 to January 2017 - linked to other German cities and European countries.

Since 14 November 2016, 38 cases of hepatitis A have been notified in Berlin; of these, 37 were male and 30 reported to have sex with men (MSM). Median age of MSM cases is 31 years (range: 24-52 years). Phylogenetic analysis revealed three distinct sequences, linking cases in Berlin to those in other German cities and to clusters recognised in other European countries in 2016.

TB infection prevention and control experiences of South African nurses--a phenomenological study.

BACKGROUND: The tuberculosis (TB) epidemic in South Africa is characterised by one of the highest levels of TB/HIV co-infection and growing multidrug-resistant TB worldwide. Hospitals play a central role in the management of TB. We investigated nurses' experiences of factors influencing TB infection prevention and control (IPC) practices to identify risks associated with potential nosocomial transmission. METHODS: The qualitative study employed a phenomenological approach, using semi-structured interviews with a quota sample of 20 nurses in a large tertiary academic hospital in Cape Town, South Africa. The data was subjected to thematic analysis. RESULTS: Nurses expressed concerns about the possible risk of TB transmission to both patients and staff. Factors influencing TB-IPC, and increasing the potential risk of nosocomial transmission, emerged in interconnected overarching themes. Influences related to the healthcare system included suboptimal IPC provision such as the lack of isolation facilities and personal protective equipment, and the lack of a TB-IPC policy. Further influences included inadequate TB training for staff and patients, communication barriers owing to cultural and linguistic differences between staff and patients, the excessive workload of nurses, and a sense of duty of care. Influences related to wider contextual conditions included TB concerns and stigma, and the role of traditional healers. Influences related to patient behaviour included late uptake of hospital care owing to poverty and the use of traditional medicine, and poor adherence to IPC measures by patients, family members and carers. CONCLUSIONS: Several interconnected influences related to the healthcare system, wider contextual conditions and patient behavior could increase the potential risk of nosocomial TB transmission at hospital level. There is an urgent need for the implementation and evaluation of a comprehensive contextually appropriate TB IPC policy with the setting and auditing of standards for IPC provision and practice, adequate TB training for both staff and patients, and the establishment of a cross-cultural communication strategy, including rapid access to interpreters.

Hepatitis A outbreak among MSM in Berlin due to low vaccination coverage: Epidemiology, management, and successful interventions.

OBJECTIVES: To describe the characteristics of a large hepatitis A virus (HAV) outbreak among men who have sex with men (MSM) in Berlin and to assess the impact of measures implemented. METHODS: Cases of laboratory-confirmed, symptomatic HAV infection notified in Berlin, Germany between August 2016 and February 2018 were analysed using routine and enhanced surveillance data including genotyping results. Several studies involving different groups of participants were conducted to further investigate the outbreak, including surveys on knowledge and practices of HAV vaccination among physicians and vaccination coverage and determinants of vaccination status among MSM. The measures implemented were categorized by target group in a Gantt chart. To assess their impact, health insurance data on HAV vaccination uptake were analysed, comparing Berlin and other federal states. RESULTS: During the outbreak period, a total of 222 cases were reported (of which 91 were sequence-confirmed), with a peak in case numbers in January 2017. Physicians were aware of the existing vaccination recommendations, but vaccination coverage among 756 MSM was low, with 32.7% being completely vaccinated and 17.3% being incompletely vaccinated before 2017. HAV vaccination before 2017 was associated with being born in Germany (odds ratio 2.36) and HIV-positive (odds ratio 1.80). HAV monovalent vaccination uptake increased by 164% from 2016 to 2017 among males in Berlin, compared to 7% in other federal states. CONCLUSIONS: Multiple measures targeting the MSM community, physicians, and public health to increase HAV vaccination uptake were successfully implemented. To prevent future HAV outbreaks, we recommend monitoring vaccination coverage among MSM, promoting awareness of existing recommendations among physicians, and ensuring access for foreign-born and young MSM.

Human immunodeficiency and Hodgkin lymphoma.

Presentation of Hodgkin lymphoma (HL) is distinctive in the infected individual being more advanced, accompanied by B symptoms and the presence of extranodal disease particularly lymphadenopathy of the head and neck. Bone marrow involvement may be found in over 50% of cases. Virtually all co express gamma-herpesvirus. Phenotypically there is prominence of the mixed-cellularity and lymphocyte depleted histopathologic subtypes that define an aggressive clinical course in comparison to other variants. Prior to the induction of cART, median survival was only 1-2 years. Notably the first chemotherapy trial using ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) in 21 patients, without treating the viral infection, resulted in a 43% complete remission rate accompanied by severe haematological toxicities but did not extend median survival with this being 1.5 years matching the negative cases. Significant change accompanied concomitant anti-retroviral therapy that could be given safely even with dose intensive regimens exemplified by BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) in 12 patients or the Stanford V regimen (doxorubicin, vinblastine, mechlorethamine, etoposide, vincristine, bleomycin, prednisone) coupled with involved-field radiation for bulky disease studied in 59 patients. BEACOPP extended overall survival (OS) to 83% at 2 years. A similar trend was seen when using the Stanford V regimen with an OS rate of 51% at 3 years, disease-free survival (DFS) of 68% and freedom from progression (FFP) in 60%. Additional benefits accrued from supportive care with stimulatory peptides such as G-CSF and when combined with bacterial prophylaxis results approached that found in the uninfected reference group. Current consensus holds this particular lymphoma as still among the non-AIDS defining cancers being lung, stomach, liver or anal despite these having recently gained more attention as several of these neoplasms may be occurring more commonly in the era of cART. While the relative risk of developing a non-AIDS-defining neoplasm in HIV-infected persons on the average is 2-3 times, the risk for developing HL in HIV-infected cases impressively ranges between 5 and 25 times when compared to the general population. Based on the precedent in which Kaposi sarcoma and the non-Hodgkin lymphomas distinctively alter the course of this retroviral infection in a way indistinguishable from concurrent Hodgkin lymphoma we propose that this entity be similarly regarded and the hypothesis tested in large randomised prospective study.

Lymphoma--emerging realities in sub-Saharan Africa.

Substantial geographical differences exist for Hodgkin and other lymphoproliferative disorders with these having previously been documented in a report from the lymphoma reclassification project. In the light of rampant human immunodeficiency syndrome, largely centred in sub-Sahara, this experience is updated in a further 512 consecutive individuals treated over an 8-year period in a privately based academic centre. Median age was 55.2 years 61% were males, 10% had Hodgkin lymphoma and, overall, constitutional symptoms were present in 20%. Prior to referral 19% had received chemotherapy and a further 20% some form of irradiation. Median survival in hairy cell leukaemia (n=14), chronic lymphocytic leukaemia-small lymphocytic lymphoma (n=103), Hodgkin (n=41) and follicular lymphoma (n=59) was not reached at the time of analysis and exceeded 36 months. This was followed by 32 months for those with mantle cell (n=7), splenic (n=2) and extranodal marginal cell (n=11), 24 months for T-cell lymphomas (n=24), 20 months for diffuse large B-cell variants (n=88) but only 12 months for the aggressive tumours exemplified by Burkitt (n=7) and lymphoblastic subtypes (n=6). The remaining 36 patients had to be excluded because numbers were too small for statistical analysis or unreliable staging. Adverse factors were constitutional symptoms, prior treatment with chemotherapy, intermediate or high-risk scores as defined by the international prognostic index, histologic grading and certain anatomical sites of primary tumour. In contrast gender, staging by Rye or Rai classification, retroviral infection and prior treatment with radiotherapy were without effect. Overall survival at 3 years in each category was compared to the curve for the entire cohort and was 100% in hairy cell leukaemia receiving two chlorodeoxyadenosine and greater than 88% in Hodgkin lymphoma treated according to the German study group protocols (p=0.0004). Corresponding figures for chronic lymphocytic leukaemia-small lymphocytic lymphoma were 82% (p=0.0006), follicular lymphoma 71% (p=0.060), peripheral T-cell lymphoma 43% (p=0.0156), diffuse large B-cell lymphoma 39% (p<0.0001), aggressive tumours 25% (p=0.0002) and for the indolent categories including mantle cell, splenic and extra nodal marginal cell lymphomas 22% (p=0.2023). Outcome argues in favour of patient management by a multidisciplinary team implicit in which are standardised protocols for diagnosis, staging and treatment. Under these circumstances the well recognized centre effect applies when results approximate those from first world reference centres. Conversely any deviation from such a disciplined approach is unlikely to achieve comparable benefit and therefore to be strongly discouraged.

Two measles clusters in connection with short inner-European air travels indicating impediments to effective measles control: A cluster analysis.

Importation and transmission of measles via air travel is a public health concern to countries, which are close to or have achieved elimination, i.e., to the majority of countries in Europe. In 2018, two measles cases occurred in Berlin residents, who flew within Europe while being infectious. In addition to contact tracing through passenger manifests, we contacted national authorities in flight destination countries or embarking countries and inquired about epidemiologically linked measles cases to the two Berlin index cases. We identified eight epidemiologically linked cases (six males, median age: 32 years) from three countries associated with three air-travels. Consequently measles was imported to Germany (Bavaria), Denmark and possibly Sweden. Our investigations revealed impediments to an effective public health response indicating the need to revisit current guidelines and methods to better control transmission of measles related to air travel.

Mind the gap! Risk factors for poor continuity of care of TB patients discharged from a hospital in the Western Cape, South Africa.

BACKGROUND: TB patients discharged from hospitals in South Africa experience poor continuity of care, failing to continue TB treatment at other levels of care. Factors contributing to poor continuity of TB care are insufficiently described to inform interventions. OBJECTIVE: To describe continuity of care and risk factors in TB patients discharged from a referral hospital in the Western Cape, South Africa. DESIGN: This retrospective observational study used routine information to describe continuity of care and risk factors in TB patients discharged from hospital. RESULTS: 788 hospitalized TB patients were identified in 6 months. Their median age was 32 years, 400 (51%) were male, and 653 (83%) were urban. A bacteriological TB test was performed for 74%, 25% were tested for HIV in hospital, and 32% of all TB patients had documented evidence of HIV co-infection. Few (13%) were notified for TB; 375 (48%) received TB medication; 284 (36%) continued TB treatment after discharge; 91 (24%) had a successful TB treatment outcome, and 166 (21%) died. Better continuity of care was associated with adults, urban residence, bacteriological TB tests in hospital and TB medication on discharge. Fragmented hospital TB data systems did not provide continuity with primary health care information systems. CONCLUSIONS: Discharged TB patients experienced poor continuity of care, with children, rural patients, those not tested for TB in hospital or discharged without TB medication at greatest risk. Suboptimal quality of hospital TB care and a fragmented hospital information system without linkages to other levels underpinned poor continuity of care.

Whole Genome Sequence Analysis of CTX-M-15 Producing Klebsiella Isolates Allowed Dissecting a Polyclonal Outbreak Scenario.

Extended-spectrum ß-lactamase (ESBL) producing Klebsiella pneumoniae pose an important threat of infection with increased morbidity and mortality, especially for immunocompromised patients. Here, we use the rise of multidrug-resistant K. pneumoniae in a German neurorehabilitation center from April 2015 to April 2016 to dissect the benefit of whole genome sequencing (WGS) for outbreak analyses. In total, 53 isolates were obtained from 52 patients and examined using WGS. Two independent analysis strategies (reference-based and -free) revealed the same distinct clusters of two CTX-M-15 producing K. pneumoniae clones (ST15, n = 31; ST405, n = 7) and one CTX-M-15 producing Klebsiella quasipneumoniae strain (ST414, n = 8). Additionally, we determined sequence variations associated with antimicrobial resistance phenotypes in single isolates expressing carbapenem and colistin resistance, respectively. For rapid detection of the major K. pneumoniae outbreak clone (ST15), a selective triplex PCR was deduced from WGS data of the major outbreak strain and K. pneumoniae genome data deposited in central databases. Moreover, we introduce two novel open-source applications supporting reference genome selection (refRank; https://gitlab.com/s.fuchs/refRank) and alignment-based SNP-filtering (SNPfilter; https://gitlab.com/s.fuchs/snpfilter) in NGS analyses.

'We are also dying like any other people, we are also people': perceptions of the impact of HIV/AIDS on health workers in two districts in Zambia.

In countries with a high AIDS prevalence, the health workforce is affected by AIDS in several ways. In Zambia, which has a prevalence rate of 16.5%, a study was carried out in 2004 with the aim to: explore the impact of HIV/AIDS on health workers, describe their coping mechanisms and recommend supportive measures. The qualitative study was complemented by a survey using self-administered questionnaires in four selected health facilities in two rural districts in Zambia, Mpika and Mazabuka. It is one of the few studies to have explored the impact of HIV/AIDS from the perspective of health workers and managers in the region. Thirty-four in-depth interviews and five group discussions were conducted with health workers, managers and volunteers, and 82 self-administered questionnaires were filled out by health workers. In addition, burnout among 42 health workers was measured using the Maslach Burnout Inventory (MBI). The MBI measures three components that contribute to burnout: emotional exhaustion, depersonalization and personal accomplishment. The results show that in both districts, HIV/AIDS has had a negative impact on workload and has considerably changed or added tasks to already overburdened health workers. In Mpika, 76% of respondents (29/38), and in Mazabuka, 79% (34/44) of respondents, expressed fear of infection at the workplace. HIV-positive health workers remained 'in hiding', did not talk about their illness and suffered in silence. Despite the fact that health workers were still relatively motivated, emotional exhaustion occurred among 62% of the respondents (26/42). The interviews revealed that counsellors and nurses were especially at risk for emotional exhaustion. In each of the selected facilities, organizational support for health workers to deal with HIV/AIDS was either haphazardly in place or not in place at all. AIDS complicates the already difficult work environment. In addition to health workers, management also needs support in dealing with AIDS at the workplace.