Delineating and Analyzing Locality-Level Determinants of Cholera, Haiti.

Centre Department, Haiti, was the origin of a major cholera epidemic during 2010-2019. Although no fine-scale spatial delineation is officially available, we aimed to analyze determinants of cholera at the local level and identify priority localities in need of interventions. After estimating the likely boundaries of 1,730 localities by using Voronoi polygons, we mapped 5,322 suspected cholera cases reported during January 2015-September 2016 by locality alongside environmental and socioeconomic variables. A hierarchical clustering on principal components highlighted 2 classes with high cholera risk: localities close to rivers and unimproved water sources (standardized incidence ratio 1.71, 95% CI 1.02-2.87; p = 0.04) and urban localities with markets (standardized incidence ratio 1.69, 95% CI 1.25-2.29; p = 0.0006). Our analyses helped identify and characterize areas where efforts should be focused to reduce vulnerability to cholera and other waterborne diseases; these methods could be used in other contexts.

Inertial measurement unit compared to an optical motion capturing system in post-stroke individuals with foot-drop syndrome.

BACKGROUND: Functional electrical stimulation (FES) can be used for compensation of foot-drop for post-stroke individuals by pre-programmed fixed stimulation; however, this stimulation seems no more effective than mechanical ankle foot orthoses. OBJECTIVE: We evaluated the metrological quality of inertial sensors for movement reconstruction as compared with the gold-standard motion capturing system, to couple FES with inertial sensors to improve dorsiflexion on the paretic side, by using an adaptive stimulation taking into account individuals' performance post-stroke. METHODS: Adults with ischemic or hemorrhagic stroke presenting foot-drop and able to walk 10m, were included from May 2016 to June 2017. Those with passive ankle dorsiflexion<0° with the knee stretched were excluded. Synchronous gait was analyzed with the VICON© system as the gold standard and inertial measurement units (IMUs) worn by participants. The main outcome was the dorsiflexion angle at the heel strike and mid-swing phase obtained from IMUs and the VICON system. Secondary outcomes were: stride length, walking speed, maximal ankle dorsiflexion velocity and fatigue detection. RESULTS: We included 26 participants [18 males; mean age 58 (range 45-84) years]. During heel strike, the dorsiflexion angle measurements demonstrated a root mean square error (RMSE) of 5.5°; a mean average error (MAE) of 3.9°; Bland-Altman bias of -0.1° with limits of agreement -10.9° to+10.7° and good intra-class correlation coefficient (ICC) at 0.87 between the 2 techniques. During the mid-swing phase, the RMSE was 5.6; MAE 3.7°; Bland-Altman bias -0.9° with limits of agreement -11.7° to+9.8° and ICC 0.88. Good agreement was demonstrated for secondary outcomes and fatigue detection. CONCLUSIONS: IMU-based reconstruction algorithms were effective in measuring ankle dorsiflexion with small biases and good ICCs in adults with ischemic or hemorrhagic stroke presenting foot-drop. The precision obtained is sufficient to observe the fatigue influence on the dorsiflexion and therefore to use IMUs to adapt FES.

Identification and tracking of Addictovigilance signals in general practice: which interactions between the general practitioners and the French Addictovigilance Network?

Addictovigilance is a health vigilance dedicated to the survey of medicinal or illicit psychoactive substance use disorders (SUDs). France is the only European country to have a vigilance system specifically dedicated to substances with an abuse/addiction potential. The French Addictovigilance system is organized in a network of regional tertiary centres (called Abuse and Dependence Monitoring Centres, CEIP-Addictovigilance) and works in close collaboration with Regional and National health authorities. Because of the essential and unavoidable nature of their practice in the French Healthcare system, general practitioners (GPs) are key actors to identify and track Addictovigilance signals. They have been involved in several of the pharmacoepidemiological surveys implemented by the French Addictovigilance Network (FAN). Now, they increasingly participate in clinical research projects and studies. In this article, interactions between GPs and the FAN are illustrated with two examples: patients on opioid substitution treatment and patients on opioid analgesics. Collaborations between GPs and the FAN could be further potentiated. In particular, more effective communication on psychoactive SUDs including abuse/addiction is necessary to optimize the implementation of preventive measures for patients on psychoactive substances medications, and to improve the attitudes of GPs and more widely health professionals in the management of any psychoactive user suffering from SUDs. In addition, both adapted training and improved collaborative research could contribute to the optimization (safety, quality) of professional practices.

Surveillance of travel-associated diseases at two referral centres in Marseille, France: a 12-year survey.

Background: With increasing international travel and historically high numbers of residents visiting friends and relatives overseas, travel-associated illnesses are frequent in Marseille, France. We report the changing epidemiology of travel-related illnesses over a 12-year period. Methods: A single site GeoSentinel surveillance analysis was undertaken for 3460 ill returned travellers presenting to two public hospitals in Marseille, France from March 2003 to October 2015, with travel-related illnesses. Demographic characteristics, travel history, presenting symptoms and information on pre-travel consultations were collected. Results: There was a predominance of travel to sub-Saharan Africa, in particular to Comoros archipelago. Tourism was the main reason for travel (1591/3460, 46%), followed by visiting friends or relatives (VFR) (895/3460, 26%), with a mean duration of 29 days; 35% (1212/3460) of travellers reported a pre-travel health consultation. The most common syndromic diagnoses were febrile systemic illness (1343, 39%), dermatologic (716, 21%), gastrointestinal (340, 10%) and respiratory/ear-nose-throat (331, ENT) (10%). Hospitalization rates were highest amongst travellers from sub-Saharan Africa (858/ 1632, 53%), and VFR (573/ 895, 64%, P < 0.001). Frequent diagnoses included malaria (797, 23%), dengue (96, 2.77%) and chikungunya (75, 2.17%), reflecting global trends. Comparison of two periods (2003-10 to 2011-15) demonstrated an increase in chikungunya and decrease in malaria and influenza-like illness. We report an increase in ill travellers from the Caribbean, Middle East and South-East Asia. Conclusion: Surveillance of travellers provides relevant sentinel information on the changing epidemiology of infectious diseases across the globe, most notably for malaria, dengue and chikungunya. We demonstrate the use of travel surveillance in improving pre-travel consultation needs and to address autochthonous vector-borne viral risks.

Patient-prosthesis mismatch in new generation trans-catheter heart valves: a propensity score analysis.

Aims: When compared with the former Sapien XT (XT-THV), the Sapien 3 trans-catheter heart valve (S3-THV) embeds an outer annular sealing cuff to prevent para-valvular regurgitation (PVR). The consequences of this new feature on valve haemodynamics have never been evaluated. We aimed to compare both types of prostheses regarding patient-prosthesis mismatch (PPM). Methods and results: Patients who underwent a TAVR for aortic stenosis were retrospectively included. Regression adjustment for the propensity score was used to compare 50 XT-THV patients with 71 S3-THV. At the 1-month follow-up, the mean indexed effective orifice area (iEOA) was 1.12 ± 0.34 cm2/m2 with XT-THV and 0.96 ± 0.27 cm2/m2 with S3-THV. The mean gradient was 11 ± 5 mmHg and 13 ± 5 mmHg, respectively. Nine patients had moderate PPM, and two exhibited severe PPM with XT-THV. Nineteen patients had moderate PPM, and seven demonstrated severe PPM with S3-THV. There was a five-fold increased risk of PPM with S3-THV (OR = 4.98; [1.38-20.94], P = 0.019). S3-THV decreased the iEOA by 0.21 cm2/m2 [-0.21; (-0.38 to - 0.05); P = 0.012] and increased the mean gradient by 4.95 mmHg [4.95; (2.27-7.64); P < 0.001]. The risk of PPM was increased 15.24-fold with 23 mm S3-THV [15.24; (2.92-101.52); P = 0.002] in comparison with the 23 mm XT-THV. PVR were reduced by 98% with S3-THV. Conclusion: There is an increased risk of PPM with 23mm S3-THV in comparison with 23 mm XT-THV. This may be attributable to the additional sub-annular cuff that avoids the risk of PVR. Regarding the increased vulnerability of younger patients to PPM, we provide essential information on the extension of TAVR indication to the younger population.

Clinical outcome after biliary drainage for metastatic colorectal cancer: Survival analysis and prognostic factors.

INTRODUCTION: Biliary obstruction secondary to colorectal cancer liver metastases is associated with a poor prognosis especially when chemotherapy cannot be re-started. The aim of this study was to determine the survival after biliary drainage and the associated prognostic factors. METHODS: Patients from two French centers were included retrospectively after first biliary endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography drainage for biliary obstruction secondary to liver metastases of colorectal cancer, occurring during chemotherapy. RESULTS: The final analysis included 69 patients. Overall median survival was 115 days. In univariate analysis, a previous liver surgery, technical and functional success of drainage and restarted chemotherapy were significantly associated with an improved survival. Chemotherapy was restarted after a median of 27 days. When drainage was efficient, survival improved from 33 to 262days (p<0.001). In multivariate analysis, significant protective factors for survival included previous a hepatectomy (HR 0.41) and functional success of the drainage (HR 0.29). Predictive factors for death included increased lines of chemotherapy (HR 1.68) and fever before drainage (HR 2.97). CONCLUSIONS: This is the first study concerning the benefits of biliary drainage for malignant biliary obstruction during the course of chemotherapy for colorectal cancer. A successful biliary drainage leads to improved survival and allows achievement of chemotherapy for 70% of patients.

Acquisition of a High Diversity of Bacteria during the Hajj Pilgrimage, Including Acinetobacter baumannii with blaOXA-72 and Escherichia coli with blaNDM-5 Carbapenemase Genes.

Pilgrims returning from the Hajj (pilgrimage to Mecca) can be carriers of multidrug-resistant bacteria (MDR). Pharyngeal and rectal swab samples were collected from 98 pilgrims before and after they traveled to the Hajj in 2014 to investigate the acquisition of MDR bacteria. The bacterial diversity in pharyngeal swab samples was assessed by culture with selective media. There was a significantly higher diversity of bacteria in samples collected after the return from the Hajj than in those collected before (P = 0.0008). Surprisingly, Acinetobacter baumannii strains were isolated from 16 pharyngeal swab samples (1 sample taken during the Hajj and 15 samples taken upon return) and 26 post-Hajj rectal swab samples, while none were isolated from samples taken before the Hajj. Testing of all samples by real-time PCR targeting blaOXA-51 gave positive results for only 1% of samples taken during the Hajj, 21/90 (23.3%) pharyngeal swab samples taken post-Hajj, and 35/90 (38.9%) rectal swab samples taken post-Hajj. One strain of A. baumannii isolated from the pharynx was resistant to imipenem and harbored a blaOXA-72 carbapenemase gene. Multilocus sequence typing analysis of 43 A. baumannii isolates revealed a huge diversity of 35 sequence types (STs), among which 18 were novel STs reported for the first time in this study. Moreover, we also found one Escherichia coli isolate, collected from a rectal swab sample from a pilgrim taken after the Hajj, which harbored blaNDM-5, blaCTX-M-15, blaTEM-1, and aadA2 (ST2659 and ST181). In conclusion, pilgrims are at a potential risk of acquiring and transmitting MDR Acinetobacter spp. and carbapenemase-producing Gram-negative bacteria during the Hajj season.

The inevitable Hajj cough: Surveillance data in French pilgrims, 2012-2014.

BACKGROUND: Respiratory tract infections are the most common infection affecting Hajj pilgrims, and the ''Hajj cough'' is considered by pilgrims almost de rigueur. METHODS: French pilgrims were recruited between January 2012-December 2014 and information on demographics, medical history, compliance with preventive measures and health problems during travel were collected. RESULTS: A total of 382 pilgrims were included with 39.3% aged ≥65 years and 55.1% suffering from a chronic disease, most frequently hypertension and diabetes. The prevalence of cough was 80.9% and a high proportion presented with associated sore throat (91.0%), rhinitis (78.7%) and hoarseness (63.0%). Myalgia was reported in 48.3% of cases and subjective fever in 47.3%. The incubation time of respiratory symptoms was 7.7 days (range 0-25 days) and 51.9% of pilgrims presenting with a cough during their stay were still symptomatic on return. Among pilgrims with a cough, 69.4% took antibiotics. The prevalence of cough was significantly higher among females than men, but age, chronic conditions and preventive measures had no significant effect. CONCLUSIONS: The Hajj cough is highly common, likely a result of crowded conditions at religious places. Pilgrims should be advised to carry symptomatic relief for the Hajj cough such as cough suppressant, soothing throat lozenges and paracetamol. Use of antibiotics should be discouraged.

Melioidosis as a travel-associated infection: Case report and review of the literature.

BACKGROUND: Increasing numbers of sporadic cases of melioidosis in returning travelers have been reported from non-endemic regions. METHODS: We report a new case and undertook a literature review. RESULTS: Eighty-two travelers with melioidosis infection were included. The mean age was 50.95 years, with only one case <15 years. A male predominance was noted, with 66 males (80.5%). Type of travel included tourism (51.2%), family visits (15.8%) and business (14.6%). The most common destinations were Asia (80.5%), America (9.7%) and Africa (7.3%). No cases were documented from Oceania. Underlying conditions were documented in 68 patients, showing a strong association with diabetes (37.8%). Exposure risks were documented in 32 patients, including contact with water. Pulmonary involvement was seen in 41 patients, cutaneous in 23, abdominal in 14, and urogenital in 10 cases. Blood cultures posed the diagnosis in 43 cases. Fifty-seven patients fully recovered, 12 died, and three relapsed. The mortality rate (14.6%) was close to that observed in Australia but lower than series in Southern Asia. CONCLUSION: Melioidosis should not only be considered in travelers returning from classically considered endemic areas (Australia and South-East Asia) but also from America and Africa, especially in diabetic patients or after contact with water.

Provision of antiretroviral care to displaced populations in humanitarian settings: a systematic review.

Providing antiretroviral treatment (ART) in humanitarian settings is challenging. Reports suggest that ART provision is feasible, but the evidence base is scarce. We systematically searched three databases for studies reporting ART outcomes among displaced populations in settings of conflict, natural disasters or political instability, and estimated overall mortality using random effects models. Fourteen studies were identified, six in conflict areas, five in areas of post-election violence and three in natural disaster settings. The pooled proportion for mortality was 7.6% (95% CI 5.3-10.0%) at six months and 9.0% (95% CI 5.8-12.2%) at 12 months. Loss-to-follow-up at six months was 6.3% (95% CI 4.3-8.3%) and at 12 months was 8.1% (4.9-11.2%). Adherence was comparable to stable settings. Strategies used to support ART provision included additional drug stocks and establishing peer communication networks. Good clinical outcomes can be achieved with ART in disaster setting, in particular if supported by regional collaboration, standardized drug regimens and contingency planning.

Public health responses to a dengue outbreak in a fragile state: a case study of Nepal.

Objectives. The number of countries reporting dengue cases is increasing worldwide. Nepal saw its first dengue outbreak in 2010, with 96% of cases reported in three districts. There are numerous policy challenges to providing an effective public health response system in a fragile state. This paper evaluates the dengue case notification, surveillance, laboratory facilities, intersectoral collaboration, and how government and community services responded to the outbreak. Methods. Qualitative data were collected through 20 in-depth interviews, with key stakeholders, and two focus-group discussions, with seven participants. Results. Limitations of case recognition included weak diagnostic facilities and private hospitals not incorporated into the case reporting system. Research on vectors was weak, with no virological surveillance. Limitations of outbreak response included poor coordination and an inadequate budget. There was good community mobilization and emergency response but no routine vector control. Conclusions. A weak state has limited response capabilities. Disease surveillance and response plans need to be country-specific and consider state response capacity and the level of endemicity. Two feasible solutions for Nepal are (1) go upwards to regional collaboration for disease and vector surveillance, laboratory assistance, and staff training; (2) go downwards to expand upon community mobilisation, ensuring that vector control is anticipatory to outbreaks.