Availability of published evidence on coverage, cost components, and funding support for digitalisation of infectious disease surveillance in Africa, 2003-2022: a systematic review.

BACKGROUND: The implementation of digital disease surveillance systems at national levels in Africa have been challenged by many factors. These include user applicability, utility of IT features but also stable financial support. Funding closely intertwines with implementations in terms of geographical reach, disease focus, and sustainability. However, the practice of evidence sharing on geographical and disease coverage, costs, and funding sources for improving the implementation of these systems on the continent is unclear. OBJECTIVES: To analyse the key characteristics and availability of evidence for implementing digital infectious disease surveillance systems in Africa namely their disease focus, geographical reach, cost reporting, and external funding support. METHODS: We conducted a systematic review of peer-reviewed and grey literature for the period 2003 to 2022 (PROSPERO registration number: CRD42022300849). We searched five databases (PubMed, MEDLINE over Ovid, EMBASE, Web of Science, and Google Scholar) and websites of WHO, Africa CDC, and public health institutes of African countries. We mapped the distribution of projects by country; identified reported implementation cost components; categorised the availability of data on cost components; and identified supporting funding institutions outside Africa. RESULTS: A total of 29 reports from 2,033 search results were eligible for analysis. We identified 27 projects implemented in 13 countries, across 32 sites. Of these, 24 (75%) were pilot projects with a median duration of 16 months, (IQR: 5-40). Of the 27 projects, 5 (19%) were implemented for HIV/AIDs and tuberculosis, 4 (15%) for malaria, 4 (15%) for all notifiable diseases, and 4 (15%) for One Health. We identified 17 cost components across the 29 reports. Of these, 11 (38%) reported quantified costs for start-up capital, 10 (34%) for health personnel compensation, 9 (31%) for training and capacity building, 8 (28%) for software maintenance, and 7(24%) for surveillance data transmission. Of 65 counts of external funding sources, 35 (54%) were governmental agencies, 15 (23%) foundations, and 7 (11%) UN agencies. CONCLUSIONS: The evidence on costing data for the digitalisation of surveillance and outbreak response in the published literature is sparse in quantity, limited in detail, and without a standardised reporting format. Most initial direct project costs are substantially donor dependent, short lived, and thus unsustainable.

Childhood and adolescence factors and multiple sclerosis: results from the German National Cohort (NAKO).

BACKGROUND: Multiple Sclerosis (MS) represents the most common inflammatory neurological disease causing disability in early adulthood. Childhood and adolescence factors might be of relevance in the development of MS. We aimed to investigate the association between various factors (e.g., prematurity, breastfeeding, daycare attendance, weight history) and MS risk. METHODS: Data from the baseline assessment of the German National Cohort (NAKO) were used to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for the association between childhood and adolescence factors and risk of MS. Analyses stratified by sex were conducted. RESULTS: Among a total of 204,273 participants, 858 reported an MS diagnosis. Male sex was associated with a decreased MS risk (HR 0.48; 95% CI 0.41-0.56), while overweight (HR 2.03; 95% CI 1.41-2.94) and obesity (HR 1.89; 95% CI 1.02-3.48) at 18 years of age compared to normal weight were associated with increased MS risk. Having been breastfed for ≤ 4 months was associated with a decreased MS risk in men (HR 0.59; 95% CI 0.40-0.86) compared to no breastfeeding. No association with MS risk was observed for the remaining factors. CONCLUSIONS: Apart from overweight and obesity at the age of 18 years, we did not observe considerable associations with MS risk. The proportion of cases that can be explained by childhood and adolescence factors examined in this study was low. Further investigations of the association between the onset of overweight and obesity in childhood and adolescence and its interaction with physical activity and MS risk seem worthwhile.

Personality and the use of cancer screenings - Results of the German National Cohort.

Objective: To determine the association between personality characteristics and use of different cancer screenings. Methods: We used data from the German National Cohort (NAKO; mean age was 53.0 years (SD: 9.2 years)) - a population-based cohort study. A total of 132,298 individuals were included in the analyses. As outcome measures, we used (self-reported): stool examination for blood (haemoccult test, early detection of bowel cancer), colonoscopy (screening for colorectal cancer), skin examination for moles (early detection of skin cancer), breast palpation by a doctor (early detection of breast cancer), x-ray examination of the breast ("mammography", early detection of breast cancer), cervical smear test, finger examination of the rectum (early detection of prostate cancer), and blood test for prostate cancer (determination of Prostate-Specific Antigen level). The established Big Five Inventory-SOEP was used to quantify personality factors. It was adjusted for several covariates based on the Andersen model. Unadjusted and adjusted multiple logistic regressions were computed. Results: A higher probability of having a skin examination for moles, for example, was associated with a higher conscientiousness (OR: 1.07, p < 0.001), higher extraversion (OR: 1.03, p < 0.001), higher agreeableness (OR: 1.02, p < 0.001), lower openness to experience (OR: 0.98, p < 0.001) and higher neuroticism (OR: 1.07, p < 0.001) among the total sample. Depending on the outcome used, the associations slightly varied. Conclusions: Particularly higher levels of extraversion, neuroticism and conscientiousness are associated with the use of different cancer screenings. Such knowledge may help to better understand non-participation in cancer screening examinations from a psychological perspective.

Differences in Anthropometric Measures Based on Sex, Age, and Health Status.

BACKGROUND: Obesity is a worldwide health problem. We conducted detailed analyses of anthropometric measures in a comprehensive, population-based, current cohort in Germany. METHODS: In the German National Cohort (NAKO), we analyzed cross-sectional data on body mass index (BMI), waist and hip circumference, subcutaneous (SAT) and visceral adipose tissue (VAT) as measured by ultrasound, and body fat percentage. The data were stratified by sex, age, and self-reported physicians' diagnoses of cardiovascular diseases (CVD), metabolic diseases (MetD), cardiometabolic diseases (CMD), and cancer. RESULTS: Data were available from 204 751 participants (age, 49.9 ± 12.8 years; 50.5% women). Body size measures generally increased with age. Men had a higher BMI, larger waist circumference, and more VAT than women, while women had a larger hip circumference, more SAT, and a higher body fat percentage than men. For example, the mean BMI of participants over age 60 was 28.3 kg/m2 in men and 27.6 kg/m2 in women. CVD, MetD, and CMD were associated with higher anthropometric values, while cancer was not. For example, the mean BMI was 25.3 kg/m2 in healthy women, 29.4 kg/m2 in women with CMD, and 25.4 kg/m2 in women with cancer. CONCLUSION: Obesity is widespread in Germany, with notable differences between the sexes in anthro - pometric values. Obesity was more common in older participants and those with chronic diseases other than cancer. Elevated values were especially common in multimorbid individuals.

Childhood Trauma and Somatic and Mental Illness in Adulthood.

BACKGROUND: Childhood trauma is associated with somatic and mental illness in adulthood. The strength of the association varies as a function of age, sex, and type of trauma. Pertinent studies to date have mainly focused on individual diseases. In this study, we investigate the association between childhood trauma and a multiplicity of somatic and mental illnesses in adulthood. METHODS: Data from 156 807 NAKO Health Study participants were analyzed by means of logistic regressions, with adjustment for age, sex, years of education, and study site. The Childhood Trauma Screener differentiated between no/minor (n = 115 891) and moderate/severe childhood trauma (n = 40 916). The outcome variables were medical diagnoses of five somatic and two mental health conditions as stated in the clinical history. RESULTS: Persons with childhood trauma were more likely to bear a diagnosis of all of the studied conditions: cancer (odds ratio [OR] = 1.10; 95% confidence interval: [1.05; 1.15]), myocardial infarction (OR = 1.13 [1.03; 1.24]), diabetes (OR = 1.16, [1.10; 1.23]), stroke (OR = 1.35 [1.23; 1.48]), chronic obstructive pulmonary disease (OR = 1.45 [1.38; 1.52]), depression (OR = 2.36 [2.29; 2.43]), and anxiety disorders (OR = 2.08 [2.00; 2.17]). All of these associations were stronger in younger persons, regardless of the nature of childhood trauma. Differences between the sexes were observed only for some of these associations. CONCLUSION: Childhood trauma was associated with a higher probability of developing mental as well as somatic illness in adulthood. As childhood trauma is an element of individual history that the victim has little to no control over, and because the illnesses that can arise in adulthood in association with it are a heavy burden on the affected persons and on society, there is a need for research on these associations and for the development of preventive measures.

Facilitators and Barriers in the Implementation of a Digital Surveillance and Outbreak Response System in Ghana Before and During the COVID-19 Pandemic: Qualitative Analysis of Stakeholder Interviews.

BACKGROUND: In the past 2 decades, many countries have recognized the use of electronic systems for disease surveillance and outbreak response as an important strategy for disease control and prevention. In low- and middle-income countries, the adoption of these electronic systems remains a priority and has attracted the support of global health players. However, the successful implementation and institutionalization of electronic systems in low- and middle-income countries have been challenged by the local capacity to absorb technologies, decisiveness and strength of leadership, implementation costs, workforce attitudes toward innovation, and organizational factors. In November 2019, Ghana piloted the Surveillance Outbreak Response Management and Analysis System (SORMAS) for routine surveillance and subsequently used it for the national COVID-19 response. OBJECTIVE: This study aims to identify the facilitators of and barriers to the sustainable implementation and operation of SORMAS in Ghana. METHODS: Between November 2021 and March 2022, we conducted a qualitative study among 22 resource persons representing different stakeholders involved in the implementation of SORMAS in Ghana. We interviewed study participants via telephone using in-depth interview guides developed consistent with the model of diffusion of innovations in health service organizations. We transcribed the interviews verbatim and performed independent validation of transcripts and pseudonymization. We performed deductive coding using 7 a priori categories: innovation, adopting health system, adoption and assimilation, diffusion and dissemination, outer context, institutionalization, and linkages among the aspects of implementation. We used MAXQDA Analytics Pro for transcription, coding, and analysis. RESULTS: The facilitators of SORMAS implementation included its coherent design consistent with the Integrated Disease Surveillance and Response system, adaptability to evolving local needs, relative advantages for task performance (eg, real-time reporting, generation of case-base data, improved data quality, mobile offline capability, and integration of laboratory procedures), intrinsic motivation of users, and a smartphone-savvy workforce. Other facilitators were its alignment with health system goals, dedicated national leadership, political endorsement, availability of in-country IT capacities, and financial and technical support from inventors and international development partners. The main barriers were unstable technical interoperability between SORMAS and existing health information systems, reliance on a private IT company for data hosting, unreliable internet connectivity, unstable national power supply, inadequate numbers and poor quality of data collection devices, and substantial dependence on external funding. CONCLUSIONS: The facilitators of and barriers to SORMAS implementation are multiple and interdependent. Important success conditions for implementation include enhanced scope and efficiency of task performance, strong technical and political stewardship, and a self-motivated workforce. Inadequate funding, limited IT infrastructure, and lack of software development expertise are mutually reinforcing barriers to implementation and progress to country ownership. Some barriers are external, relate to the overall national infrastructural development, and are not amenable even to unlimited project funding.

Associations of Migration, Socioeconomic Position and Social Relations With Depressive Symptoms - Analyses of the German National Cohort Baseline Data.

Objectives: We analyze whether the prevalence of depressive symptoms differs among various migrant and non-migrant populations in Germany and to what extent these differences can be attributed to socioeconomic position (SEP) and social relations. Methods: The German National Cohort health study (NAKO) is a prospective multicenter cohort study (N = 204,878). Migration background (assessed based on citizenship and country of birth of both participant and parents) was used as independent variable, age, sex, Social Network Index, the availability of emotional support, SEP (relative income position and educational status) and employment status were introduced as covariates and depressive symptoms (PHQ-9) as dependent variable in logistic regression models. Results: Increased odds ratios of depressive symptoms were found in all migrant subgroups compared to non-migrants and varied regarding regions of origins. Elevated odds ratios decreased when SEP and social relations were included. Attenuations varied across migrant subgroups. Conclusion: The gap in depressive symptoms can partly be attributed to SEP and social relations, with variations between migrant subgroups. The integration paradox is likely to contribute to the explanation of the results. Future studies need to consider heterogeneity among migrant subgroups whenever possible.

Providing laypeople with results from dynamic infectious disease modelling studies affects their allocation preference for scarce medical resources-a factorial experiment.

BACKGROUND: Allocation of scarce medical resources can be based on different principles. It has not yet been investigated which allocation schemes are preferred by medical laypeople in a particular situation of medical scarcity like an emerging infectious disease and how the choices are affected by providing information about expected population-level effects of the allocation scheme based on modelling studies. We investigated the potential benefit of strategic communication of infectious disease modelling results. METHODS: In a two-way factorial experiment (n = 878 participants), we investigated if prognosis of the disease or information about expected effects on mortality at population-level (based on dynamic infectious disease modelling studies) influenced the choice of preferred allocation schemes for prevention and treatment of an unspecified sexually transmitted infection. A qualitative analysis of the reasons for choosing specific allocation schemes supplements our results. RESULTS: Presence of the factor "information about the population-level effects of the allocation scheme" substantially increased the probability of choosing a resource allocation system that minimized overall harm among the population, while prognosis did not affect allocation choices. The main reasons for choosing an allocation scheme differed among schemes, but did not differ among those who received additional model-based information on expected population-level effects and those who did not. CONCLUSIONS: Providing information on the expected population-level effects from dynamic infectious disease modelling studies resulted in a substantially different choice of allocation schemes. This finding supports the importance of incorporating model-based information in decision-making processes and communication strategies.

Effect modification of the association between comorbidities and severe course of COVID-19 disease by age of study participants: a systematic review and meta-analysis.

BACKGROUND: Comprehensive evidence synthesis on the associations between comorbidities and behavioural factors with hospitalisation, intensive care unit (ICU) admission, and death due to COVID-19 is required for deriving national and international recommendations on primary targets for non-pharmacological interventions (NPI) and vaccination strategies. METHODS: We performed a rapid systematic review and meta-analysis on studies and publicly accessible data to quantify associations between predisposing health conditions, demographics, behavioural factors on the one hand and hospitalisation, ICU admission, and death from COVID-19 on the other hand. We provide ranges of reported and calculated effect estimates and pooled relative risks derived from a meta-analysis and meta-regression. RESULTS: Seventy-five studies were included in qualitative and 74 in quantitative synthesis, with study populations ranging from 19 to 44,672 COVID-19 cases. The risk of dying from COVID-19 was significantly associated with cerebrovascular [pooled relative risk (RR) 2.7 (95% CI 1.7-4.1)] and cardiovascular [RR 3.2 (CI 2.3-4.5)] diseases, hypertension [RR 2.6 (CI 2.0-3.4)], and renal disease [RR 2.5 (CI 1.8-3.4)], with high heterogeneity in pooled estimates, partly but not solely explained by age of study participants. For some comorbidities, our meta-regression showed a decrease in effect on the severity of disease with a higher median age of the study population. Compared to death, associations between several comorbidities and hospitalisation and ICU admission were less pronounced. CONCLUSIONS: We obtained robust estimates on the magnitude of risk for COVID-19 hospitalisation, ICU admission, and death associated with comorbidities, demographic, and behavioural risk factors and show that these estimates are modified by age of study participants. This interaction is an important finding to be kept in mind for current vaccination strategies and for the protection of individuals with high risk for a severe COVID-19 course.

Effectiveness of Trainings of General Practitioners on Antibiotic Stewardship: Methods of a Pragmatic Quasi-Experimental Study in a Controlled Before-After Design in South-East-Lower Saxony, Germany (WASA).

Introduction: Antibiotic resistance is a serious threat to global public health. It reduces the effectiveness of treatments for serious bacterial infections and thus increases the risk of fatal outcomes. Antibiotic prescriptions are often not in line with clinical evidence-based guidelines. The process of emergence of resistant bacteria can be slowed down by adherence to guidelines. Yet this adherence seems to be lacking in primary health care. Methods and Analysis: This pragmatic quasi-experimental study using a controlled before-after design was carried out in South-East-Lower Saxony in 2018-2020. The voluntary attendance of interactive trainings with condensed presentation of current guidelines for general practitioners (GP) on antibiotic management for urinary and respiratory tract infections is regarded as intervention. Those GP not attending the trainings constitute the control group. Data were collected via questionnaires; routine health records are provided by a statutory health insurance. The primary outcome is the proportion of (guideline-based) prescriptions in relation to the relevant ICD-10 codes as well as daily defined doses and the difference in proportion of certain prescriptions according to guidelines before and after the intervention as compared to the control group. Further outcomes are among others the subjectively perceived risk of antibiotic resistance and the attitude toward the guidelines. The questionnaires to assess this are based on theory of planned behavior (TPB) and health action process approach (HAPA). Variations over time and effects caused by measures other than WASA (Wirksamkeit von Antibiotika-Schulungen in der niedergelassenen Aerzteschaft-Effectiveness of antibiotic management training in the primary health care sector) training are taken into account by including the control group and applying interrupted time series analysis. Ethics and Dissemination: The study protocol and the data protection concept respectively were reviewed and approved by the Ethics Committee of the Hannover Medical School and the Federal Commissioner for Data Protection and Freedom of Information. Trial Registration: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013951, identifier DRKS00013951.

Epidemiologic estimates of hepatitis E virus infection in European countries.

OBJECTIVES: Reliable epidemiologic estimates of Hepatitis E Virus (HEV) infection and evidence on factors determining country-differences are sparse. We systematically assessed and extracted research data on three HEV infection markers and identified factors influencing HEV-positivity to generated adjusted EU/EEA country-specific estimates by a meta-analysis. METHODS: Reports on HEV published 2005-2015 for EU/EEA countries were obtained from PubMed, Embase, Scopus, and Cochrane databases. Utilizing data on anti-HEV IgG, IgM and HEV-RNA we estimated HEV sero-prevalence, recent and acute HEV infections. Respective magnitude of factors influencing HEV-positivity was characterized using deviance. Country-specific estimates were generated by multivariable logistic regression. RESULTS: Of 4980 records, 165 covering 18 EU/EEA countries met inclusion criteria. The majority of collected data were published for Germany, France, United Kingdom, The Netherlands, and Spain. Most influential factor for anti-HEV IgG was the assay used (42% of total deviance); IgM and HEV-RNA were predominately determined by studied population (34%, 74%). Adjusted country-specific estimates for anti-HEV IgG ranged from 1.82%-17.06%, IgM 0.14%-6.54%, and HEV-RNA 0.00%-0.10%. No general geographical pattern of HEV-positivity was visible. CONCLUSIONS: Our analysis revealed a high heterogeneity regarding data availability and HEV-seropositivity across EU/EEA countries. Determinants of HEV-estimates including assay are to be considered when interpreting HEV-epidemiology and its burden.

Perceptions of Zika virus risk in Germany in 2016.

Background: Risks associated with Zika virus (ZIKV) transmission in the Americas have been discussed widely in the media as several European athletes declined to participate in the 2016 Summer Olympic Games. Since risk perceptions of individuals in unaffected areas are unknown, we assessed the risk perceptions of ZIKV and related behaviour in Lower Saxony, Germany, with a specific focus on pregnant women and their partners. Methods: In May 2016, we surveyed 1,037 participants aged 15-69 years of an online panel (addressing hygiene and preventive behaviour regarding infections) in Lower Saxony with respect to their risk perceptions related to ZIKV. We additionally included 26 expectant parents who were recruited at antenatal preparation courses in Braunschweig and Hannover between May and July 2016. Results: Six hundred fifty-five (69.1%) of the panel participants had ever heard about ZIKV. About 8% of the study participants reported to be concerned about ZIKV. Pregnant women had the highest odds of reporting concern about ZIKV (OR: 6.24; 95% CI: 2.94-13.26, reference: non-pregnant women). The vast majority of participants (79%) would travel to the Olympics if they won a free trip; this proportion was lower in currently pregnant women (46%). Risk perceptions towards ZIKV were considerably lower than those towards Ebola during the 2014 epidemic. Conclusion: This study showed that fear of contracting ZIKV is not a major deterrent for travelling to high-risk areas. Pregnant women are appropriately concerned about the risk of ZIKV. Studies modelling the further spread of ZIKV need to account for these results.

Advising vaccinations for the elderly: a cross-sectional survey on differences between general practitioners and physician assistants in Germany.

BACKGROUND: In Germany, the coverage of officially recommended vaccinations for the elderly is below a desirable level. It is known that advice provided by General Practitioners and Physician Assistants influences the uptake in patients ≥60 years. Therefore, the predictors of advice-giving behavior by these professions should be investigated to develop recommendations for possible actions for improvement. METHODS: We conducted a postal cross-sectional survey on knowledge, attitudes and advice - giving behavior regarding vaccinations in the elderly among General Practitioners and Physician Assistants in 4995 practices in Germany. To find specific predictors, we performed logistic regressions with non-advising on any officially recommended vaccination or on three specific vaccinations as four separate outcomes, first using all participants, then only General Practitioners and lastly only Physician Assistants as our study population. RESULTS: Participants consisted of 774 General Practitioners and 563 Physician Assistants, of whom overall 21 % stated to have not advised an officially recommended vaccination in elderly patients. The most frequent explanation was having forgotten about it. The habit of not counselling on vaccinations at regular intervals was associated with not advising any vaccination (OR: 2.8), influenza vaccination (OR: 2.3), and pneumococcal vaccination (OR: 3.1). While more General Practitioners than Physician Assistants felt sufficiently informed (90 % vs. 79 %, p < 0.001), General Practitioners displayed higher odds to not advise specific vaccinations (ORs: 1.8-2.8). CONCLUSIONS: To reduce the high risk of forgetting to advice on vaccinations, we recommend improving and promoting standing recall-systems, encouraging General Practitioners and Physician Assistants to counsel routinely at regular intervals regarding vaccinations, and providing Physician Assistants with better, tailor-made information on official recommendations and their changes.

Determinants of tetanus, pneumococcal and influenza vaccination in the elderly: a representative cross-sectional study on knowledge, attitude and practice (KAP).

BACKGROUND: Severity and incidence of vaccine-preventable infections with influenza viruses, s. pneumoniae and c. tetani increase with age. Furthermore, vaccine coverage in the elderly is often insufficient. The aim of this study is to identify socio-economic and knowledge-, attitude- and practice- (KAP)-related determinants of vaccination against influenza, pneumococcal disease and tetanus in the older German population. METHODS: We analysed data from a German nationally representative questionnaire-based KAP-survey on infection prevention and hygiene behavior in the elderly (n = 1223). We used logistic regressions to assess impacts of socio-demographic- and KAP-related variables on vaccine uptake in general and on tetanus-, influenza- and pneumococcal vaccination. To generate KAP-scores, we applied factor analyses and analysed scores as predictors of specific vaccinations. RESULTS: A low rated personal health status was associated with a higher uptake of influenza vaccine whereas place of residence within Germany strongly impacted on pneumococcal vaccination. For tetanus and influenza vaccination, the strongest single vaccination predictor was attitude-related, i.e., the perceived importance of the vaccine (OR = 18.1, 95 % CI = 4.5-71.8; OR = 23.0, 95 % CI = 14.9-35.3, respectively). Pneumococcal vaccination was mostly knowledge-associated, i.e., knowing the recommendation predicted uptake (OR = 17.1, 95 % CI = 9.5-30.7). Regarding the generated KAP-scores, the practice-score reflecting vaccine related behavior such as having a vaccination record, was predictive for all vaccines considered. The knowledge-score was associated with influenza (OR = 1.3, 95 % CI = 1.0-1.6) and pneumococcal vaccination (OR = 1.2, 95 % CI = 1.0-1.5). Uniquely for influenza vaccination, the attitude-score was linked to vaccine uptake (OR = 1.1, 95 % CI = 1.0-1.1). CONCLUSIONS: Our results indicate that predictors of vaccination uptake in the elderly strongly depend on vaccine type and that scores of KAP are useful and valid to condense information from numerous individual KAP-variables. While awareness for vaccinations against influenza and tetanus is fairly high already it might have to be increased for vaccinations against pneumocoocal infections.