LASSA FEVER IN INTERNALLY-DISPLACED PERSONS' CAMP: A CASE REPORT AT ZABARMARI, BORNO STATE, NIGERIA.

Introdution: Lassa fever is a viral hemorrhagic disease caused by the Lassa virus, a single stranded RNA virus of the Arenavirus family. It is a zoonotic illness spread by rats of the speciesMastomys natalensis . Between weeks 1 and 17, (2017), 242 suspected Lassa fever cases were reported in Nigeria, with 58 laboratory confirmed cases and 46 fatalities (CFR, 19.01%) from 50 Local Government Areas (LGAs) in 20 States. Methods: We conducted an outbreak investigation and gathered a thorough clinical history of the index case as well as contacts, who were then followed up using the standard viral hemorrhagic fever contact monitoring form. Following that, blood samples were collected from this patient. A total of 54 contacts were tracked for 21 days and their temperatures were recorded using a clinical thermometer. Furthermore, an environmental evaluation of the Zabarmari community and the Madinatu Internally-displaced persons' (IDP) camp was carried out. Results: The index case was a 32-year-old woman who was internallydisplaced in Zabarmari community. Her symptoms began with fever and vaginal bleeding and progressed to bleeding from the nose, mouth, and urethra. There was a history of rat exposure as well as inadequate environmental sanitation and hygiene. Real Time PCR detected Lassa fever in the blood sample. The Borno State Ministry of Environment, in partnership with the Ministry of Health, undertook public health education on Lassa fever prevention and implemented excellent sanitary measures. Conclusion: Increased awareness creation on good infection prevention and control practices is crucial among internally-displaced person and health care providers to prevent occurrence and spread of the disease.

The impact of screening for tuberculosis exposure in the household in children with tuberculosis disease: A difficult riddle to solve.

BACKGROUND: Tuberculosis (TB) infection is transmitted by sharing the same airway with people with active TB. Children are often not considered the source of TB bacilli, and index case investigation is carried out after diagnosis. Here, we describe the impact of the presence of a household index case on childhood TB disease. METHODS: The data of patients aged between 1 month and 18 years who were diagnosed with TB were collected. We compared patients according to whether they had an index case in the household or not. RESULTS: A total of 202 TB patients were enrolled, of whom 62 (30.7%) had a household index case. There was no significant difference in having a household index case between TB patients under the age of five (23.3%) and older children (33.8%) (p = .140). Pulmonary TB was present in 61.4% of the cases, and extrapulmonary TB was present in 38.6% of the cases. The rate of patients who had a household index case was significantly higher in pulmonary TB (46.8%) compared to extrapulmonary TB (5.1%) (p < .001). Pulmonary TB patients with a history of household contact were more likely to have diagnostic radiological findings (93.1%) compared to those without (75.8%) (p = .009). However, pulmonary TB patients without household contact history had a higher rate of diagnostic microbiological findings (59.1%) and constitutional symptoms (63.6%) (p = .019 and p = .013, respectively). CONCLUSION: Household contact research is an important epidemiological tool. However, considering the contact rates in the household, new and more comprehensive public health programs are required to prevent the spread of childhood tuberculosis.

Estimating dengue burden among family contacts through cluster investigation around probable cases in 2022 and 2023 in the Central Region, Burkina Faso.

BACKGROUND: In 2023, Burkina Faso experienced the largest dengue epidemic ever in Africa. This study aimed to estimate the prevalence of symptomatic, subclinical, and asymptomatic dengue and determine the associated factors among adult contacts of dengue in the Central Region, Burkina Faso. METHODS: This cross-sectional study included contacts of dengue probable cases through cluster sampling in 2022-2023. These suspected cases that tested positive were identified from the five health facilities (Pissy CMA, Saaba CM, Kossodo CMA, Samandin CM, and Marcoussis CSPS) that reported the highest number of cases in 2021 per district. All participants underwent dengue and malaria rapid diagnostic tests (RDT). Samples positive for non-structural 1 protein antigen (AgNS1) and/or immunoglobulin M (IgM) were tested for serotype detection by reverse transcription polymerase chain reaction (RT-PCR). Binary logistic regression was done to identify the determinants of asymptomatic, subclinical, and symptomatic dengue among contacts of probable dengue cases. RESULTS: A total of 484 contacts were included, mostly in 2023 (75.2%). Most participants were females (58.6%), residing (24.3%) and passing their daytime (23.1%) in Saaba. The overall prevalence of dengue was estimated at 15.1% [95% confidence interval (CI): 12.0-18.6%], representing cases not seeking care in hospitals. Asymptomatic cases represented 2.9% (95% CI: 1.6-4.8%). Subclinical and symptomatic cases accounted for 6.0% (95% CI: 4.1-8.5%) and 6.2% (95% CI: 4.2-8.7%), respectively. Of the 58 samples tested by RT-PCR, 10 were confirmed for serotype 3 in 2023. Malaria cases were estimated at 5.6% (95% CI: 3.7-8.0%). After adjustment, participants claiming that a virus transmits dengue were likelier to have asymptomatic dengue [adjusted odds ratio (aOR) = 7.1, 95% CI: 2.4-21.0]. From the multivariable analysis, subclinical dengue was statistically associated with being included in the study in 2023 (aOR = 30.2, 95% CI: 2.0-455.5) and spending the daytime at Arrondissement 4 (aOR = 11.5, 95% CI: 1.0-131.0). After adjustment, symptomatic dengue was associated with living less than 50 m away from cultivated land (aOR = 2.8, 95% CI: 1.1-6.9) and living less than 50 m from a stretch of water (aOR = 0.1, 95% CI: 0.0-0.6). CONCLUSIONS: The overall burden of dengue among populations not seeking care in hospitals was quite high, with few asymptomatic cases. Efforts to manage dengue cases should also target non-hospital cases and raise population awareness. The 2023 epidemic could be due to dengue virus (DENV)-3.

Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi.

BACKGROUND: Assisted index case testing (ICT), in which health care workers take an active role in referring at-risk contacts of people living with HIV for HIV testing services, has been widely recognized as an evidence-based intervention with high potential to increase status awareness in people living with HIV. While the available evidence from eastern and southern Africa suggests that assisted ICT can be an effective, efficient, cost-effective, acceptable, and low-risk strategy to implement in the region, it reveals that feasibility barriers to implementation exist. This study aims to inform the design of implementation strategies to mitigate these feasibility barriers by examining "assisting" health care workers' experiences of how barriers manifest throughout the assisted ICT process, as well as their perceptions of potential opportunities to facilitate feasibility. METHODS: In-depth interviews were conducted with 26 lay health care workers delivering assisted ICT in Malawian health facilities. Interviews explored health care workers' experiences counseling index clients and tracing these clients' contacts, aiming to inform development of a blended learning implementation package. Transcripts were inductively analyzed using Dedoose coding software to identify and describe key factors influencing feasibility of assisted ICT. Analysis included multiple rounds of coding and iteration with the data collection team. RESULTS: Participants reported a variety of barriers to feasibility of assisted index case testing implementation, including sensitivities around discussing ICT with clients, privacy concerns, limited time for assisted index case testing amid high workloads, poor quality contact information, and logistical obstacles to tracing. Participants also reported several health care worker characteristics that facilitate feasibility (knowledge, interpersonal skills, non-stigmatizing attitudes and behaviors, and a sense of purpose), as well as identified process improvements with the potential to mitigate barriers. CONCLUSIONS: Maximizing assisted ICT's potential to increase status awareness in people living with HIV requires equipping health care workers with effective training and support to address and overcome the many feasibility barriers that they face in implementation. Findings demonstrate the need for, as well as inform the development of, implementation strategies to mitigate barriers and promote facilitators to feasibility of assisted ICT. TRIAL REGISTRATION: NCT05343390. Date of registration: April 25, 2022.

Hepatitis B virus infection, associated factors, knowledge and vaccination status among household contacts of hepatitis B index cases in Mwanza, Tanzania.

Objectives: To determine the prevalence of hepatitis B virus (HBV) infection, knowledge regarding HBV, vaccination status, and associated factors among household contacts of HBV index cases in Mwanza, Tanzania. Methods: Between July and August 2023, a cross-sectional study involving 97 index cases and 402 household contacts was conducted. Data were collected using pre-tested structured questionnaire and blood samples were collected from household contacts for HBV surface antigen (HBsAg) testing. Results: The prevalence of HBV among household contacts was 5.4% (95% confidence interval, 2.9-9.0) with a significantly high proportion observed in > 45 years (16.6%) and in males (9.9%). A total of 40.0% of the household contacts had completed the full HBV vaccination series. On multivariate analysis, being male was significantly associated with HBsAg positivity (odds ratio: 7.16, 95% confidence interval: 1.81-28.2, P = 0.005). Conclusion: About one-tenth of adults' male household contacts were HBsAg positive. In addition, the majority of household contacts had poor to fair knowledge regarding HBV infection with more than half being unvaccinated against HBV. There is a need to enhance awareness and education regarding HBV infection among household contacts in Tanzania and other low- and middle-income countries.

Higher outdoor mosquito density and Plasmodium infection rates in and around malaria index case households in low transmission settings of Ethiopia: Implications for vector control.

BACKGROUND: Understanding the clustering of infections for persistent malaria transmission is critical to determining how and where to target specific interventions. This study aimed to determine the density, blood meal sources and malaria transmission risk of anopheline vectors by targeting malaria index cases, their neighboring households and control villages in Arjo-Didessa, southwestern Ethiopia. METHODS: An entomological study was conducted concurrently with a reactive case detection (RCD) study from November 2019 to October 2021 in Arjo Didessa and the surrounding vicinity, southwestern Ethiopia. Anopheline mosquitoes were collected indoors and outdoors in index case households and their surrounding households (neighboring households), as well as in control households, using pyrethrum spray cache (PSC) and U.S. Centers for Disease Control and Prevention (CDC) light traps. Adult mosquitoes were morphologically identified, and speciation in the Anopheles gambiae complex was done by PCR. Mosquito Plasmodium infections and host blood meal sources were detected by circumsporozoite protein enzyme-linked immunosorbent assay (CSP-ELISA) and cytochrome b-based blood meal PCR, respectively. RESULTS: Among the 770 anopheline mosquitoes collected, An. gambiae sensu lato (A. gambiae s.l.) was the predominant species, accounting for 87.1% (n = 671/770) of the catch, followed by the Anopheles coustani complex and Anopheles pharoensis, which accounted for 12.6% (n = 97/770) and 0.26% (n = 2/770) of the catch, respectively. From the sub-samples of An. gambiae s.l.analyzed with PCR, An. arabiensis and Anopheles amharicus were identified. The overall mean density of mosquitoes was 1.26 mosquitoes per trap per night using the CDC light traps. Outdoor mosquito density was significantly higher than indoor mosquito density in the index and neighboring households (P = 0.0001). The human blood index (HBI) and bovine blood index (BBI) of An. arabiensis were 20.8% (n = 34/168) and 24.0% (n = 41/168), respectively. The overall Plasmodium sporozoite infection rate of anophelines (An. arabiensis and An. coustani complex) was 4.4% (n = 34/770). Sporozoites were detected indoors and outdoors in captured anopheline mosquitoes. Of these CSP-positive species for Pv-210, Pv-247 and Pf, 41.1% (n = 14/34) were captured outdoors. A significantly higher proportion of sporozoite-infected mosquitoes were caught in index case households (5.6%, n = 8/141) compared to control households (1.1%, n = 2/181) (P = 0.02), and in neighboring households (5.3%, n = 24/448) compared to control households (P = 0.01). CONCLUSIONS: The findings of this study indicated that malaria index cases and their neighboring households had higher outdoor mosquito densities and Plasmodium infection rates. The study also highlighted a relatively higher outdoor mosquito density, which could increase the potential risk of outdoor malaria transmission and may play a role in residual malaria transmission. Thus, it is important to strengthen the implementation of vector control interventions, such as targeted indoor residual spraying, long-lasting insecticidal nets and other supplementary vector control measures such as larval source management and community engagement approaches. Furthermore, in low transmission settings, such as the Arjo Didessa Sugarcane Plantation, providing health education to local communities, enhanced environmental management and entomological surveillance, along with case detection and management by targeting of malaria index cases and their immediate neighboring households, could be important measures to control residual malaria transmission and achieve the targeted elimination goals.

Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi.

Background: Assisted index case testing, in which health care workers take an active role in referring at-risk contacts of people living with HIV for HIV testing services, has been widely recognized as an evidence-based intervention with high potential to increase PLHIV status awareness. Promising evidence for the approach has led to several attempts to scale assisted index case testing throughout eastern and southern Africa in recent years. However, despite effective implementation being at the heart of any assisted index case testing strategy, there is limited implementation science research from the perspective of the HCWs who are doing the "assisting". This study examines the feasibility of assisted index case testing from the perspective of health care workers implementing the approach in Malawi. Methods: In-depth interviews were conducted with 26 lay health care workers delivering assisted index case testing in Malawian health facilities. Interviews explored health care workers' experiences counselling index clients and tracing these clients' contacts, aiming to inform development of a blended learning implementation package. Transcripts were inductively analyzed using Dedoose coding software to identify and describe key factors influencing feasibility of assisted index case testing. Analysis included multiple rounds of coding and iteration with the data collection team. Results: Participants reported a variety of barriers to feasibility of assisted index case testing implementation, including privacy concerns, limited time for assisted index case testing amid high workloads, poor quality contact information, logistical obstacles to tracing, and challenges of discussing sexual behavior with clients. Participants also reported several health care worker characteristics that facilitate feasibility: robust understanding of assisted index case testing's rationale and knowledge of procedures, strong interpersonal skills, positive attitudes towards clients, and sense of purpose in their work. Conclusions: Findings demonstrate that maximizing assisted index case testing's potential to increase HIV status awareness requires adequately equipping health care workers with appropriate knowledge, skills, and support to address and overcome the many feasibility challenges that they face in implementation. Trial Registration Number: NCT05343390 Date of registration: April 25, 2022.

Role of surgical embolectomy in the management of acute massive and submassive pulmonary embolism in the setting of a small island developing state.

Acute pulmonary embolism (PE) remains a life-threatening condition despite advances in diagnostic and therapeutic modalities. Treatment modalities include systemic thrombolysis, catheter-based therapies and surgical embolectomy. This case report describes the first recorded surgical embolectomy for acute PE in Barbados, a small island developing state.

Acceptance of Index Case HIV Testing and Its Associated Factors Among HIV/AIDS Clients on ART Follow-Up in West Ethiopia: A Multi-Centered Facility-Based Cross-Sectional Study.

Background: Index case HIV/AIDS testing (ICHT) is a good approach for addressing and improving the efficiency and yield of testing among high-risk populations. Partners and families of people living with HIV/AIDS are among the high-risk populations for contracting HIV/AIDS. However, there is limited study on index case HIV testing among HIV patients attending Anti-Retroviral Therapy (ART). Hence, this study was aimed at assessing the magnitude and factors associated with ICHT among HIV patients attending ART in Nekemte town public health facilities. Methods: An institution-based cross-sectional study was conducted at Nekemte town public health facilities from May 20 to July 21, 2020. A systematic random sampling method was used to select the study participants. Multivariable logistic regression analysis was used to determine the predictors of acceptance of ICHT among HIV patients. Results: The ICHT acceptance was 85.2% (95% CI=84.9-91.1%). Disclosure of their HIV status (AOR=9.74, 95% CI=4.11-23.06), having good knowledge of ICHT (AOR=4.70, 95% CI=1.92-11.61), believing HIV index case testing has benefits (AOR=3.43, 95% CI=1.27-9.29), and being on ART for more than 1 year (AOR=4.78, 95% CI=2.13-10.76) were significantly associated with index case HIV test acceptance. Conclusion and Recommendation: This study revealed a significant proportion of index case HIV testing acceptance. HIV status disclosure of index cases, knowledge of ICHT, the perceived benefit of ICHT, and long duration on ART were found to be significantly associated with acceptance of ICHT. Hence, it is essential to give attention to counseling on the importance of ICHT, enhance people living with HIV (PLWHIV) to have positive belief on the advantage of ICHT, strengthen disclosure counseling, and assist HIV status disclosure in health facilities.

Covid-19: Early Cases and Disease Spread.

The emergence and global spread of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is critical to understanding how to prevent or control a future viral pandemic. We review the tools used for this retrospective search, their limits, and results obtained from China, France, Italy and the USA. We examine possible scenarios for the emergence of SARS-CoV-2 in the human population. We consider the Chinese city of Wuhan where the first cases of atypical pneumonia were attributed to SARS-CoV-2 and from where the disease spread worldwide. Possible superspreading events include the Wuhan-based 7th Military World Games on October 18-27, 2019 and the Chinese New Year holidays from January 25 to February 2, 2020. Several clues point to an early regional circulation of SARS-CoV-2 in northern Italy (Lombardi) as soon as September/October 2019 and in France in November/December 2019, if not before. With the goal of preventing future pandemics, we call for additional retrospective studies designed to trace the origin of SARS-CoV-2.

Analysis of Factors Affecting the Rate of Latent Tuberculosis Infection and Management in Pediatrics.

The incidence of tuberculosis remains high in South Korea; the management of latent tuberculosis infection (LTBI) has become the prime target for reducing the infection rate. The management of pediatric LTBI is especially crucial because children can serve as a long-term source of infection upon developing active tuberculosis. Therefore, it is important to assess pediatric LTBI using contact investigation and follow-up. We conducted a retrospective study on children aged between 0 and 18 years who visited our hospital for tuberculosis contact screening from February 2012 to February 2021. Tuberculosis index cases and their clinical characteristics were also reviewed retrospectively. A total of 350 children were investigated, and 68 of 247 (27.5%) were diagnosed with LTBI. The rate of LTBI (r = 7.98, p < 0.001) and the risk of loss to follow-up (r = 27.038, p < 0.001) were higher in cases with close household contact. Sputum (r = 10.992, p < 0.001) and positive acid-fast bacillus (AFB) stain (r = 4.458, p = 0.001) in tuberculosis index cases were related to the diagnosis of LTBI in pediatric contacts. Active management is needed for tuberculosis screening in pediatric contacts, especially when the contacts are older and the index case is within the family, and when the index case has sputum and has tested positive for AFB smear.

Impact of COVID-19 on routine immunization in Oyo State, Nigeria: trend analysis of immunization data in the pre- and post-index case period; 2019-2020.

Introduction: the response to COVID-19 pandemic has posed new obstacles to the fragile health system, most especially in the area of vaccination across much of Africa. As the response to the pandemic intensifies through the application of non-pharmacologic interventions as well as enforcement of the lockdowns across African cities, there is a significant risk that more children will miss out on life-saving vaccines that can prevent childhood killer diseases. This study was therefore conducted to look at the impact of the COVID-19 pandemic on routine immunization in Oyo State, Nigeria. Methods: we conducted a descriptive secondary analysis of immunization data between July 2019 and August 2020. These data were retrieved from the monitoring and evaluation unit of Oyo State Primary Health Care Board. The data were extracted from the original paper format and entered into Excel sheets. Line graphs were plotted to compare the trends of the coverage rates before and after the index case of the COVID-19 pandemic. Results: the average coverage rates for Bacillus Calmette-Guérin (BCG) before and after index case were 85.8% and 82.1% respectively, while it was 63.5% and 60.0% for HBV0. For the co-administered vaccines at 14 weeks, Penta 3, OPV 3, PCV 3 and IPV coverage rates dropped from 76.1%, 75.4%, 75.1% and 73.5% to 72.0%, 71.4%, 72.0% and 71.9% respectively. The average coverage rates for yellow fever and measles dropped sharply from 77.0% and 74.5% and 64.6% and 58.6% respectively. The average drop-out rates for the pre-and post-index case periods were 5.0% and 4.7% respectively. For the planned fixed and outreach sessions, none of the monthly sessions met the target of 100.0% in the post-index case period. Conclusion: decreased vaccination coverage for vaccine-preventable diseases could cause parallel outbreaks with COVID-19 and further exacerbate the strain on health systems attempting to end the acute phase of this pandemic. Therefore, as the dramatic second wave unfolds, the Government of Nigeria must take deliberate steps to strike a balance between a fresh lockdown and the imperative of uninterrupted social service. In this wise, it must remain committed to a timely vaccination program.

Home-based HIV Testing for Children: A Useful Complement for Caregivers with More Children, Who are Male, and with an HIV Negative Partner.

Expanding index and family-based testing (HBT) is a priority for identifying children living with HIV. Our study characterizes predictors that drive testing location choice for children of parents living with HIV. Kenyan adults living with HIV were offered a choice of HBT or clinic-based testing (CBT) for any of their children (0-12 years) of unknown HIV status. Multilevel generalized linear models were used to identify correlates of choosing HBT or CBT for children and testing all versus some children within a family, including caregiver demographics, HIV history, social support, cost, and child demographics and HIV prevention history. Among 244 caregivers living with HIV and their children of unknown HIV status, most (72%) caregivers tested children using CBT. In multivariate analysis, female caregivers [aRR 0.52 (95% CI 0.34-0.80)] were less likely to choose HBT than male caregivers. Caregivers with more children requiring testing [aRR 1.23 (95% CI 1.05-1.44)] were more likely to choose HBT than those with fewer children requiring testing. In subgroup univariate analysis, female caregivers with a known HIV negative spouse were significantly more likely to choose HBT over CBT than those with a known HIV positive spouse [RR 2.57 (95% CI 1.28-5.14), p = 0.008], no association was found for male caregivers. Child demographics and clinical history was not associated with study outcomes. Caregiver-specific factors were more influential than child-specific factors in caregiver choice of pediatric HIV testing location. Home-based testing may be preferable to families with higher child care needs and may encourage pediatric HIV testing if offered as an alternative to clinic testing.

Assessment of Index Case Family Testing Among Adults Attending Art Clinic at Kule Refugee Camp, Southwest Ethiopia: 2021.

BACKGROUND: Human immune virus testing and counseling is the gateway to accessing anti-retro viral treatment. As a priority population group, families of index clients have been largely neglected due to a number of different factors. Testing sexual partners and children of human immunodeficiency virus (HIV) positive persons (index case finding) is a promising way of identifying HIV-positive persons unaware of their HIV status. OBJECTIVE: The aim of this study was to determine the proportion of index case family testing and its associated factors among adults attending an ART clinic at Kule Refugee Camp, southwestern Ethiopia, 2021. METHODS AND MATERIALS: An institution-based cross-sectional study was conducted at Kule Refugee Camp, Gambela region. A total of 348 adult ART clinic attendants were selected by using systematic random sampling technique. Data were collected by using a pre-tested interviewer-administered semi-structured questionnaire. The collected data were entered into Epi-Data 3.1 and exported to SPSS version 23. Bivariable and multivariable logistic regression analyses were used to identify factors associated with index case family testing. The strength of association was assessed by adjusted odds ratio, and statistical significance was declared at a p-value <0.05 and 95% CI. RESULTS: The proportion of index case family testing was 49.%. Educational level: primary level (AOR=2.4, 95% CI=1.24-4.42), secondary level and above (AOR=2.6, 95% CI=1.20-4.70), ART adherence (AOR=6, 95% CI=2.8-14.1), years on ART (AOR=2, 95% CI=1.10-3.20), discussion about HIV testing (AOR=3.6, 95% CI=1.30-10.30), disclosure status (AOR 6, 95% CI=2.21-16.94), and being tested through voluntary counseling and testing (AOR=3.0, 95% CI1.70-5.70) were factors significantly associated with index case family HIV testing. CONCLUSION AND RECOMMENDATIONS: This study revealed that the proportion of index case family HIV testing in Kule Refugee Camp was 49%. Educational status, adherence status, disclosure status, years on ART, and voluntary counseling and testing were determinant factors. Health professionals should advise index cases to adhere to ART drugs, to disclose their HIV status to their families, and should provide counseling based on guidelines.

The Effect of Advanced Practice Providers on ACGME Colon and Rectal Surgery Resident Diagnostic Index Case Volumes.

OBJECTIVE: Prior to 2015 residents in our Accreditation Council for Graduation Medical Education (ACGME) colon and rectal surgery training program were in charge of managing, with faculty oversight, the outpatient anorectal clinic at our institution. Starting in 2015 advanced practice providers (APPs) working in the division assumed management of the clinic. The effect of APPs on ACGME resident index diagnostic case volumes has not been explored. Herein we examine ACGME case log graduate statistics to determine if the inclusion of APPs into our anorectal clinic practice has negatively affected resident index diagnostic anorectal case volumes. DESIGN: ACGME year-end program reports were obtained for the years 2011 to 2019. Program anorectal diagnostic index volumes were recorded and compared to division volumes. Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) tests were conducted to assess whether the number of cases per year (for each respective case type) prior to the introduction of APPs into the anorectal clinic (2011-2014) differed from the number of cases per year with the APP clinic in place (2015-2018). A p-value <0.05 was considered statistically significant. SETTING: Mayo Clinic, Rochester, Minnesota (quaternary referral center). PARTICIPANTS: Colon and rectal surgery resident year-end ACGME reports (2011-2019). RESULTS: ANOVAs revealed a marginally significant (p = 0.007) downtrend for hemorrhoid diagnostic codes, and a significant uptrend (p = 0.000) for fistula cases. Controlling for overall division volume, ANCOVA only reveled significance for fistula cases (p = 0.004) with the involvement of APPs. CONCLUSIONS: At our institution we found the inclusion of APPs into our anorectal clinic practice did not negatively affect colon and rectal surgery resident ACGME index diagnostic anorectal case volumes. Inclusion of APPs into a multidisciplinary practice can promote resident education by allowing trainees to pursue other educational opportunities without hindering ACGME index case volumes.

Genetic testing for familial hypercholesterolemia-past, present, and future.

In the early 1980s, the Nobel Prize winning cellular and molecular work of Mike Brown and Joe Goldstein led to the identification of the LDL receptor gene as the first gene where mutations cause the familial hypercholesterolemia (FH) phenotype. We now know that autosomal dominant monogenic FH can be caused by pathogenic variants of three additional genes (APOB/PCSK9/APOE) and that the plasma LDL-C concentration and risk of premature coronary heart disease differs according to the specific locus and associated molecular cause. It is now possible to use next-generation sequencing to sequence all exons of all four genes, processing 96 patient samples in one sequencing run, increasing the speed of test results, and reducing costs. This has resulted in the identification of not only many novel FH-causing variants but also some variants of unknown significance, which require further evidence to classify as pathogenic or benign. The identification of the FH-causing variant in an index case can be used as an unambiguous and rapid test for other family members. An FH-causing variant can be found in 20-40% of patients with the FH phenotype, and we now appreciate that in the majority of patients without a monogenic cause, a polygenic etiology for their phenotype is highly likely. Compared with those with a monogenic cause, these patients have significantly lower risk of future coronary heart disease. The use of these molecular genetic diagnostic methods in the characterization of FH is a prime example of the utility of precision or personalized medicine.

Human Immune Deficiency Virus Serostatus and Associated Factors Among Children of Adult Index Cases in Northern Ethiopia.

INTRODUCTION: Children whose parents with human immunodeficiency virus (HIV) and family of index clients are at high risk of HIV infection. Family testing is an efficient and effective way of identifying children's HIV. The number of children becoming newly infected with HIV remains unacceptably high. This study is to assess human immune deficiency, virus serostatus, and associated factors among children of adult index cases in central Tigrai, Northern Ethiopia, 2019. METHODS: An institution-based cross-sectional study design was conducted to select a total of 454 index cases from February 01 to April 30, 2019. Data were collected from adult clients on antiretroviral treatment who have children using administered questionnaires and data extraction from the hospital antiretroviral register. Simple random sampling was used to select the index cases using the medical record number. Binary logistic regression analysis, odds ratio, and 95% confidence interval were used to determine the strength of association between dependent and independent variables. Statistical significance was declared a P-value <0.05. RESULTS: The prevalence of HIV in children from family index case testing was 8.9% with 95% CI (6.5-11.6). Female index clients [AOR=0.18, 95% CI: 06-0.55], the age of the child [AOR=0.86, 95% CI: 0.76, 0.97], importance of HIV testing [AOR=5.20, 95% CI: 2.2011.96], and discussion HIV testing [AOR=3.22, 95% CI: 1.5-16.84]. Participants who did not discuss HIV were 3.2 more likely have HIV positive child than who discussed with family members. CONCLUSION: The majority of the index clients test their children, but the prevalence rate of HIV in children from family index case testing is high. Strategies should be developed on how to communicate with household members about HIV.

Evaluating the measures taken to contain a Candida auris outbreak in a tertiary care hospital in South India: an outbreak investigational study.

BACKGROUND: Candida auris infections are an emerging global threat with poor clinical outcome, high mortality rate, high transmission rate and outbreak potential. The objective of this work is to describe a multidisciplinary approach towards the investigation and containment of a Candida auris outbreak and the preventive measures adopted in a resource limited setting. METHODS: This outbreak investigational study was conducted at a 1300-bedded tertiary care academic hospital in South India. The study included 15 adult inpatients with laboratory confirmed Candida auris isolates. The outbreak cluster was identified in adult patients admitted from September 2017 to 2019. The system response consisted of a critical alert system for laboratory confirmed Candida auris infection and multidisciplinary 'Candida auris care team' for patient management. The team implemented stringent Infection Prevention and Control (IPC) measures including patient cohorting, standardized therapy and decolonization, staff training, prospective surveillance and introduction of Candida auris specific care bundle. RESULTS: Two outbreak clusters were identified; first cluster occurring between October and November 2017 and the second cluster in May 2018. The cohorts consisted of 7 and 8 Candida auris positive patients in the first and second waves of the outbreak respectively with a total survival rate of 93% (14/15). Deployment of containment measures led to gradual decline in the incidence of adult Candida auris positive cases and prevented further cluster formation. CONCLUSIONS: The sustained implementation of guideline and evidence-based IPC measures and training of healthcare workers for improving awareness on systematically following standardized protocols of Candida auris related IPC practices successfully contained Candida auris outbreaks at our hospital. This demonstrates the feasibility of establishing a multidisciplinary model and bundling of practices for preventing Candida auris outbreaks in a Low- and Middle-income country.

Epidemiological burden of parents being the index cases of COVID-19 infected children.

BACKGROUND: In the ongoing coronavirus disease 2019 (COVID-19) pandemic, when children remain home-confined secondary to the closure of schools, little is known of the burden of the parents being their index case. AIM: To determine the prevalence of parents being the index case of COVID-19 infected children. METHODS: A database search in PubMed and Scopus ensued to recruit studies reporting the index case information of COVID-19 infected individuals aged ≤ 18. The reviewed articles' quality evaluation included the use of the National Heart, Lung, and Blood Institute's tool. A random-effect meta-analysis ensued to determine the prevalence of the parent being and not-being the index case. Heterogeneity was assessed by I 2 and Chi 2 statistics. The publication bias was evaluated by funnel plots and Egger's test. RESULTS: Overall, this review included 13 eligible studies sourcing data from 622 children of 33 nations. Study designs were heterogeneous and primarily included descriptive reports (38.4%). The prevalence of parent being the index case was 54% (95%CI: 0.29-0.79; I 2: 62.3%, Chi 2 P < 0.001). In > 70% of children, their index-case parent was symptomatic due to COVID-19 at the time of infection transmitting. Studies for which a risk of bias assessment was possible were of fair quality. CONCLUSION: There is a substantial global burden of parents being the index case of COVID-19 infected children, and frequently these parents are symptomatic. Therefore, from a public health perspective, early detection of these parents is crucial.

COVID-19 caseness: An epidemiologic perspective.

The concept of caseness in the COVID-19 virus is important for early case finding and reporting. These are essential steps for prevention and control. This review defines and differentiates between types of cases and specifies the elements of each case definition in general with their application to COVID-19, where appropriate. These terms and their application are useful for the surveillance team, epidemiologists, clinicians, policy makers as well as the public in general.