A comparison of COVID-19 incidence rates across six European countries in 2021.

International comparisons of COVID-19 incidence rates have helped gain insights into the characteristics of the disease, benchmark disease impact, shape public health measures and inform potential travel restrictions and border control measures. However, these comparisons may be biased by differences in COVID-19 surveillance systems and approaches to reporting in each country. To better understand these differences and their impact on incidence comparisons, we collected data on surveillance systems from six European countries: Belgium, England, France, Italy, Romania and Sweden. Data collected included: target testing populations, access to testing, case definitions, data entry and management and statistical approaches to incidence calculation. Average testing, incidence and contextual data were also collected. Data represented the surveillance systems as they were in mid-May 2021. Overall, important differences between surveillance systems were detected. Results showed wide variations in testing rates, access to free testing and the types of tests recorded in national databases, which may substantially limit incidence comparability. By systematically including testing information when comparing incidence rates, these comparisons may be greatly improved. New indicators incorporating testing or existing indicators such as death or hospitalisation will be important to improving international comparisons.

Why are there so many hospital beds in Germany?

The place of hospitals in health systems is undergoing rapid change worldwide due to the high cost of hospital care and the changing health needs of the population. The Covid-19 pandemic has recently drawn public attention towards hospital capacity and has added new urgency to discussions on the future role of hospitals. In this context, recent experience in Germany provides valuable information for health systems seeking to manage hospital capacity. Despite reform efforts to reduce hospital capacity, Germany has the highest rates of intensive care beds among high-income countries and the highest overall hospital capacity in Europe. The capacity of the German hospital system can be explained in large part by the high number of elderly in-patients. This, in turn, is driven by (1) a fragmented ambulatory care system; (2) physicians admitting and maintaining elderly patients in hospital at a high rate; (3) a hospital market adding incentives to admit patients; and (4) a political commitment to egalitarian access and universal care. Additionally, recent policies to reduce hospital capacity have had limited impact because hospitals have not responded to financial incentives in the expected manner. Countries looking to learn from Germany's hospital capacity must therefore consider systemic features, political commitments, and unintended policy consequences.

Excess risk of subsequent infection in hospitalized children from a community cohort study in Cambodia and Madagascar.

BACKGROUND: Children in low- and middle-income countries are particularly vulnerable in the months following an initial health event (IHE), with increased risk of mortality caused mostly by infectious diseases. Due to exposure to a wide range of environmental stressors, hospitalization in itself might increase child vulnerability at discharge. The goal of this study was to disentangle the role of hospitalization on the risk of subsequent infection. METHODS: Data from a prospective, longitudinal, international, multicenter mother-and-child cohort were analysed. The main outcome assessed was the risk of subsequent infection within 3 months of initial care at hospital or primary healthcare facilities. First, risk factors for being hospitalized for the IHE (Step 1) and for having a subsequent infection (Step 2) were identified. Then, inpatients were matched with outpatients using propensity scores, considering the risk factors identified in Step 1. Finally, adjusted on the risk factors identified in Step 2, Cox regression models were performed on the matched data set to estimate the effect of hospitalization at the IHE on the risk of subsequent infection. RESULTS: Among the 1312 children presenting an IHE, 210 (16%) had a subsequent infection, mainly lower-respiratory infections. Although hospitalization did not increase the risk of subsequent diarrhoea or unspecified sepsis, inpatients were 1.7 (95% Confidence Intervals [1.0-2.8]) times more likely to develop a subsequent lower-respiratory infection than comparable outpatients. CONCLUSION: For the first time, our findings suggest that hospitalization might increase the risk of subsequent lower-respiratory infection adjusted on severity and symptoms at IHE. This highlights the need for robust longitudinal follow-up of at-risk children and the importance of investigating underlying mechanisms driving vulnerability to infection.

Severe bacterial neonatal infections in Madagascar, Senegal, and Cambodia: A multicentric community-based cohort study.

BACKGROUND: Severe bacterial infections (SBIs) are a leading cause of neonatal deaths in low- and middle-income countries (LMICs). However, most data came from hospitals, which do not include neonates who did not seek care or were treated outside the hospital. Studies from the community are scarce, and few among those available were conducted with high-quality microbiological techniques. The burden of SBI at the community level is therefore largely unknown. We aimed here to describe the incidence, etiology, risk factors, and antibiotic resistance profiles of community-acquired neonatal SBI in 3 LMICs. METHODS AND FINDINGS: The BIRDY study is a prospective multicentric community-based mother and child cohort study and was conducted in both urban and rural areas in Madagascar (2012 to 2018), Cambodia (2014 to 2018), and Senegal (2014 to 2018). All pregnant women within a geographically defined population were identified and enrolled. Their neonates were actively followed from birth to 28 days to document all episodes of SBI. A total of 3,858 pregnant women (2,273 (58.9%) in Madagascar, 814 (21.1%) in Cambodia, and 771 (20.0%) in Senegal) were enrolled in the study, and, of these, 31.2% were primigravidae. Women enrolled in the urban sites represented 39.6% (900/2,273), 45.5% (370/814), and 61.9% (477/771), and those enrolled in the rural sites represented 60.4% (1,373/2,273), 54.5% (444/814), and 38.1% (294/771) of the total in Madagascar, Cambodia, and Senegal, respectively. Among the 3,688 recruited newborns, 49.6% were male and 8.7% were low birth weight (LBW). The incidence of possible severe bacterial infection (pSBI; clinical diagnosis based on WHO guidelines of the Integrated Management of Childhood Illness) was 196.3 [95% confidence interval (CI) 176.5 to 218.2], 110.1 [88.3 to 137.3], and 78.3 [59.5 to 103] per 1,000 live births in Madagascar, Cambodia, and Senegal, respectively. The incidence of pSBI differed between urban and rural sites in all study countries. In Madagascar, we estimated an incidence of 161.0 pSBI per 1,000 live births [133.5 to 194] in the urban site and 219.0 [192.6 to 249.1] pSBI per 1,000 live births in the rural site (p = 0.008). In Cambodia, estimated incidences were 141.1 [105.4 to 189.0] and 85.3 [61.0 to 119.4] pSBI per 1,000 live births in urban and rural sites, respectively (p = 0.025), while in Senegal, we estimated 103.6 [76.0 to 141.2] pSBI and 41.5 [23.0 to 75.0] pSBI per 1,000 live births in urban and rural sites, respectively (p = 0.006). The incidences of culture-confirmed SBI were 15.2 [10.6 to 21.8], 6.5 [2.7 to 15.6], and 10.2 [4.8 to 21.3] per 1,000 live births in Madagascar, Cambodia, and Senegal, respectively, with no difference between urban and rural sites in each country. The great majority of early-onset infections occurred during the first 3 days of life (72.7%). The 3 main pathogens isolated were Klebsiella spp. (11/45, 24.4%), Escherichia coli (10/45, 22.2%), and Staphylococcus spp. (11/45, 24.4%). Among the 13 gram-positive isolates, 5 were resistant to gentamicin, and, among the 29 gram-negative isolates, 13 were resistant to gentamicin, with only 1 E. coli out of 10 sensitive to ampicillin. Almost one-third of the isolates were resistant to both first-line drugs recommended for the management of neonatal sepsis (ampicillin and gentamicin). Overall, 38 deaths occurred among neonates with SBI (possible and culture-confirmed SBI together). LBW and foul-smelling amniotic fluid at delivery were common risk factors for early pSBI in all 3 countries. A main limitation of the study was the lack of samples from a significant proportion of infants with pBSI including 35 neonatal deaths. Without these samples, bacterial infection and resistance profiles could not be confirmed. CONCLUSIONS: In this study, we observed a high incidence of neonatal SBI, particularly in the first 3 days of life, in the community of 3 LMICs. The current treatment for the management of neonatal infection is hindered by antimicrobial resistance. Our findings suggest that microbiological diagnosis of SBI remains a challenge in these settings and support more research on causes of neonatal death and the implementation of early interventions (e.g., follow-up of at-risk newborns during the first days of life) to decrease the burden of neonatal SBI and associated mortality and help achieve Sustainable Development Goal 3.

International comparison of pressure ulcer measures in long-term care facilities: Assessing the methodological robustness of 4 approaches to point prevalence measurement.

INTRODUCTION: Pressure ulcer indicators are among the most frequently used performance measures in long-term care settings. However, measurement systems vary and there is limited knowledge about the international comparability of different measurement systems. The aim of this analysis was to identify possible avenues for international comparisons of data on pressure ulcer prevalence among residents of long-term care facilities. MATERIAL AND METHODS: A descriptive analysis of the four point prevalence measurement systems programs used in 28 countries on three continents was performed. The criteria for the description and analysis were based on the scientific literature on criteria for indicator selection, on issues in international comparisons of data and on specific challenges of pressure ulcer measurements. RESULTS: The four measurement systems use a prevalence measure based on very similar numerator and denominator definitions. All four measurement systems also collect data on patient mobility. They differ in the pressure ulcer classifications used and the requirements for a head-to-toe resident examination. The regional or country representativeness of long-term care facilities also varies among the four measurement systems. CONCLUSIONS: Methodological differences among the point prevalence measurement systems are an important barrier to reliable comparisons of pressure ulcer prevalence data. The alignment of the methodologies may be improved by implementing changes to the study protocols, such as aligning the classification of pressure ulcers and requirements for a head-to-toe resident skin assessment. The effort required for each change varies. All these elements need to be considered by any initiative to facilitate international comparison and learning.

Resistance proportions for eight priority antibiotic-bacterium combinations in OECD, EU/EEA and G20 countries 2000 to 2030: a modelling study.

BackgroundAntimicrobial resistance is widely considered an urgent global health issue due to associated mortality and disability, societal and healthcare costs.AimTo estimate the past, current and projected future proportion of infections resistant to treatment for eight priority antibiotic-bacterium combinations from 2000 to 2030 for 52 countries.MethodsWe collated data from a variety of sources including ResistanceMap and World Bank. Feature selection algorithms and multiple imputation were used to produce a complete historical dataset. Forecasts were derived from an ensemble of three models: exponential smoothing, linear regression and random forest. The latter two were informed by projections of antibiotic consumption, out-of-pocket medical spending, populations aged 64 years and older and under 15 years and real gross domestic product. We incorporated three types of uncertainty, producing 150 estimates for each country-antibiotic-bacterium-year.ResultsAverage resistance proportions across antibiotic-bacterium combinations could grow moderately from 17% to 18% within the Organisation for Economic Co-operation and Development (OECD; growth in 64% of uncertainty sets), from 18% to 19% in the European Union/European Economic Area (EU/EEA; growth in 87% of uncertainty sets) and from 29% to 31% in Group of Twenty (G20) countries (growth in 62% of uncertainty sets) between 2015 and 2030. There is broad heterogeneity in levels and rates of change across countries and antibiotic-bacterium combinations from 2000 to 2030.ConclusionIf current trends continue, resistance proportions are projected to marginally increase in the coming years. The estimates indicate there is significant heterogeneity in resistance proportions across countries and antibiotic-bacterium combinations.

Does size matter? The impact of caseload and expertise concentration on AMI 30-day mortality-A comparison across 10 OECD countries.

OBJECTIVE: To examine the variability of hospital performance within and across countries, using 30-day acute myocardial infarction (AMI) mortality, and to study the impact of hospital characteristics on performance. STUDY SETTING: Hospital-level adjusted risk standardized mortality rates (RSMR) and hospital characteristics were collected from 10 OECD and two collaborating countries including 1,163 hospitals. STUDY DESIGN: Associations between RSMR and hospital characteristics were studied using univariate and multivariate linear regressions. Clusters of hospitals were created using hierarchical clustering and mortality compared using linear regression. FINDINGS: Wide variation between countries was found for RSMR and hospital characteristics. Regression models showed large country effects. A high volume of AMI admission was associated with lower RSMR in a model using a restricted number of hospital characteristics (-0.83, p < 0.001) but not in a model using all characteristics (-1.03, p = 0.06). Analysis within countries supported this association. Hospital clusters showed clear differences in characteristic distributions but no difference in RSMR. CONCLUSIONS: The effect of volume may support policies toward a concentration of services within the hospital sector. The effect of other hospital characteristics was inconclusive and suggests the importance of system-wide characteristics or pathways of care (i.e. timeliness and nature of initial response and during transportation to a hospital, transfers between hospitals, post-discharge organization) in explaining variation.

Bacterial Infections in Neonates, Madagascar, 2012-2014.

Severe bacterial infections are a leading cause of death among neonates in low-income countries, which harbor several factors leading to emergence and spread of multidrug-resistant bacteria. Low-income countries should prioritize interventions to decrease neonatal infections; however, data are scarce, specifically from the community. To assess incidence, etiologies, and antimicrobial drug-resistance patterns of neonatal infections, during 2012-2014, we conducted a community-based prospective investigation of 981 newborns in rural and urban areas of Madagascar. The incidence of culture-confirmed severe neonatal infections was high: 17.7 cases/1,000 live births. Most (75%) occurred during the first week of life. The most common (81%) bacteria isolated were gram-negative. The incidence rate for multidrug-resistant neonatal infection was 7.7 cases/1,000 live births. In Madagascar, interventions to improve prevention, early diagnosis, and management of bacterial infections in neonates should be prioritized.

Acquisition of extended spectrum beta-lactamase-producing enterobacteriaceae in neonates: A community based cohort in Madagascar.

In low and middle income countries (LMICs), where the burden of neonatal sepsis is the highest, the spread of extended spectrum beta-lactamase-producing enterobacteriaceae (ESBL-PE) in the community, potentially contributing to the neonatal mortality, is a public health concern. Data regarding the acquisition of ESBL-PE during the neonatal period are scarce. The routes of transmission are not well defined and particularly the possible key role played by pregnant women. This study aimed to understand the neonatal acquisition of ESBL-PE in the community in Madagascar. The study was conducted in urban and semi-rural areas. Newborns were included at birth and followed-up during their first month of life. Maternal stool samples at delivery and six stool samples in each infant were collected to screen for ESBL-PE. A Cox proportional hazards model was performed to identify factors associated with the first ESBL-PE acquisition. The incidence rate of ESBL-PE acquisition was 10.4 cases/1000 newborn-days [95% CI: 8.0-13.4 cases per 1000 newborn-days]. Of the 83 ESBL-PE isolates identified, Escherichia coli was the most frequent species (n = 28, 34.1%), followed by Klebsiella pneumoniae (n = 20, 24.4%). Cox multivariate analysis showed that independent risk factors for ESBL-PE acquisition were low birth weight (adjusted Hazard-ratio (aHR) = 2.7, 95% CI [1.2; 5.9]), cesarean-section, (aHR = 3.4, 95% CI [1.7; 7.1]) and maternal use of antibiotics at delivery (aHR = 2.2, 95% CI [1.1; 4.5]). Our results confirm that mothers play a significant role in the neonatal acquisition of ESBL-PE. In LMICs, public health interventions during pregnancy should be reinforced to avoid unnecessary caesarean section, unnecessary antibiotic use at delivery and low birth weight newborns.

A community survey of antibiotic consumption among children in Madagascar and Senegal: the importance of healthcare access and care quality.

BACKGROUND: Antibiotic resistance is growing in low-income countries (LICs). Children in LICs are particularly at risk. Information on antibiotic consumption is needed to control the development and spread of resistant bacteria. METHODS: To measure antibiotic consumption and related factors, a community survey was undertaken in two sites in Madagascar (Antananarivo and Moramanga) and in Senegal (Guediawaye) among children under 2. Face-to-face interviews were conducted with parents or caregivers of eligible children. Regression analysis was used to determine variables associated with reported antibiotic consumption. Availability of health structures and health policies were also investigated. RESULTS: Population estimates for antibiotic consumption in the last 3 months were 37.2% (95% CI 33.4%-41.2%) in Guediawaye, 29.3% (95% CI 25.0%-34.1%) in Antananarivo and 24.6% (95% CI 20.6%-29.1%) in Moramanga. In all sites, the large majority of antibiotics were taken with a prescription (92.2%, 87.0% and 92.0% for Antananarivo, Moramanga and Guediawaye, respectively) and purchased in pharmacies (89.4%, 73.5% and 78.5%, respectively). Living in houses without flushing toilets and baby age were significantly associated with any antibiotic consumption after adjusting for site. A higher density of public health structures was associated with lower antibiotic consumption levels, while a higher density of private pharmacies was associated with higher levels across sites. CONCLUSIONS: These data are crucial for the implementation of local programmes aimed at optimizing antibiotic consumption. Factors such as density of healthcare facilities, prescriber training and national policy must be taken into account when developing strategies to optimize antibiotic consumption in LICs.

Measuring antibiotic consumption in low-income countries: a systematic review and integrative approach.

Antibiotic resistance is a global issue. Risk factors specific to low-income countries (LICs), including non-prescribed antibiotic use, place them at risk for the emergence of resistance and make them important targets for reducing the burden of resistance worldwide. Responding to this threat in LICs means first having access to appropriate antibiotic consumption data. A PubMed search was conducted for studies examining antibiotic consumption in the community in LICs. For the articles included in the analysis, the methodologies used, type of data gathered and methodological appropriateness in responding to specific LIC data needs were noted. Of the 487 articles identified by the search strategy, 27 were retained for final analysis. Four main investigative methods were identified, including pharmacy/hospital document reviews, the simulated client method, observed prescribing encounters/patient exit interviews and community surveys. Observed encounters and exit interviews are well adapted to answering a number of important questions surrounding antibiotic consumption but may include bias and miss some sources of non-prescribed antibiotics. Community surveys are the only approach able to fully account for non-prescribed antibiotics and should be used as the first step in an integrative approach towards antibiotic consumption measurement and monitoring in LICs. Antibiotic consumption data needed for programmes to control use must take into account the LIC context. An integrated and adaptive approach beginning with community surveys responds to the various data needs and difficulties of LIC contexts and may help facilitate the investigation and optimisation of antibiotic consumption in these settings.

Colonization of extended-spectrum-ß-lactamase- and NDM-1-producing Enterobacteriaceae among pregnant women in the community in a low-income country: a potential reservoir for transmission of multiresistant Enterobacteriaceae to neonates.

The spread of extended-spectrum-ß-lactamase-producing Enterobacteriaceae (ESBL-PE) in low-income countries, where the burden of neonatal sepsis is high, may have a serious impact on neonatal mortality rates. Given the potential for mother-to-child transmission of multiresistant bacteria, this study investigated the ESBL-PE rectal colonization among pregnant women at delivery in the community in Madagascar and estimated a prevalence of 18.5% (95% confidence interval, 14.5% to 22.6%). One strain of Klebsiella pneumoniae isolated was also a New Delhi metallo-ß-lactamase-1 (NDM-1) producer.

Burden of bacterial resistance among neonatal infections in low income countries: how convincing is the epidemiological evidence?

BACKGROUND: Antibiotic resistance is a threat in developing countries (DCs) because of the high burden of bacterial disease and the presence of risk factors for its emergence and spread. This threat is of particular concern for neonates in DCs where over one-third of neonatal deaths may be attributable to severe infections and factors such as malnutrition and HIV infection may increase the risk of death. Additional, undocumented deaths due to severe infection may also occur due to the high frequency of at-home births in DCs. METHODS: We conducted a systematic review of studies published after 2000 on community-acquired invasive bacterial infections and antibiotic resistance among neonates in DCs. Twenty-one articles met all inclusion criteria and were included in the final analysis. RESULTS: Ninety percent of studies recruited participants at large or university hospitals. The majority of studies were conducted in Sub-Saharan Africa (n=10) and the Indian subcontinent (n=8). Neonatal infection incidence ranged from 2.9 (95% CI 1.9-4.2) to 24 (95% CI 21.8-25.7) for 1000 live births. The three most common bacterial isolates in neonatal sepsis were Staphylococcus aureus, Escherichia coli, and Klebsiella. Information on antibiotic resistance was sparse and often relied on few isolates. The majority of resistance studies were conducted prior to 2008. No conclusions could be drawn on Enterobacteriaceae resistance to third generation cephalosporins or methicillin resistance among Staphylococcus aureus. CONCLUSIONS: Available data were found insufficient to draw a true, recent, and accurate picture of antibiotic resistance in DCs among severe bacterial infection in neonates, particularly at the community level. Existing neonatal sepsis treatment guidelines may no longer be appropriate, and these data are needed as the basis for updated guidelines. Reliable microbiological and epidemiological data at the community level are needed in DCs to combat the global challenge of antibiotic resistance especially among neonates among whom the burden is greatest.