Implementing a pilot study of COVID-19 self-testing in high-risk populations and remote locations: results and lessons learnt.

BACKGROUND: Rapid antigen-detection tests for SARS-CoV-2 self-testing represent a useful tool for pandemic control and expanding access to community-level case screening. COVID-19 self-tests have been extensively used in high-income countries since 2021; however, their introduction and programmatic implementation in low- and middle-income countries was delayed. We aimed to identify and continuously improve a weekly COVID-19 self-testing model among staff at healthcare facilities and schools. METHODS: This mixed-methods, observational prospective study was conducted in 5 healthcare centres and 24 schools in Georgia, between June and December 2022. The study comprised the integration of COVID-19 self-testing into the national mandatory testing programme for high-risk groups, with primary distribution of self-tests among staff performed weekly, plus secondary distribution to their household members. These use cases were selected because NCDC was seeking to strengthen their already strong weekly testing programme, by investigating self-testing to ease the burden of testing in the healthcare system. Online surveys and semi-structured interviews were used for data collection. RESULTS: In total, 2156 participants were enrolled (1963 female, 72%). At baseline and mid- and end-points, 88%, 97% and 99%, respectively, of participants agreed/strongly agreed they would self-test. Similarly, the majority were willing to report their self-testing results (88%, 98% and 96% at baseline and mid- and end-points, respectively). Weekly reporting of test results to the national COVID-19 database was high during all the implementation. There were 622 COVID-19 positive results reported, and linked to care, from 601 individuals (282 participants and 319 household members). Findings from qualitative interviews showed great satisfaction with self-testing for its convenience, ease of use, trust in the results, no need to travel for diagnostics, and increased perception of safety. CONCLUSIONS: Our findings contribute to the evidence-base regarding self-testing strategies conducted via workplaces and secondary distribution to households. Willingness to perform a COVID-19 self-test increased after implementation. This pilot enhanced pandemic preparedness through expansion of the national self-testing reporting system, development of communications materials, changes in the national legal framework and coordination mechanisms, and improved perceptions around self-care in the community. The lessons learnt can inform operational aspects of the introduction and scale-up of self-care strategies.

Nationwide Hepatitis C Serosurvey and Progress Towards Hepatitis C Virus Elimination in the Country of Georgia, 2021.

BACKGROUND: The country of Georgia initiated its hepatitis C virus (HCV) elimination program in 2015, at which point a serosurvey showed the adult prevalence of HCV antibody (anti-HCV) and HCV RNA to be 7.7% and 5.4%, respectively. This analysis reports hepatitis C results of a follow-up serosurvey conducted in 2021, and progress towards elimination. METHODS: The serosurvey used a stratified, multistage cluster design with systematic sampling to include adults and children (aged 5-17 years) providing consent (or assent with parental consent). Blood samples were tested for anti-HCV and if positive, HCV RNA. Weighted proportions and 95% confidence intervals (CI) were compared with 2015 age-adjusted estimates. RESULTS: Overall, 7237 adults and 1473 children were surveyed. Among adults, the prevalence of anti-HCV was 6.8% (95% CI, 5.9-7.7). The HCV RNA prevalence was 1.8% (95% CI, 1.3-2.4), representing a 67% reduction since 2015. HCV RNA prevalence decreased among those reporting risk factors of ever injecting drugs (51.1% to 17.8%), and ever receiving a blood transfusion (13.1% to 3.8%; both P < .001). No children tested positive for anti-HCV or HCV RNA. CONCLUSIONS: These results demonstrate substantial progress made in Georgia since 2015. These findings can inform strategies to meet HCV elimination targets.

Toward reaching hepatitis B goals: hepatitis B epidemiology and the impact of two decades of vaccination, Georgia, 2021.

BackgroundGeorgia has adopted the World Health Organization European Region's and global goals to eliminate viral hepatitis. A nationwide serosurvey among adults in 2015 showed 2.9% prevalence for hepatitis B virus (HBV) surface antigen (HBsAg) and 25.9% for antibodies against HBV core antigen (anti-HBc). HBV infection prevalence among children had previously not been assessed.AimWe aimed to assess HBV infection prevalence among children and update estimates for adults in Georgia.MethodsThis nationwide cross-sectional serosurvey conducted in 2021 among persons aged ≥ 5 years used multi-stage stratified cluster design. Participants aged 5-20 years were eligible for hepatitis B vaccination as infants. Blood samples were tested for anti-HBc and, if positive, for HBsAg. Weighted proportions and 95% confidence intervals (CI) were calculated for both markers.ResultsAmong 5-17 year-olds (n = 1,473), 0.03% (95% CI: 0-0.19) were HBsAg-positive and 0.7% (95% CI: 0.3-1.6) were anti-HBc-positive. Among adults (n = 7,237), 2.7% (95% CI: 2.3-3.4) were HBsAg-positive and 21.7% (95% CI: 20.4-23.2) anti-HBc-positive; HBsAg prevalence was lowest (0.2%; 95% CI: 0.0-1.5) among 18-23-year-olds and highest (8.6%; 95% CI: 6.1-12.1) among 35-39-year-olds.ConclusionsHepatitis B vaccination in Georgia had remarkable impact. In 2021, HBsAg prevalence among children was well below the 0.5% hepatitis B control target of the European Region and met the ≤ 0.1% HBsAg seroprevalence target for elimination of mother-to-child transmission of HBV. Chronic HBV infection remains a problem among adults born before vaccine introduction. Screening, treatment and preventive interventions among adults, and sustained high immunisation coverage among children, can help eliminate hepatitis B in Georgia by 2030.

Evaluation of barriers to cervical cancer screening in Georgia.

OBJECTIVES: The Cervical Cancer (CC) Screening Programme in Georgia provides insufficient coverage of the target population. The aim of the study is to identify the barriers to cervical cancer screening for women in Georgia in order to plan and implement adequate measures to increase the screening effectiveness. METHODS: The study is based on the results of a survey of 582 women aged 25-60 years (mean age 42.11 + 12.17). Respondents were selected in out-patient clinics. The questionnaire included questions related to the place of residence, ethnicity, religion, marital status, education, employment, cervical cancer awareness and screening, screening participation practices, and barriers to participation. RESULTS: The following factors reliably increase the chance of participating in the screening: residing in Tbilisi, OR = 1.84 (95% CI: 1.10-3.07); higher education, OR = 1.87 (95% CI: 1.09-3.19); being employed as a nurse, OR = 3.42 (95% CI: 1.49-7.85); receiving screening-related information from medical staff, OR = 2.43 (95% CI: 1.42-4.15); and from television, OR = 2.57 (95% CI: 1.47-4.50). The chance of participating in the screening is reduced due to incomplete secondary education, OR = 0.10 (95% CI: 0.01-0.77); single marital status, OR = 0.49 (95% CI: 0.28-0.87); employment in public service, OR = 0.39 (95% CI: 0.17-0.89); and receiving screening-related information from friends, OR = 0.26 (95% CI: 0.09-0.77). Women with higher education are undoubtedly more informed about screening, screening procedures and free programmes than those without higher education. The common barrier to participation in the screening was "fear of the manipulation-related pain" but the most frequent answer was "I'm afraid that the test will detect cancer (36.3%)." Women with a lower level of education are more likely to believe that "Pap testing is appropriate for the women who have active sexual life", and/or "have multiple sexual partners", and/or "have children," and "it is not necessary if a woman has no complaints". CONCLUSION: Screening participation among women in Georgia depends on screening availability, formal education and awareness of CC, sources of information, and employment type.

Geographic distribution and genetic characterization of poxviruses from human infections in Georgia, 2009-2014.

Anthrax is endemic in Georgia, as are multiple zoonotic poxviruses. Poxvirus-associated infections share some clinical manifestations and exposure risks with anthrax, and so it is important to distinguish between the two. With this in mind, an archived collection of anthrax-negative DNA samples was retrospectively screened for poxviruses, and of the 148 human samples tested, 64 were positive. Sequence analysis confirmed the presence of orf virus, bovine papular stomatitis virus, and pseudocowpox virus. This study provides evidence of previously unrecognized poxvirus infections in Georgia and highlights the benefit of the timely identification of such infections by improving laboratory capacity.

Hepatitis C prevalence and risk factors in Georgia, 2015: setting a baseline for elimination.

BACKGROUND: The country of Georgia launched the world's first Hepatitis C Virus (HCV) Elimination Program in 2015 and set a 90% prevalence reduction goal for 2020. We conducted a nationally representative HCV seroprevalence survey to establish baseline prevalence to measure progress toward elimination over time. METHODS: A cross-sectional seroprevalence survey was conducted in 2015 among adults aged ≥18 years using a stratified, multi-stage cluster design (n = 7000). Questionnaire variables included demographic, medical, and behavioral risk characteristics and HCV-related knowledge. Blood specimens were tested for antibodies to HCV (anti-HCV) and HCV RNA. Frequencies were computed for HCV prevalence, risk factors, and HCV-related knowledge. Associations between anti-HCV status and potential risk factors were calculated using logistic regression. RESULTS: National anti-HCV seroprevalence in Georgia was 7.7% (95% confidence interval (CI) = 6.7, 8.9); HCV RNA prevalence was 5.4% (95% CI = 4.6, 6.4). Testing anti-HCV+ was significantly associated with male sex, unemployment, urban residence, history of injection drug use (IDU), incarceration, blood transfusion, tattoos, frequent dental cleanings, medical injections, dialysis, and multiple lifetime sexual partners. History of IDU (adjusted odds ratio (AOR) = 21.4, 95% CI = 12.3, 37.4) and blood transfusion (AOR = 4.5, 95% CI = 2.8, 7.2) were independently, significantly associated with testing anti-HCV+ after controlling for sex, age, urban vs. rural residence, and history of incarceration. Among anti-HCV+ participants, 64.0% were unaware of their HCV status, and 46.7% did not report IDU or blood transfusion as a risk factor. CONCLUSIONS: Georgia has a high HCV burden, and a majority of infected persons are unaware of their status. Ensuring a safe blood supply, implementing innovative screening strategies beyond a risk-based approach, and intensifying prevention efforts among persons who inject drugs are necessary steps to reach Georgia's HCV elimination goal.

Investigation of Yersinia pestis and Yersinia pseudotuberculosis strains from Georgia and neighboring countries in the Caucasus by high-density SNP microarray.

Yersinia pestis, the causative agent of plague, is a recently evolved clone of the enteropathogenic bacterium Yersinia pseudotuberculosis. Y. pestis has been extensively studied for decades; however, there are insufficient data about the intra-species diversity of this microorganism in certain parts of the world, including the Caucasus region. Using a high-density single-nucleotide polymorphism (SNP) microarray, we genotyped a total of 46 Y. pestis isolates from two plague foci in Georgia and neighboring Caucasus countries together with 12 Y. pseudotuberculosis isolates from Georgia. The genotyping microarray captured a total of 13,525 SNP positions across the Y. pestis and Y. pseudotuberculosis genomes and plasmids with high-throughput capability and superior reproducibility. From this analysis, we confirmed the presence of two independent and relatively distant phylogenetic groups of Y. pestis in the Caucasus region. The signature SNP patterns identified from this study will allow assay development for plague surveillance and pseudotuberculosis diagnostics.

Impact of hepatitis C virus recombinant form RF1_2k/1b on treatment outcomes within the Georgian national hepatitis C elimination program.

AIM: Hepatitis C virus (HCV) recombinant form RF1_2k/1b is common in ethnic Georgians. This chimera virus contains genomic fragments of genotype 2 and genotype 1 and is misclassified as genotype 2 by standard genotyping. We aimed to identify RF1_2k/1b strains among genotype 2 patients and assess its impact on treatment outcomes. METHODS: The study included 148 patients with HCV genotype 2 as determined by 5-untranslated region/core genotyping assay. RF1_2k/1b was identified by sequencing the non-structural protein 5B region. Patients were treated within the national hepatitis C elimination program with sofosbuvir/ribavirin (SOF/RBV), interferon (IFN)/SOF/RBV, or ledipasvir (LDV)/SOF/RBV. RESULTS: Of 148 patients, 103 (69.5%) had RF1_ 2k/1b. Sustained virologic response (SVR) data was available for 136 patients (RF1_ 2k/1b, n = 103; genotype 2, n = 33). Sustained virologic response was achieved in more genotype 2 patient than in RF1_2k/1b patients (97.0% vs. 76.7%, P = 0.009). Twelve weeks of LDV/SOF/RBV treatment was highly effective (100% SVR) in both genotypes. Among RF1_2k/1b patients, LDV/SOF/RBV for 12 weeks was superior (100% SVR) to SOF/RBV for 12 weeks (56.4%, P < 0.0001) or 20 weeks (79.2%, P = 0.05). Twelve weeks of IFN/SOF/RBV also showed better response than SOF/RBV for 12 weeks (88.9% vs. 56.4%, P = 0.02) in these patients. CONCLUSIONS: High prevalence of the RF1_2k/1b strain can significantly affect treatment outcomes. Treatment with IFN/SOF/RBV and especially LDV/SOF/RBV ensured significantly higher SVR in patients infected with RF1_2k/1b strain compared to standard HCV genotype 2 treatment with SOF/RBV. There is a need to reassess existing methods for the management of HCV genotype 2 infections, especially in areas with high prevalence of the RF1_2k/1b strain.

Human Lymphadenopathy Caused by Ratborne Bartonella, Tbilisi, Georgia.

Lymphadenopathy and fever that developed in a woman in Tbilisi, Georgia, most likely were caused by a ratborne Bartonella strain related B. tribocorum and B. elizabethae. The finding suggests that this Bartonella strain could be spread by infected rats and represents a potential human risk.

National Progress Toward Hepatitis C Elimination - Georgia, 2015-2016.

The country of Georgia has a high prevalence of hepatitis C virus (HCV) infection, associated with exposures to HCV in health care settings with inadequate infection control and unsafe injections among persons who inject drugs (1). In April 2015, in collaboration with CDC and other partners, Georgia embarked on a program to eliminate HCV infection, subsequently defined as achieving a 90% reduction in prevalence by 2020. The initial phase of the program focused on providing HCV treatment to infected persons with advanced liver disease and at highest risk for HCV-associated morbidity and mortality. By April 27, 2016, a total of 27,392 HCV-infected persons registered for the program, 8,448 (30.8%) started treatment, and 5,850 patients (69.2%) completed HCV treatment. Among patients completing treatment who were eligible for posttreatment testing, 2,398 received polymerase chain reaction (PCR) testing for HCV at least 12 weeks after completion of treatment; 1,980 (82.6%) had no detectable virus, indicative of a sustained virologic response* (i.e., cure). Major challenges to achieving elimination remain, including the need to increase access to care and treatment services and implement a comprehensive approach to prevention and control of HCV infection. As a global leader in this effort, the Georgia HCV Elimination Program can help pave the way for other countries experiencing high rates of HCV infection to undertake similar initiatives.

Human cutaneous anthrax, Georgia 2010-2012.

We assessed the occurrence of human cutaneous anthrax in Georgia during 2010--2012 by examining demographic and spatial characteristics of reported cases. Reporting increased substantially, as did clustering of cases near urban centers. Control efforts, including education about anthrax and livestock vaccination, can be directed at areas of high risk.

Surveillance of bacterial meningitis in the country of Georgia, 2006-2010.

Bacterial meningitis remains important cause of morbidity and mortality worldwide, particularly in developing countries. This study analyzed the data from sentinel surveillance for bacterial meningitis among children <5 years of age hospitalized in largest children's hospital in Tbilisi, capital of Georgia and adult patients hospitalized in infectious diseases hospital during 2006-2010 with suspected bacterial meningitis. The surveillance is conducted by National Center for Disease Control and Public Health (NCDCPH). The number of patients with identified organism was 127 (19 %). In the subsample of patients with laboratory confirmed bacterial meningitis Streptococcus pneumoniae was the most frequently isolated organism (67 cases, 52.8 %), followed by. influenza (17 cases, 13.4 %) and Neisseria meningitidis (16 cases, 12.6 %). The number of patients with suspected TB meningitis was 27 (21.3 %). The overall case fatality rate in the subgroup of patients with identified organism was 12.3 %. The highest mortality was observed among TB patients (22.2 %) with 14.3 % mortality for N. meningitidis and 10.3 % for S. pneumoniae. No lethal outcome was observed among patients with Haemophilus influenzae.

Identifying Sources of Lead Exposure for Children in the Republic of Georgia, with Lead Isotope Ratios.

In the Republic of Georgia, a 2018 national survey estimated that more than 40% of children aged 2-7 years had a blood lead concentration (BLC) of more than 5 µg/dL. The objective of this study was to document the feasibility of employing lead isotope ratios (LIRs) to identify and rank the Pb (lead) exposure sources most relevant to children across Georgia. A cross-sectional survey between November 2019 and February 2020 of 36 children previously identified as having BLCs > 5 µg/dL from seven regions of Georgia involved the collection of blood and 528 environmental samples, a questionnaire on behaviours and potential exposures. The LIRs in blood and environmental samples were analysed in individual children and across the whole group to ascertain clustering. A fitted statistical mixed-effect model to LIR data first found that the blood samples clustered with spices, tea, and paint, then, further isotopically distinct from blood were sand, dust, and soil, and lastly, milk, toys, pens, flour, and water. Analysis of the LIRs provided an indication and ranking of the importance of Pb environmental sources as explanatory factors of BLCs across the group of children. The findings support the deployment of interventions aimed at managing the priority sources of exposure in this population.

Geo-temporal patterns to design cost-effective interventions for zoonotic diseases -the case of brucellosis in the country of Georgia.

Introduction: Control of zoonosis can benefit from geo-referenced procedures. Focusing on brucellosis, here the ability of two methods to distinguish disease dissemination patterns and promote cost-effective interventions was compared. Method: Geographical data on bovine, ovine and human brucellosis reported in the country of Georgia between 2014 and 2019 were investigated with (i) the Hot Spot (HS) analysis and (ii) a bio-geographical (BG) alternative. Results: More than one fourth of all sites reported cases affecting two or more species. While ruminant cases displayed different patterns over time, most human cases described similar geo-temporal features, which were associated with the route used by migrant shepherds. Other human cases showed heterogeneous patterns. The BG approach identified small areas with a case density twice as high as the HS method. The BG method also identified, in 2018, a 2.6-2.99 higher case density in zoonotic (human and non-human) sites than in non-zoonotic sites (which only reported cases affecting a single species) -a finding that, if corroborated, could support cost-effective policy-making. Discussion: Three dissemination hypotheses were supported by the data: (i) human cases induced by sheep-related contacts; (ii) human cases probably mediated by contaminated milk or meat; and (iii) cattle and sheep that infected one another. This proof-of-concept provided a preliminary validation for a method that may support cost-effective interventions oriented to control zoonoses. To expand these findings, additional studies on zoonosis-related decision-making are recommended.

Campylobacteriosis, Shigellosis and Salmonellosis in Hospitalized Children with Acute Inflammatory Diarrhea in Georgia.

This is the first study on campylobacteriosis carried out in Georgia. It targeted 382 hospitalized children with acute inflammatory diarrhea. The study was conducted between July 2020 to July 2021 based on the main infection clinic of the capital city. Culture-based bacteriological methods were followed by phenotypic and Real-time PCR tests for bacterial confirmation and identification. The data revealed recent epidemiologic prevalences of the three main causative bacteria in the target population. Shigella sonnei with 19.1% (95% CI: 15.2-23.4%) was the most frequently detected pathogen followed by Campylobacter spp. with 12.3% (95% CI: 9.2-16.0%) and Salmonella spp. with 4.9% (95% CI: 3.0-7.6%). However, in 63.6% of the samples, the causative agent remained unknown. Species differentiation of Campylobacter spp. revealed 81% Campylobacter jejuni and 19% Campylobacter coli. An epidemiological pyramid with estimated magnification factors may give more insights into the burden of campylobacteriosis among the studied population, resulting in a putative annual incidence of 6 per 1000 children in Tbilisi. Children with campylobacteriosis were younger (median age 40 months (interquartile range (IQR) 22-95)) than with shigellosis (median age 92 months (interquartile range (IQR) 52-140)). However, no statistically significant difference was found with the age range of patients with campylobacteriosis and salmonellosis as well as with salmonellosis and shigellosis. In conclusion, Campylobacter spp. may be suspected to be the second most frequent bacterial causative agent of acute inflammatory diarrhea in hospitalized children and the primary cause in the 0-3 age group in Georgia. In addition, Campylobacter CROMagar showed better selectivity in comparison to mCCDA selective agar of stool samples in our study.

Comparison of Antimicrobial Susceptibility Profiles of Thermotolerant Campylobacter spp. Isolated from Human and Poultry Samples in Georgia (Caucasus).

Antimicrobial resistance remains a public health concern globally. This study presents antimicrobial resistance by microdilution and genetic diversity by the whole-genome sequencing of Campylobacter spp. from human and poultry samples isolated in Georgia in 2020/2021. The major species in poultry samples was C. coli, while C. jejuni was preferentially isolated from human samples. Resistance against tetracycline was highest (100%) in C. coli from industrial chicken and lowest in C. jejuni from clinical isolates (36%), while resistance against ciprofloxacin varied from 80% in C. jejuni from backyard chicken to 100% in C. jejuni and C. coli from industrial chicken. The point mutations in gyrA (T86I) and tet (O) genes were detected as resistance determinants for (fluoro-)quinolone or tetracycline resistance, respectively. Ertapenem resistance is still enigmatic. All isolates displayed sensitivity towards erythromycin, gentamicin and chloramphenicol. Multi-resistance was more frequently observed in C. coli than in C. jejuni, irrespective of the isolation matrix, and in chicken isolates compared to human isolates, independent of the Campylobacter species. The Georgian strains showed high variability of multi-locus sequence types (ST), including novel STs. This study provides the first antibiotic resistance data from Campylobacter spp. in Georgia and addresses the need for follow-up monitoring programs.

Risk factors and genotype distribution of hepatitis C virus in Georgia: A nationwide population-based survey.

In preparation for the National Hepatitis C Elimination Program in the country of Georgia, a nationwide household-based hepatitis C virus (HCV) seroprevalence survey was conducted in 2015. Data were used to estimate HCV genotype distribution and better understand potential sex-specific risk factors that contribute to HCV transmission. HCV genotype distribution by sex and reported risk factors were calculated. We used explanatory logistic regression models stratified by sex to identify behavioral and healthcare-related risk factors for HCV seropositivity, and predictive logistic regression models to identify additional variables that could help predict the presence of infection. Factors associated with HCV seropositivity in explanatory models included, among males, history of injection drug use (IDU) (aOR = 22.4, 95% CI = 12.7, 39.8) and receiving a blood transfusion (aOR = 3.6, 95% CI = 1.4, 8.8), and among females, history of receiving a blood transfusion (aOR = 4.0, 95% CI 2.1, 7.7), kidney dialysis (aOR = 7.3 95% CI 1.5, 35.3) and surgery (aOR = 1.9, 95% CI 1.1, 3.2). The male-specific predictive model additionally identified age, urban residence, and history of incarceration as factors predictive of seropositivity and were used to create a male-specific exposure index (Area under the curve [AUC] = 0.84). The female-specific predictive model had insufficient discriminatory performance to support creating an exposure index (AUC = 0.61). The most prevalent HCV genotype (GT) nationally was GT1b (40.5%), followed by GT3 (34.7%) and GT2 (23.6%). Risk factors for HCV seropositivity and distribution of HCV genotypes in Georgia vary substantially by sex. The HCV exposure index developed for males could be used to inform targeted testing programs.

Phylogeography of Francisella tularensis subspecies holarctica from the country of Georgia.

BACKGROUND: Francisella tularensis, the causative agent of tularemia, displays subspecies-specific differences in virulence, geographic distribution, and genetic diversity. F. tularensis subsp. holarctica is widely distributed throughout the Northern Hemisphere. In Europe, F. tularensis subsp. holarctica isolates have largely been assigned to two phylogenetic groups that have specific geographic distributions. Most isolates from Western Europe are assigned to the B.Br.FTNF002-00 group, whereas most isolates from Eastern Europe are assigned to numerous lineages within the B.Br.013 group. The eastern geographic extent of the B.Br.013 group is currently unknown due to a lack of phylogenetic knowledge about populations at the European/Asian juncture and in Asia. In this study, we address this knowledge gap by describing the phylogenetic structure of F. tularensis subsp. holarctica isolates from the country of Georgia, and by placing these isolates into a global phylogeographic context. RESULTS: We identified a new genetic lineage of F. tularensis subsp. holarctica from Georgia that belongs to the B.Br.013 group. This new lineage is genetically and geographically distinct from lineages previously described from the B.Br.013 group from Central-Eastern Europe. Importantly, this new lineage is basal within the B.Br.013 group, indicating the Georgian lineage diverged before the diversification of the other known B.Br.013 lineages. Although two isolates from the Georgian lineage were collected nearby in the Ukrainian region of Crimea, all other global isolates assigned to this lineage were collected in Georgia. This restricted geographic distribution, as well as the high levels of genetic diversity within the lineage, is consistent with a relatively older origin and localized differentiation. CONCLUSIONS: We identified a new lineage of F. tularensis subsp. holarctica from Georgia that appears to have an older origin than any other diversified lineages previously described from the B.Br.013 group. This finding suggests that additional phylogenetic studies of F. tularensis subsp. holarctica populations in Eastern Europe and Asia have the potential to yield important new insights into the evolutionary history and phylogeography of this broadly dispersed F. tularensis subspecies.

Setting up laboratory-based antimicrobial resistance surveillance in low- and middle-income countries: lessons learned from Georgia.

BACKGROUND: Antimicrobial resistance (AMR) is a growing problem worldwide, with an estimated high burden in low- and middle-income countries (LMICs). In these settings, tackling the problem of AMR is often constrained by a lack of reliable surveillance data due to limited use of microbiological diagnostics in clinical practice. OBJECTIVES: The aim of this article is to present an overview of essential elements for setting up an AMR surveillance system in LMICs, to summarize the steps taken to develop such a system in the country of Georgia, and to describe its impact on microbiology laboratories. SOURCES: A literature review of published papers using PubMed and experiences of experts involved in setting up AMR surveillance in Georgia. CONTENT: Basic requirements for implementing a laboratory-based surveillance system in LMICs can be captured under four pillars: (a) governmental support, (b) laboratory capacity and quality management, (c) materials and supplies, and (d) sample collection, data management, analysis and reporting. In Georgia, the World Health Organization Proof-of-Principle project helped to start the collection of AMR surveillance data on a small scale by promoting the use of microbiological diagnostics in clinics, and by providing training and materials for laboratories. Thanks to governmental support and a strong lead by the national reference laboratory, the AMR surveillance network was sustained and expanded after the project ended. IMPLICATIONS: This review describes the Georgian approach in building and expanding a functional AMR surveillance system, considering the elements identified from the literature. The introduction of quality management systems, standardization of guidelines and training paired with targeted capacity building led to improved laboratory standards and management of patients with bloodstream infections. Reliable AMR surveillance data may inform and facilitate policy-making on AMR control. The Georgian experience can guide other countries in the process of building up their national AMR surveillance system.

Evidence of Extensive Circulation of Yersinia enterocolitica in Rodents and Shrews in Natural Habitats from Retrospective and Perspective Studies in South Caucasus.

Yersinia enterocolitica culture-positive rodents and shrews were reported in different territories across Georgia during 14 of 17 years of investigations conducted for the period of 1981-1997. In total, Y. enterocolitica was isolated from 2052 rodents (15 species) and 33 shrews. Most isolates were obtained from Microtus arvalis, Rattus norvegicus, Mus musculus, and Apodemus spp. During the prospective study (2017-2019), isolates of Yersinia-like bacteria were cultured from 53 rodents collected in four parts of Georgia. All the Yersinia-like isolates were confirmed as Y. enterocolitica based on the API 20E and the BD Phenix50 tests. Whole-genome (WG) sequencing of five rodents and one shrew strain of Y. enterocolitica revealed that they possessed a set of virulence genes characteristic of the potentially pathogenic strains of biogroup 1A. All isolates lacked distinguished virulence determinants for YstA, Ail, TccC, VirF, and virulence plasmid pYV but carried the genes for YstB, YmoA, HemPR-HmuVSTU, YaxAB, PhlA, PldA, ArsCBR, and a flagellar apparatus. One strain contained a gene highly homologous to heat-labile enterotoxin, a chain of E. coli, a function not previously described for Y. enterocolitica. The WG single-nucleotide polymorphism-based typing placed the isolates in four distinct phylogenetic clusters.