[COVID-19 and Its Potential for Disruption and Transformation in Public Health: Lessons Learned from the Perspective of Young Professionals]. / COVID-19 zwischen Disruption und Transformation der öffentlichen Gesundheit: Erste Lehren aus Perspektive des Nachwuchses.

The COVID-19 pandemic has both exposed and intensified various challenges for Public Health and the Public Health service (ÖGD) in Germany. However, it also offers a window of opportunity for effective long-term transformation of the country's Public Health system. Against this backdrop, an online survey was carried out among the members of the German Network of Young Professionals in Public Health (Nachwuchsnetzwerk Öffentliche Gesundheit (NÖG)) in October and November 2020. It sought to elicit members' experiences and views related to Public Health during the COVID-19 pandemic. The resulting preliminary "lessons learned" for the German Public Health context are presented in this article. Based on the results of the survey, recommendations were formulated which are intended to provide targeted and concrete advice for the strengthening and transformation of Public Health in Germany. The main issues that preoccupied the young professionals were the increased public and political attention to Public Health and the narrow focus on infectious disease control, the standing of Public Health in Germany and the strengths and weaknesses of Public Health structures and workforce. The recommendations are aimed at promoting long-term and holistic strengthening of Public Health, with the training of an interdisciplinary workforce of young professionals presenting a key focus.

ONSL and OSKM cocktails act synergistically in reprogramming human somatic cells into induced pluripotent stem cells.

The advent of human induced pluripotent stem cells (hiPSC) is revolutionizing many research fields including cell-replacement therapy, drug screening, physiopathology of specific diseases and more basic research such as embryonic development or diseases modeling. Despite the large number of reports on reprogramming methods, techniques in use remain globally inefficient. We present here a new optimized approach to improve this efficiency. After having tested different monocistronic vectors with poor results, we adopted a polycistronic cassette encoding Thomson's cocktail OCT4, NANOG, SOX2 and LIN28 (ONSL) separated by 2A peptides. This cassette was tested in various vector backbones, based on lentivirus or retrovirus under a LTR or EF1 alpha promoter. This allowed us to show that ONSL-carrier retrovectors reprogrammed adult fibroblast cells with a much higher efficiency (up to 0.6%) than any other tested. We then compared the reprogramming efficiencies of two different polycistronic genes, ONSL and OCT4, SOX2, KLF4 and cMYC (OSKM) placed in the same retrovector backbone. Interestingly, in this context ONSL gene reprograms more efficiently than OSKM but OSKM reprograms faster suggesting that the two cocktails may reprogram through distinct pathways. By equally mixing RV-LTR-ONSL and RV-LTR-OSKM, we indeed observed a remarkable synergy, yielding a reprogramming efficiency of >2%. We present here a drastic improvement of the reprogramming efficiency, which opens doors to the development of automated and high throughput strategies of hiPSC production. Furthermore, non-integrative reprogramming protocols (i.e. mRNA) may take advantage of this synergy to boost their efficiency.

Visions for planetary health: Results from open-ended questions of survey participants after a virtual planetary health lecture series.

INTRODUCTION: A profound transformation of all areas of human activities is urgently needed for planetary health. Developing a shared vision of the future that is grounded in values aligned with planetary health is indispensable in this regard. The Planetary Health Academy is the first open online lecture series in Germany aiming for transformative planetary health education. As part of a recent evaluation of the impact of the lecture series, participants' visions for planetary health were also examined. METHODS: As part of a retrospective, cross-sectional, self-administered online survey, participants were asked to respond to an open-ended question on their visions for planetary health. Results were analysed using summarising qualitative content analysis according to Mayring. Sociodemographic details of those participants who provided a valid answer (n = 197) were calculated. RESULTS: Eight main categories were developed to summarise participants' visions for planetary health. These were: Awareness for planetary health - Planetary health integrated in all types of education - Establishment and development of the concept - A different understanding of health (care) - A transformative movement and global community - Transforming human activities - Planetary health as a guiding principle - The future state of planetary health. DISCUSSION: Broadly, the participants' visions were about planetary health as a goal and the means necessary to achieve this goal. Our findings can only be seen as a first explorative step in eliciting aspects of a common vision for planetary health, as our study design did not include a mechanism of building consensus towards one common vision. Besides the field of planetary health, similar concepts and associated movements exist or are emerging. Facilitating dialogue and exchange across disciplines and narratives about the prevailing future visions will be key to achieving what we call planetary health and what others might call Ubuntu or buen vivir. CONCLUSION: The results of this study provide first insights into the planetary health visions of those whom we would consider members of a movement aligned behind the idea of planetary health. In future editions, the Planetary Health Academy could integrate more discursive elements with a particular focus on negotiating future visions to support the creation of a critical mass of change agents within the health community and beyond.

[Clostridioides difficile - New Insights and Therapy Recommendations]. / Clostridioides difficile ­ Neue Erkenntnisse und Therapieempfehlungen.

After an increase in Clostridioides difficile infections (CDI) until 2013 due to epidemic ribotypes such as 027 and 078, CDI incidence in Germany is now declining, as confirmed by recent epidemiological data. Despite this success through antimicrobial stewardship and hospital hygiene, the burden of disease remains high, especially in older patients (>65 years) with comorbidities. The main risk factor for CDI is the use of broad-spectrum antibiotics, which disrupt the gut microbiota, allowing C. difficile colonization. Coinfection with other intestinal pathogens such as enterococci can further increase the virulence of C. difficile. The updated 2021 ESCMID guidelines recommend fidaxomicin instead of vancomycin as the antibiotic of choice for the treatment of CDI because of its lower recurrence rate. Vancomycin remains a good alternative; however, metronidazole should only be used if neither antibiotic is available. In the future, ridinilazole may be available as another therapeutic option that has a narrow spectrum of activity and low intestinal absorption. For the treatment of recurrent CDI, the new guidelines also include the use of the monoclonal antibody bezlotoxumab. In addition, a new oral microbiome therapy, SER-109 (capsules containing purified Firmicutes spores), which showed promising results in a phase 3 study, may provide an easy-to-administer alternative to fecal microbiota transplantation. Hopes for a well-performing toxoid vaccine for primary and secondary prevention of CDI have unfortunately not been fulfilled in the CLOVER trial.

A case for routine microbial diagnostics: Results from antimicrobial susceptibility testing in post-traumatic wound infections at a Ugandan tertiary care hospital.

The global spread of antimicrobial resistance (AMR) poses an increasing challenge for clinicians in Uganda, where microbiological diagnostics are not routinely available or accessible. The aim of this study was to determine pathogen prevalence and antibiotic resistance patterns in patients with wound infections following trauma at a national referral hospital in Kampala, Uganda. In addition, the suitability of currently used empirical treatment options in this setting was evaluated. This prospective, observational study analysed antimicrobial prescriptions, culture results and antimicrobial sensitivity testing (AST) of wound swabs and blood samples from patients with clinical signs of wound infections on the trauma ward. A total of 124 patients (n = 99, 79.8% male) with a median age of 30 years (IQR 23-39) were enrolled between October 2021 and January 2022. Wound infections were classified as nosocomial in 69% of the cases. Pathogens were isolated from 122 wound swabs, yielding 238 bacterial isolates. The most prevalent pathogens were gram-negative bacteria including Escherichia coli (n = 48, 20.2%) and Acinetobacter spp. (n = 43, 18.1%). Empiric treatment consisted of ceftriaxone and gentamicin which was administered to 67.2% (n = 78) and 62.1% (n = 72) of patients, respectively. High rates of antimicrobial resistance could be demonstrated across gram-negative and gram-positive species towards the most common empiric antibiotics. Following the AST results, over 95% (n = 111) of patients required a change of treatment. Our findings demonstrate that current empiric treatment for wound infections is missing its target in hospitalized patients in Kampala. To address the growing problem of AMR in Uganda, there is a pressing need to enhance diagnostic capacity and implement structured antimicrobial stewardship programs.

Initiatives promoting planetary health education in Germany: An overview.

Planetary health education focuses on the climate and ecological crises and their adverse health effects. Given the acceleration of these crises, nationwide integration of planetary health education into undergraduate and graduate education, postgraduate training and continuing education for all health professionals has repeatedly been called for. Since 2019, planetary health education has been promoted by several national initiatives in Germany that are summarized in this commentary: 1. National Working Group Planetary Health Education, 2. Manual for planetary health education, 3. Catalog of National Planetary Health Learning Objectives in the National Competency-Based Catalog of Learning Objectives for Medical Education, 4. Working Group Climate, Environment and Health Impact Assessment at the Institute for Medical and Pharmaceutical Examinations, 5. Planetary Health Report Card, and 6. PlanetMedEd study: planetary health education in medical schools in Germany. We hope these initiatives promote collaboration across institutions involved in educating and training health professionals, inter-professional cooperation as well as rapid implementation of planetary health education.

The Planetary Health Academy-a virtual lecture series for transformative education in Germany.

The planetary crises require health professionals to understand the interlinkages between health and environmental changes, and how to reduce ecological harm (ie, ecological footprint) and promote positive change (ie, ecological handprint). However, health professions' education and training are mostly lacking these aspects. In this Viewpoint, we report findings from the evaluation of the Planetary Health Academy, the first open online lecture series for transformative planetary health education in Germany. In a retrospective online survey, 458 of 3656 Planetary Health Academy participants reported on their emotions towards climate change, attitudes towards health professionals' responsibilities, self-efficacy, and the contribution of the Planetary Health Academy to their knowledge and actions. Additionally, motivators and barriers to acting were assessed. Our findings provide insights that can inform future efforts for transformative education. Combined with network and movement building, education could act as a social tipping element toward actions to mitigate global environmental changes.

Fever in the Returning Traveler.

BACKGROUND: It is predicted that approximately two billion tourist trips to foreign countries will be taken worldwide each year by 2030. Germany has long been among the most active countries in tourism. The frequency of illness among persons returning from developing and newly industrialized countries is 43-79%. The appropriate diagnosis of fever in returning travelers is a clinically important matter, as it can be a sign of a life-threatening illness. METHODS: This review is based on publications (2001-2022) retrieved by a selective search in PubMed for studies on the epidemiology, diagnosis, and treatment of febrile illnesses in returning travelers, or on specific tropical diseases. RESULTS: Diarrhea, fever, and skin changes are the most common manifestations of disease after travel to tropical and sub - tropical areas. The diagnostic evaluation should be performed in a series of steps, beginning with a precise travel history and the identification of specific risk factors. Among travelers returning from sub-Saharan Africa, Plasmodium falciparum malaria is the most common cause of fever on presentation to centers for infectious diseases and tropical medicine, affecting approximately 50 per 1000 travelers. Among persons returning from travel to Southeast Asia, dengue fever is the most common infectious disease, affecting 50-160 per 1000 travelers. Further potentially dangerous diseases include chikungunya and zika fever, typhoid and paratyphoid fever, amoebic liver abscess, visceral leishmaniasis (kala-azar), leptospirosis, and, very rarely, imported cases of viral hemorrhagic fever. COVID-19 and influenza are important differential diagnoses. CONCLUSION: The differential diagnosis can be narrowed by thorough history-taking with particular attention to the patient's travel route, combined with a good knowledge of the geographic spread and incubation times of the main tropical diseases. Algorithms help clinicians to focus the diagnostic work-up and select the appropriate further laboratory tests and diagnostic procedures.

How to Increase the Attractiveness of the Public Health Service in Germany as a Prospective Employer? Part II of the OeGD-Studisurvey.

The Public Health Service (PHS) in Germany has had difficulties in recruiting enough qualified staff for years, but there is limited research on what factors drive decisions to (not) join the PHS workforce. We explored reasons for this perceived (lack of) attractiveness. We conducted two cross-sectional surveys among medical students (MS), public health students and students from other PHS-relevant fields (PH&ONM) in Germany before (2019/2020) and during the COVID-19 pandemic (2021). Both waves surveyed self-reported reasons for why students did (not) consider working in the PHS as attractive and how this could be improved, using open-question items. Qualitative and quantitative content analyses were conducted according to Mayring. In total, 948 MS and 445 PH&ONM provided valid written responses. Reasons for considering the PHS as attractive were, among others, the perception of a good work-life balance, high impact, population health focus, and generally interesting occupations. Suggestions to increase attractiveness included reducing bureaucracy, modernization/digitalization, and more acknowledgement of non-medical professionals. Among MS, reasons against were too little clinical/patient-related activities, low salary, and occupations regarded as boring. Our findings indicate areas for improvement for image, working conditions in, and institutional structures of the PHS in Germany to increase its attractiveness as an employer among young professionals.

What Factors Influence the Interest in Working in the Public Health Service in Germany? Part I of the OeGD-Studisurvey.

As in many European countries, the Public Health Service (PHS) in Germany has had considerable difficulties in attracting well-qualified personnel for decades. Despite ongoing political and societal debate, limited empirical research on possible causes and explanations is available. To identify areas of action, we explored reasons for the (lack of) interest in working in the PHS by conducting two cross-sectional surveys among 3019 medical students (MS), public health students, and students from other PHS-relevant fields (PH&ONM) in Germany right before (wave 1, 2019/2020) and during the COVID-19 pandemic (wave 2, 2021). While interest in working in the PHS among MS was low, it was considerably higher among PH&ONM. The prevalent underestimation of the importance of public health and low levels of knowledge about the PHS were identified as potential barriers. Although core activities of the PHS were often considered attractive, they were repeatedly not attributed to the PHS. A negative perception of the PHS (e.g., it being too bureaucratic) was prevalent among students with and without PHS interest, indicating that both a negative image and potentially structural deficits need to be overcome to increase attractiveness. Based on the findings, we propose approaches on how to sustainably attract and retain qualified personnel.

Extreme events and gender-based violence: a mixed-methods systematic review.

The intensity and frequency of extreme weather and climate events are expected to increase due to anthropogenic climate change. This systematic review explores extreme events and their effect on gender-based violence (GBV) experienced by women, girls, and sexual and gender minorities. We searched ten databases until February, 2022. Grey literature was searched using the websites of key organisations working on GBV and Google. Quantitative studies were described narratively, whereas qualitative studies underwent thematic analysis. We identified 26 381 manuscripts. 41 studies were included exploring several types of extreme events (ie, storms, floods, droughts, heatwaves, and wildfires) and GBV (eg, sexual violence and harassment, physical violence, witch killing, early or forced marriage, and emotional violence). Studies were predominantly cross-sectional. Although most qualitative studies were of reasonable quality, most quantitative studies were of poor quality. Only one study included sexual and gender minorities. Most studies showed an increase in one or several GBV forms during or after extreme events, often related to economic instability, food insecurity, mental stress, disrupted infrastructure, increased exposure to men, tradition, and exacerbated gender inequality. These findings could have important implications for sexual-transformative and gender-transformative interventions, policies, and implementation. High-quality evidence from large, ethnographically diverse cohorts is essential to explore the effects and driving factors of GBV during and after extreme events.

Does global health governance walk the talk? Gender representation in World Health Assemblies, 1948-2021.

BACKGROUND: While an estimated 70%-75% of the health workforce are women, this is not reflected in the leadership roles of most health organisations-including global decision-making bodies such as the World Health Assembly (WHA). METHODS: We analysed gender representation in WHA delegations of Member States, Associate Members and Observers (country/territory), using data from 10 944 WHA delegations and 75 815 delegation members over 1948-2021. Delegates' information was extracted from WHO documentation. Likely gender was inferred based on prefixes, pronouns and other gendered language. A gender-to-name algorithm was used as a last resort (4.6%). Time series of 5-year rolling averages of the percentage of women across WHO region, income group and delegate roles are presented. We estimated (%) change ±SE of inferred women delegation members at the WHA per year, and estimated years±SE until gender parity from 2010 to 2019 across regions, income groups, delegate roles and countries. Correlations with these measures were assessed with countries' gender inequality index and two Worldwide Governance indicators. RESULTS: While upwards trends could be observed in the percentage of women delegates over the past 74 years, men remained over-represented in most WHA delegations. Over 1948-2021, 82.9% of delegations were composed of a majority of men, and no WHA had more than 30% of women Chief Delegates (ranging from 0% to 30%). Wide variation in trends over time could be observed across different geographical regions, income groups and countries. Some countries may take over 100 years to reach gender parity in their WHA delegations, if current estimated trends continue. CONCLUSION: Despite commitments to gender equality in leadership, women remain gravely under-represented in global health governance. An intersectional approach to representation in global health governance, which prioritises equity in participation beyond gender, can enable transformative policymaking that fosters transparent, accountable and just health systems.

Challenging the "old boys club" in academia: Gender and geographic representation in editorial boards of journals publishing in environmental sciences and public health.

In light of global environmental crises and the need for sustainable development, the fields of public health and environmental sciences have become increasingly interrelated. Both fields require interdisciplinary thinking and global solutions, which is largely directed by scientific progress documented in peer-reviewed journals. Journal editors play a critical role in coordinating and shaping what is accepted as scientific knowledge. Previous research has demonstrated a lack of diversity in the gender and geographic representation of editors across scientific disciplines. This study aimed to explore the diversity of journal editorial boards publishing in environmental science and public health. The Clarivate Journal Citation Reports database was used to identify journals classified as Public, Environmental, and Occupational (PEO) Health, Environmental Studies, or Environmental Sciences. Current EB members were identified from each journal's publicly available website between 1 March and 31 May 2021. Individuals' names, editorial board roles, institutional affiliations, geographic locations (city, country), and inferred gender were collected. Binomial 95% confidence intervals were calculated for the proportions of interest. Pearson correlations with false discovery rate adjustment were used to assess the correlation between journal-based indicators and editorial board characteristics. Linear regression and logistic regression models were fitted to further assess the relationship between gender presence, low- and middle-income country (LMIC) presence and several journal and editor-based indicators. After identifying 628 unique journals and excluding discontinued or unavailable journals, 615 journal editorial boards were included. In-depth analysis was conducted on 591 journals with complete gender and geographic data for their 27,772 editors. Overall, the majority of editors were men (65.9%), followed by women (32.9%) and non-binary/other gender minorities (0.05%). 75.5% journal editorial boards (n = 446) were composed of a majority of men (>55% men), whilst only 13.2% (n = 78) demonstrated gender parity (between 45-55% women/gender minorities). Journals categorized as PEO Health had the most gender diversity. Furthermore, 84% of editors (n = 23,280) were based in high-income countries and only 2.5% of journals (n = 15) demonstrated economic parity in their editorial boards (between 45-55% editors from LMICs). Geographically, the majority of editors' institutions were based in the United Nations (UN) Western Europe and Other region (76.9%), with 35.2% of editors (n = 9,761) coming solely from the United States and 8.6% (n = 2,373) solely from the United Kingdom. None of the editors-in-chief and only 27 editors in total were women based in low-income countries. Through the examination of journal editorial boards, this study exposes the glaring lack of diversity in editorial boards in environmental science and public health, explores the power dynamics affecting the creation and dissemination of knowledge, and proposes concrete actions to remedy these structural inequities in order to inform more equitable, just and impactful knowledge creation.

A Scoping Review to Assess Sexual and Reproductive Health Outcomes, Challenges and Recommendations in the Context of Climate Migration.

Background: As growing numbers of people may be forced to migrate due to climate change and variability, it is important to consider the disparate impacts on health for vulnerable populations, including sexual and reproductive health (SRH). This scoping review aims to explore the relationship between climate migration and SRH. Methods: We searched PubMed/MEDLINE, CINAHL Plus, EMBASE, Web of Science, Scopus, Global Health and Google for peer-reviewed and gray literature published before 2nd July 2021 in English that reported on SRH in the context of climate migration. Data were extracted using a piloted extraction tool and findings are reported in a narrative synthesis. Results: We screened 1,607 documents. Ten full-text publications were included for analysis: five peer-reviewed articles and five gray literature documents. Reported SRH outcomes focused on maternal health, access to family planning and antiretroviral therapy, sexual and gender-based violence, transactional sex, and early/forced marriage. Recommendations to improve SRH in the context of climate migration called for gender-transformative health systems, education and behavior change programmes, and the involvement of local women in policy planning and programme implementation. Discussion: While the disparate impacts of climate change and migration are well-established, primary data on the scope of impact due to climate migration is limited. The SRH outcomes reported in the literature focus on a relatively narrow range of SRH domains, emphasizing women and girls, over men. Achieving holistic and equitable SRH in the context of climate migration requires engaging all genders across the range of SRH outcomes and migration contexts. This review highlights the need for further empirical evidence on the effect of climate migration on SRH, with research that is context-specific and engages communities in order to reflect the heterogeneity of outcomes and impact in the climate-migration-SRH nexus.

Human-Centered Design of a Low Molecular Weight Heparin Order Set to Reduce Medication Errors.

Inpatient anticoagulation medication errors for venous thromboembolism (VTE) therapy are common. Our VTE Team identified frequent dosing and duplicate order errors for therapeutic-dose low molecular weight heparin, which (lacking computerized physician order entry) was ordered using blank forms. To decrease such errors, a nonmandatory order form with weight-based dosing and prechecked orders discontinuing existing injectable anticoagulation was developed using human-centered design innovation principles/processes emphasizing end-user engagement in all phases: observation, exploring solutions, and rapid prototyping/feedback. Three physicians independently reviewed ordering errors the year before versus after implementation. Before implementation, 11% of orders contained any error versus 10.5% after implementation (p = .82); 6.2% had a dosing or duplicate therapy error versus 4.2% after implementation (all made when the form was not used; p = .19). No dosing or duplicate therapy errors were made when the form was used. Were the form mandatory, all such ordering errors would likely have been eliminated, leaving 11% before versus 6.3% after implementation orders with any error (p = .015), and 6.2% before versus 0% after implementation orders with duplicate or dosing therapy errors (p < .001). Human-centered design of an anticoagulation order form can reduce anticoagulation order errors; such principles can be applied to other health care innovations, including electronic order sets.

Managing bone loss in men with locally advanced prostate cancer receiving androgen deprivation therapy.

PURPOSE: We reviewed the pathogenesis, diagnosis, prevalence, prevention and treatment of bone loss in patients with nonmetastatic prostate cancer receiving androgen deprivation therapy. MATERIALS AND METHODS: Using PubMed we performed a comprehensive literature search to identify articles on bone mineral density loss in patients with nonmetastatic prostate cancer receiving androgen deprivation therapy. Pertinent articles were reviewed and evaluated. RESULTS: Bone mineral density loss and related fractures were recently established as significant adverse events associated with androgen deprivation therapy. Patients with nonmetastatic prostate cancer receiving androgen deprivation therapy experience annual bone mineral density losses of 0.6% to 4.6% with the most significant loss within year 1 of therapy. In addition to calcium and vitamin D supplements, current treatment options for androgen deprivation therapy induced bone loss include synthetic estrogens, selective estrogen receptor modulators and bisphosphonates. Recent safety concerns have been identified, including renal dysfunction with intravenous bisphosphonates and osteonecrosis of the jaw with oral and intravenous bisphosphonates. However, minimal renal dysfunction and no cases of osteonecrosis of the jaw have been reported in this setting. CONCLUSIONS: Because the most significant bone mineral density loss occurs within year 1 of androgen deprivation therapy and most fractures in healthy men occur in those without osteoporosis, early intervention is warranted to prevent skeletal morbidity in patients with nonmetastatic prostate cancer receiving androgen deprivation therapy. Although the majority of and the most compelling evidence supports the use of bisphosphonates for preventing and treating androgen deprivation therapy induced bone loss, further study is needed to define the optimal regimen, timing of initiation and duration of therapy as well as long-term efficacy and safety.

Comparative Analysis of Dry and Wet Porometry Methods for Characterization of Regular and Cross-Linked Virus Removal Filter Papers.

Pore-size distribution (PSD) is the most critical parameter for size-exclusion virus removal filters. Yet, different dry- and wet-state porometry methods yield different pore-size values. The goal of this work is to conduct comparative analysis of nitrogen gas sorption (NGSP), liquid-liquid and cryoporometry with differential scanning calorimetry (CP-DSC) methods with respect to characterization of regular and cross-linked virus removal filter paper based on cellulose nanofibers, i.e. the mille-feuille filter. The filters were further characterized with atomic force and scanning electron microscopy. Finally, the removal of the worst-case model virus, i.e. minute virus of mice (MVM; 20 nm, nonenveloped parvovirus) was evaluated. The results revealed that there is no difference of the obtained PSDs between the wet methods, i.e. DSC and liquid-liquid porometry (LLP), as well as no difference between the regular and cross-linked filters regardless of method. MVM filtration at different trans membrane pressure (TMP) revealed strong dependence of the virus removal capability on applied pressure. It was further observed that cross-linking filters showed enhanced virus removal, especially at lower TMP. In all, the results of this study highlight the complex nature of virus capture in size-exclusion filters.