[COVID-19 outbreak investigation in a geriatric palliative hospital]. / COVID-19-Ausbruch-Untersuchung in einer geriatrisch-palliativmedizinischen Klinik.

BACKGROUND: During the second COVID-19 wave, a large COVID-19 outbreak happened at a 90-bed geriatric palliative care hospital in December 2020, whereby 32 % of the healthcare personnel (HCP) and 29 patients became infected within 23 days and 13 patients died. The bed occupancy rate dropped to 20 %. Drastically enhanced hygiene measures directly after outbreak detection could stop further nosocomial infections among patients but were less effective among HCP. OBJECTIVE: Outbreak investigation and detection of risk factors for infection in HCP. MATERIAL AND METHODS: Anonymous online survey among HCP from January and February 2021 investigating potential risk factors for PCR positive infections (poorly fitting FFP2 masks, close contacts with positive patients, team meetings with positive HCP). RESULTS: Of 184 HCP, 96 completed the survey (52.2 %), including 38 who became infected. Of the HCP 8 remained asymptomatic/oligosymptomatic, 30 HCP became ill for a median of 10 days and in 2 continuously. Factors associated with an infection were close contacts with positive patients in a time-dependent manner despite wearing an FFP2 mask (OR 6.0; 95 % CI 1.6-22). Out of 88 HCP 55 described poorly fitting FFP2 masks. An infection was mostly attributed to a longer contact with positive, sometimes restless patients. The overall exhausting working situation was repeatedly mentioned. CONCLUSION: A COVID outbreak within the care-intense geriatric context is challenging to control especially among HCP. Longer patient contacts and limited compliance by patients counteracts strict hygiene measures. Vulnerability of HCP and patients requires additional preventive interventions by rapidly effective vaccinations and has to be a priority for health policy.

Imported cholera with acute renal failure after a short business-trip to the Philippines, Germany, October 2015.

A German businessman developed acute watery diarrhoea after a three-day trip to the Philippines. He was admitted with severe hypotension and acute renal failure, but recovered with rapid rehydration. Vibrio cholerae O1 serotype Ogawa was isolated. Physicians need to be aware of endemic cholera in Asia including the Philippines and consider this in their pre-travel advice.

Road traffic injuries in northern Laos: trends and risk factors of an underreported public health problem.

OBJECTIVES: Road traffic injuries (RTI) have become a leading cause for admissions at Luang Namtha Provincial Hospital (LNPH) in rapidly developing northern Laos. Objectives were to investigate trends, risk factors and better estimates of RTI. METHODS: Repeated annual surveys were conducted with structured questionnaires among all RTI patients at LNPH from 2007 to 2011. Hospital and police data were combined by capture-recapture method. RESULTS: The majority of 1074 patients were young [median 22 years (1-88)], male (68%), motorcyclists (76%), drove without licence (85%) and without insurance (95%). Most accidents occurred during evenings and Lao New Year. Serious motorbike injuries were associated with young age (1-15 years), male sex (OR 2.2, 95% CI 1.1-4.6) and drivers (OR 2.1, 95% CI 1.1-4.3); more serious head injuries with alcohol consumption (OR 2.5, 95% CI 1.7-3.7), male sex (OR 2.3, 95% CI 1.4-3.7) and no helmet use (OR 2.0, 95% CI 1.2-3.4). No helmet use was associated with young age, time period, pillion passengers (OR 2.7, 95% CI 1.6-4.7), alcohol (OR 1.9, 95% CI 1.2-2.8) and no driver license (OR 2.0; 95% CI 1.1-3.4). Main reasons not to wear helmets were not possessing one, and being pillion passenger. Capture-recapture analysis showed four times higher RTI estimates than officially reported. Mortality rate was 11.6/100.000 population (95% CI 5.1-18.1/100.000). CONCLUSIONS: RTI were substantially underestimated. Combining hospital with police data can provide better estimates in resource-limited settings. Preventive programmes and law enforcement have to target male drivers, alcohol, licensing and helmet use, especially among children and pillion passengers. Increased efforts are needed during evening time and special festivals.

Acute muscular sarcocystosis: an international investigation among ill travelers returning from Tioman Island, Malaysia, 2011-2012.

BACKGROUND: Through 2 international traveler-focused surveillance networks (GeoSentinel and TropNet), we identified and investigated a large outbreak of acute muscular sarcocystosis (AMS), a rarely reported zoonosis caused by a protozoan parasite of the genus Sarcocystis, associated with travel to Tioman Island, Malaysia, during 2011-2012. METHODS: Clinicians reporting patients with suspected AMS to GeoSentinel submitted demographic, clinical, itinerary, and exposure data. We defined a probable case as travel to Tioman Island after 1 March 2011, eosinophilia (>5%), clinical or laboratory-supported myositis, and negative trichinellosis serology. Case confirmation required histologic observation of sarcocysts or isolation of Sarcocystis species DNA from muscle biopsy. RESULTS: Sixty-eight patients met the case definition (62 probable and 6 confirmed). All but 2 resided in Europe; all were tourists and traveled mostly during the summer months. The most frequent symptoms reported were myalgia (100%), fatigue (91%), fever (82%), headache (59%), and arthralgia (29%); onset clustered during 2 distinct periods: "early" during the second and "late" during the sixth week after departure from the island. Blood eosinophilia and elevated serum creatinine phosphokinase (CPK) levels were observed beginning during the fifth week after departure. Sarcocystis nesbitti DNA was recovered from 1 muscle biopsy. CONCLUSIONS: Clinicians evaluating travelers returning ill from Malaysia with myalgia, with or without fever, should consider AMS, noting the apparent biphasic aspect of the disease, the later onset of elevated CPK and eosinophilia, and the possibility for relapses. The exact source of infection among travelers to Tioman Island remains unclear but needs to be determined to prevent future illnesses.

Chromoblastomycosis after a leech bite complicated by myiasis: a case report.

BACKGROUND: Chromoblastomycosis is a chronic mycotic infection, most common in the tropics and subtropics, following traumatic fungal implantation. CASE PRESENTATION: A 72 year-old farmer was admitted to Luang Namtha Provincial Hospital, northern Laos, with a growth on the left lower leg which began 1 week after a forefoot leech bite 10 years previously. He presented with a cauliflower-like mass and plaque-like lesions on his lower leg/foot and cellulitis with a purulent tender swelling of his left heel. Twenty-two Chrysomya bezziana larvae were extracted from his heel. PCR of a biopsy of a left lower leg nodule demonstrated Fonsecaea pedrosoi, monophora, or F. nubica. He was successfully treated with long term terbinafin plus itraconazole pulse-therapy and local debridement. CONCLUSIONS: Chromoblastomycosis is reported for the first time from Laos. It carries the danger of bacterial and myiasis superinfection. Leech bites may facilitate infection.

Auto-antibodies to type I IFNs can underlie adverse reactions to yellow fever live attenuated vaccine.

Yellow fever virus (YFV) live attenuated vaccine can, in rare cases, cause life-threatening disease, typically in patients with no previous history of severe viral illness. Autosomal recessive (AR) complete IFNAR1 deficiency was reported in one 12-yr-old patient. Here, we studied seven other previously healthy patients aged 13 to 80 yr with unexplained life-threatening YFV vaccine-associated disease. One 13-yr-old patient had AR complete IFNAR2 deficiency. Three other patients vaccinated at the ages of 47, 57, and 64 yr had high titers of circulating auto-Abs against at least 14 of the 17 individual type I IFNs. These antibodies were recently shown to underlie at least 10% of cases of life-threatening COVID-19 pneumonia. The auto-Abs were neutralizing in vitro, blocking the protective effect of IFN-α2 against YFV vaccine strains. AR IFNAR1 or IFNAR2 deficiency and neutralizing auto-Abs against type I IFNs thus accounted for more than half the cases of life-threatening YFV vaccine-associated disease studied here. Previously healthy subjects could be tested for both predispositions before anti-YFV vaccination.

Risk of latent tuberculosis infection in children living in households with tuberculosis patients: a cross sectional survey in remote northern Lao People's Democratic Republic.

BACKGROUND: Tuberculosis is highly prevalent in Laos (289 per 100,000). We evaluated the risk of latent tuberculosis infection (LTBI) among children (0-15 years) living with tuberculosis patients in rural northern Laos. METHODS: In a cross sectional survey of 30 randomly selected villages, 72 tuberculosis patients were traced and their 317 contacts (148 were children) investigated using a questionnaire, a tuberculin skin tests (positive: > = 10 mm), a 3-day sputum examination for acid-fast bacilli (AFB), and chest radiography. RESULTS: None of the 148 contact-children received prophylaxis, one had cervical tuberculosis; the risk for LTBI was 31.0%. Awareness of the infectiousness of tuberculosis was low among patients (31%) and their contacts (31%), and risky behavior was common. After multivariate logistic analysis, increased LTBI was found in children with contact with sputum positive adults (OR: 3.3, 95% CI: 1.4-7.7), patients highly positive sputum prior to treatment (AFB >2+; OR: 4.7, 95% CI: 1.7-12.3), and living in ethnic minorities (OR: 5.4, 95% CI: 2.2-13.6). CONCLUSION: The study supports the importance of contact tracing in remote settings with high TB prevalence. Suggestions to improve the children's detection rate, the use of existing guidelines, chemoprophylaxis of contact-children and the available interventions in Laos are discussed. Improving education and awareness of the infectiousness of TB in patients is urgently needed to reduce TB transmission.

Fatal Chromobacterium violaceum septicaemia in northern Laos, a modified oxidase test and post-mortem forensic family G6PD analysis.

BACKGROUND: Chromobacterium violaceum is a Gram negative facultative anaerobic bacillus, found in soil and stagnant water, that usually has a violet pigmented appearance on agar culture. It is rarely described as a human pathogen, mostly from tropical and subtropical areas. CASE PRESENTATION: A 53 year-old farmer died with Chromobacterium violaceum septicemia in Laos. A modified oxidase method was used to demonstrate that this violacious organism was oxidase positive. Forensic analysis of the glucose-6-phosphate dehydrogenase genotypes of his family suggest that the deceased patient did not have this possible predisposing condition. CONCLUSION: C. violaceum infection should be included in the differential diagnosis in patients presenting with community-acquired septicaemia in tropical and subtropical areas. The apparently neglected but simple modified oxidase test may be useful in the oxidase assessment of other violet-pigmented organisms or of those growing on violet coloured agar.

Adverse events in vaccinations for travelers - a 1-year prospective survey in a travel clinic in Germany.

Background: The study goal was to assess and compare adverse events (AE) of current vaccinations for travelers under 'real-life conditions'. Methods: A prospective observational online questionnaire study was performed from May 2015 till April 2016 in a travel clinic in Germany. Online questionnaire links were sent 1 week after the first vaccination date. Severity was rated on a scale from 1 to 5 (minor to very severe AE). Results: Of 1357 vaccinees 781 (57.6%) responded to the questionnaire, corresponding to 1415 vaccinations (1-7 simultaneous vaccinations). Responders were more often female (f:m = 1.29:1). Main age groups were 20-29 years old (36.1%). Most frequent vaccinations were against rabies (277; chick embryo cell vaccine (CEC): 97, human diploid cell vaccine (HDC): 180), yellow fever (250), typhoid fever (198), meningococcal meningitis (126) and Japanese encephalitis (104). A total of 217 vaccinees (27.8%) reported AE; 82 (10.5%) rated AE as more severe (grade 3: 61, grade 4: 18, grade 5: 3). No life-threatening AE was reported. Of 157 systemic AE the most frequent were: fatigue (75), headaches (46) and pyrexia (31). Of 94 local AE most frequently reported were pain (66), myalgia (25) and swelling (12). AE after single vaccinations were more often associated with rabies vaccine (OR 2.2; 1.2-4.2). AE increased with the number of simultaneous vaccinations (single vaccination: 24.1%, 88/365; 2 vaccinations: 26.6%, 73/274, ≥3 vaccinations: 39.4%, 56/142, χ2 = 12.24, P = 0.002, CCorr = 0.18), but more severe AE showed no association with the number of vaccinations (χ2 = 5.55, P = 0.06, CCorr = 0.12). Conclusions: Single and simultaneous vaccinations were overall well tolerated. AE were reported more frequently with rabies vaccinations in single vaccinations. Increased numbers of simultaneous vaccinations led to some incremental AE but not to more severe AE. Simultaneous vaccinations should be encouraged to reduce missed opportunities for immunizations.

[Severe Yellow fever vaccine-associated disease: a case report and current overview]. / Schwere Gelbfieber-impfassoziierte Erkrankung: ein Fallbericht und aktuelle Übersicht.

History and physical examination A 56-year-old man developed high fever with severe headaches, fatigue, impaired concentration skills, and an exanthema 5 days after a yellow fever (YF) vaccination. Laboratory tests Liver enzymes and YF antibody titers were remarkably elevated. YF vaccine virus was detected in urine by PCR. Diagnosis and therapy Initially, severe YF vaccine-associated visceral disease was suspected and treated symptomatically. Clinical Course His fever ceased after 10 days in total, no organ failure developed. However, postencephalitic symptoms persisted with fatigue and impaired concentration, memory, and reading skills and partly incapability to work for over 3 months. A diagnosis was made of suspected YF vaccine-associated neurotropic disease. Conclusion Severe vaccine-derived adverse effects need to be considered in the indication process for YF vaccination.

Human Invasive Muscular Sarcocystosis Induces Th2 Cytokine Polarization and Biphasic Cytokine Changes, Based on an Investigation among Travelers Returning from Tioman Island, Malaysia.

Sarcocystis nesbitti is a parasite responsible for a biphasic eosinophilic febrile myositis syndrome in two recent outbreaks in Malaysia. We demonstrate Th2 cytokine polarization in infected travelers, an overall cytokine production decrease in the early phase of the disease suggestive of initial immunosuppression, and elevated levels of proinflammatory and chemotactic cytokines in the later myositic phase.

Comparison of subcutaneous and intravenous rehydration in geriatric patients: a randomized trial.

OBJECTIVES: To compare the acceptance, feasibility, and adverse effects of subcutaneous (SC) and intravenous (IV) rehydration in dehydrated geriatric patients and clinical changes exhibited by the patients. DESIGN: A prospective, randomized, open clinical trial. SETTING: Hospital geriatric wards during a period of 20 months. PARTICIPANTS: Ninety-six patients with a mean age +/- standard deviation of 85.3 +/- 6.7 with signs of mild to moderate dehydration needing parenteral fluids. INTERVENTION: Geriatric patients were randomly allocated to receive SC or IV infusions of half-normal saline-glucose solutions as long as clinically necessary. MEASUREMENTS: A standardized patient record form was used to document the observed adverse effects. Using a Likert-like scale based on the German school marks system with scores ranging from 1 = very good to 6 = very bad, patients were asked to score their discomfort; nurses and doctors scored the feasibility of the intervention. Changes in laboratory and clinical findings (including patients' orientation and activities of daily living using the Barthel Index) and adverse effects were recorded. RESULTS: Forty-eight patients were randomized into each group. Median duration of fluid administration was 6 days (SC and IV, P =.33). Median volume was 750 mL/day (SC) and 1,000 mL/day (IV, P =.002). In 13 patients, the therapy had to be changed from SC to IV (SC/IV subgroup): 11 times because of the exigency of an IV drug application and twice because of poor resorption. In 17 patients, there was a change from IV to SC (IV/SC subgroup), mainly because of impossibility of further peripheral IV punctures (8 times) and permanent removal of the IV cannula (5 times). The patients of the IV/SC subgroup scored their discomfort significantly worse (median 5.5 vs all other groups median 2, P =.017). This corresponded with the scoring of feasibility by the nurses (IV/SC: median 4.25 vs all other groups median 2, P =.009) and by the doctors (IV/SC: median 4 vs all other groups: median 2, P =.001). Both methods of rehydration caused only few systemic adverse reactions; acute cardiac failure occurred twice in the SC group versus four times in the IV group (P =.68) and hyponatremia once in the SC group versus twice in the IV group (P = 1.0). Some patients experienced local side effects (SC, n = 29 vs IV, n = 24; P =.41), mainly to a mild extent (SC, n = 25 vs IV, n = 24; P = 1.0). Major local side effects (large edema, phlebitis, cellulitis, erythema and strong pain) occurred in nine SC and eight IV (P = 1.0) patients. The clinical and laboratory changes during therapy were similar in both trial arms. CONCLUSIONS: Rehydration by hypodermoclysis is equally well accepted by geriatric patients as the IV therapy and offers a similarly easy feasibility. Additionally, in confused patients and in those in whom IV punctures are difficult to achieve, it represents the far superior method. Both techniques are comparably safe and effective.

Causes of non-malarial fever in Laos: a prospective study.

BACKGROUND: Because of reductions in the incidence of Plasmodium falciparum malaria in Laos, identification of the causes of fever in people without malaria, and discussion of the best empirical treatment options, are urgently needed. We aimed to identify the causes of non-malarial acute fever in patients in rural Laos. METHODS: For this prospective study, we recruited 1938 febrile patients, between May, 2008, and December, 2010, at Luang Namtha provincial hospital in northwest Laos (n=1390), and between September, 2008, and December, 2010, at Salavan provincial hospital in southern Laos (n=548). Eligible participants were aged 5-49 years with fever (≥38°C) lasting 8 days or less and were eligible for malaria testing by national guidelines. FINDINGS: With conservative definitions of cause, we assigned 799 (41%) patients a diagnosis. With exclusion of influenza, the top five diagnoses when only one aetiological agent per patient was identified were dengue (156 [8%] of 1927 patients), scrub typhus (122 [7%] of 1871), Japanese encephalitis virus (112 [6%] of 1924), leptospirosis (109 [6%] of 1934), and bacteraemia (43 [2%] of 1938). 115 (32%) of 358 patients at Luang Namtha hospital tested influenza PCR-positive between June and December, 2010, of which influenza B was the most frequently detected strain (n=121 [87%]). Disease frequency differed significantly between the two sites: Japanese encephalitis virus infection (p=0·04), typhoid (p=0·006), and leptospirosis (p=0·001) were more common at Luang Namtha, whereas dengue and malaria were more common at Salavan (all p<0·0001). With use of evidence from southeast Asia when possible, we estimated that azithromycin, doxycycline, ceftriaxone, and ofloxacin would have had significant efficacy for 258 (13%), 240 (12%), 154 (8%), and 41 (2%) of patients, respectively. INTERPRETATION: Our findings suggest that a wide range of treatable or preventable pathogens are implicated in non-malarial febrile illness in Laos. Empirical treatment with doxycycline for patients with undifferentiated fever and negative rapid diagnostic tests for malaria and dengue could be an appropriate strategy for rural health workers in Laos. FUNDING: Wellcome Trust, WHO-Western Pacific Region, Foundation for Innovative New Diagnostics, US Centers for Disease Control and Prevention

Bartonella and Rickettsia in arthropods from the Lao PDR and from Borneo, Malaysia.

Rickettsioses and bartonelloses are arthropod-borne diseases of mammals with widespread geographical distributions. Yet their occurrence in specific regions, their association with different vectors and hosts and the infection rate of arthropod-vectors with these agents remain poorly studied in South-east Asia. We conducted entomological field surveys in the Lao PDR (Laos) and Borneo, Malaysia by surveying fleas, ticks, and lice from domestic dogs and collected additional samples from domestic cows and pigs in Laos. Rickettsia felis was detected by real-time PCR with similar overall flea infection rate in Laos (76.6%, 69/90) and Borneo (74.4%, 268/360). Both of the encountered flea vectors Ctenocephalides orientis and Ctenocephalides felis felis were infected with R. felis. The degrees of similarity of partial gltA and ompA genes with recognized species indicate the rickettsia detected in two Boophilus spp. ticks collected from a cow in Laos may be a new species. Isolation and further characterization will be necessary to specify it as a new species. Bartonella clarridgeiae was detected in 3/90 (3.3%) and 2/360 (0.6%) of examined fleas from Laos and Borneo, respectively. Two fleas collected in Laos and one flea collected in Borneo were co-infected with both R. felis and B. clarridgeiae. Further investigations are needed in order to isolate these agents and to determine their epidemiology and aetiological role in unknown fever in patients from these areas.

Bowel obstruction from wild bananas: a neglected health problem in Laos.

We investigated the significance and risk factors of bowel obstruction caused by the consumption of wild bananas (BOWB) in Laos. Of six patients with BOWB in Luang Namtha, North Laos, five required enterotomy for phytobezoars. All had eaten wild banana (WB) seeds. Of 227 other patients/relatives: 91.2% had eaten WB; 46.3% had also eaten the seeds and 45.4% knew of complications resulting from eating WB; 42.3% were aware of the complications of ingesting the seeds (constipation [37.9%], appendicitis/abdominal pain/vomiting [2.6% each] and bloated stomach/death [1.3% each]). Middle/highland Lao ethnicity was associated with WB and seed consumption (odds ratio [OR] 9.91 and 2.33), male sex with WB consumption and unawareness (OR 4.31 and 1.78). At all surgically-equipped hospitals in Laos, 33/44 doctors knew of BOWB, describing patients as young adults (16/30), male (24/30) and from middleland Lao (18/30). Countrywide, 46/48 patients with BOWB required laparotomy in 2009 (incidence 0.8/100,000). All consumed WB seeds. BOWB is widespread in Laos, especially among young middleland Lao men consuming WB seeds on an empty stomach.