Healthcare-associated infections in sub-Saharan Africa.

BACKGROUND: Healthcare-associated infections (HCAIs) are the most frequent adverse consequences of healthcare worldwide, threatening the health of both patients and healthcare workers (HCWs). The impact of HCAI is particularly felt in resource-poor countries, with an already overstretched health workforce and a high burden of community-acquired infection. AIM: To provide an overview of the current situation in sub-Saharan Africa with regards to the spectrum of HCAI, antimicrobial resistance, occupational exposure and infection prevention. METHODS: We reviewed the literature published between 1995 and 2013 and from other sources such as national and international agencies. FINDINGS: Sparse data suggest that HCAIs are widespread in sub-Saharan Africa, with surgical site being the dominant focus of infection. Nosocomial transmission of multidrug-resistant tuberculosis is a considerable concern, as is the prevalence of meticillin-resistant S. aureus and resistant Enterobacteriaceae. In HCWs, vaccination rates against vaccine-preventable occupational hazards are low, as is reporting and subsequent human immunodeficiency virus-testing after occupational exposure. HCWs have an increased risk of tuberculosis relative to the general population. Compliance with hand hygiene is highly variable within the region. Injection safety in immunization programmes has improved over the past decade, mainly due to the introduction of autodestruct syringes. CONCLUSIONS: Despite the scarcity of data, the burden of HCAI in sub-Saharan Africa appears to be high. There is evidence of some improvement in infection prevention and control, though widespread surveillance data are lacking. Overall, measures of infection prevention and occupational safety are scarce.

[Public health measures at the airport of Hamburg during the early phase of pandemic influenza (H1N1) 2009]. / Infektionsschutz am Flughafen Hamburg während der Anfangsphase der Influenzapandemie (H1N1) 2009.

BACKGROUND AND METHODS: After the World Health Organization issued a global alert for the occurrence of a novel pandemic influenza (H1N1) in 2009, most international airports in Germany implemented intensified public health measures to delay local transmission. At Hamburg airport it was decided not to implement a general entry and exit screening of all travelers during the pandemic influenza (H1N1) 2009. Travelers were advised on symptoms and protective measures by public information displayed in the airport. A mobile Airport Medical Assessment Center (AMAC) for up to 260 persons was used which barred 6 gates from traffic for this reason. Travelers were medically examined by the public health authority after notification from the flight captain according to Article 28 (4) of the International Health Regulations or were referred to the medical assessment by other service providers such as the information desk in the airport. From May to August 2009 n=108 affected travelers were medically examined and advised by the public health authority at the airport. 9 out of 108 affected travelers (8.3%) who presented to the public health service at the airport were diagnosed with pandemic influenza (H1N1) 2009. Overall, only 0.002% of all travelers through the airport in the given time-frame were seen by the service. Most of the affected travelers presented themselves to the public health service before embarkation or after disembarkation. On 6 occasions the pilots declared a person with illness on board to the public health authority. Out of the 6 persons 4 were diagnosed with pandemic influenza (H1N1) 2009. In the case of notification, the delay in traveling for contact persons ranged from 30 min to 2 h. None of the sick travelers was referred to a hospital, all returned home. In addition to the medical assessment of affected travelers the public health authority issued "free-pratique" according to Article 28 (3) of the International Health Regulations, after talking to the cabin crew or flight captain. Out of 167 (0.3% of all flights to Hamburg) inspected airplanes only in one case was a notification not issued by the pilot despite a known case of sickness on the plane. CONCLUSIONS: To avoid unnecessary interference with travel, the public health service at airports must be able to react in a timely manner to notifications of disease. During the influenza pandemic (H1N1) 2009, 4 out 9 (36%) of the cases that were diagnosed with pandemic influenza (H1N1) 2009 were notified to the public health authority via the aircraft. It is the authors' experience during the pandemic influenza (H1N1) 2009 that the notification requirement of the pilot is of importance because it enables the public health service to react before disembarkation. However, more often affected persons sought advice from the public health service before or after the flight. A prerequisite for this is that the public health service is known to the relevant bodies at the airport and accessible to the public. Routine health inspections of airplanes with visual inspection of travelers result in high manpower requirements. In the authors' view these routine inspections of airplanes are only justified if there is a suspicion of disease on board, or to train the staff of public health authorities. It can be concluded from the experiences during the pandemic influenza (H1N1) 2009 that the core capacities required for designated airports according to Annex 1 B of the International Health Regulations must include trained medical professionals, communication and transportation infrastructure amongst appropriate facilities. One must distinguish between medical facilities for some affected travelers in the public areas of the airport, and a medical assessment area in the security area of the airport that is appropriate for the number of persons that may be carried by the largest vessel to that destination.

Assessment of three conventional automated external defibrillators in seafaring telemedicine.

BACKGROUND: Germany was the first country worldwide to issue a directive regulating the provision of automated external defibrillators (AEDs) on board merchant ships. AIMS: To test the applicability and suitability for telemedicine in seafaring, including long-term electrocardiogram (ECG) monitoring, of three currently available AEDs. METHODS: Sixty nautical officers were asked to record and transmit a one-lead ECG with one of three AEDs under test. Subsequently, they evaluated the user-friendliness of the devices. RESULTS: The number of steps required for ECG transmission (as a pdf file) varied from three to six between the various AEDs. Correspondingly, differences were found in the subjects' understanding of the AED software. After theoretical instruction in the use of the AEDs, 55 officers (92%) succeeded in telemedical transmission of the pdf file without any help. At the time of our investigation, long-term ECG monitoring was possible with only one of the AEDs. CONCLUSIONS: The study results suggest that most trained lay rescuers can use conventional AEDs effectively for ECG transmission.

[H1N1 pandemic. Measures and experiences on the state level]. / H1N1-Pandemie. Maßnahmen und Erfahrungen auf Landesebene.

In order to establish a joint pandemic strategy, the German states ("Länder") together with the German federal government ("Bund") agreed on joint preparations for pandemic scenarios. This included the description of procedures, such as infection control measures, stockpiling of antiviral drugs, and contracts with vaccine manufacturers to ensure supply of vaccines in the event of a pandemic. The situation during the influenza H1N1 pandemic differed from that planned so that many short-term adjustments were required. It highlighted the need to make pandemic planning more flexible. In spite of several obstacles which had to be overcome during the situation, the states managed to achieve a relatively coordinated procedure and provided the availability of vaccines. In the course of the pandemic, gaps and shortcoming in existing surveillance systems were identified, which should lead to further improvements. A key point for future pandemic events is successful communication between all interested parties, especially with the medical profession, to increase the acceptance of public policies.

The decision making process on public health measures related to passenger ships: the example of influenza pandemic 2009.

BACKGROUND: Public health measures at sea ports have posed a challenge for public health competent authorities, especially in the context of the influenza pandemic of 2009. This paper discusses the response of authorities to notifications of infectious diseases on passenger ships and the importance of assessing the risks related to cases of influenza. It further provides options for health measures and considerations for decision making during a pandemic such as the influenza pandemic of 2009. DISCUSSION: Prevention and control of influenza have included action taken by both competent port authorities and ships' crews. Assessing the public health risk of each event reported from ships to competent authorities at ports is important before advice is given on implementation of control measures. Public health risk assessment involves appraisal of threats to passengers and crew on board the ship as well as to the population in the community. SUMMARY: Any public health measures taken should be necessary and proportional to the threat. Measures at ports cannot alone be effective in the prevention of the spread of a disease to the community since other means of transport play a major role. Measures taken on board ships can be effective in containing the disease. Consistent policy based on common protocols and carried out by competent authorities at local, national, European, or international levels are essential.

Preparedness for the prevention and control of influenza outbreaks on passenger ships in the EU: the SHIPSAN TRAINET project communication.

Passenger ships carry a large number of people in confined spaces. A case of the new influenza A (H1N1) virus aboard a passenger ship is an expected event and would lead to rapid spread of the virus, if preventive measures are not in place. However, many cruise lines have detailed policies and procedures to deal with cases of influenza like illness (ILI). The EU SHIPSAN and SHIPSAN TRAINET projects include in their objectives guidelines for the prevention and control of communicable diseases aboard passenger ships. A literature review showed that from 1997 to 2005, nine confirmed outbreaks of influenza were linked to passenger ships, with attack rates up to 37%. It is important to establish and maintain a surveillance system for ILI aboard passenger ships, in order to systematically collect data that can help to determine the baseline illness levels. Monitoring these will enable early identification of outbreaks and allow timely implementation of control measures.

Reduced pulmonary function in patients with spinal osteoporotic fractures.

Vertebral deformation in spinal osteoporosis results in spinal and thoracic deformation, causing pain, disability and an overall decrease in quality of life. We sought to determine whether thoracic spinal deformation may lead to impaired pulmonary function. We studied expiratory relaxed vital capacity (VC) and forced expiratory volume in 1 s (FEV1) in 34 patients with spinal osteoporotic fractures and 51 patients with chronic low back pain (CLBP) due to reasons other than osteoporosis. Measurements of pulmonary function tests were calculated as a percentage of the normal range adjusting for age, sex, and height using the equations for normal values of the EKGS (Europäische Gesellschaft für Kohle und Stahl). Severity of osteoporosis was determined by calculation of the spine deformity index (SDI-total and SDI-anterior) on lateral radiographs of the spine and clinical measures of body stature (height reduction, distance from lowest ribs to iliac crest and distance from the occiput to the wall). Patients with osteoporosis had a lower vital capacity (%VC of the reference value) than patients with CLBP. The differences were more prominent (p < 0.05) when the previous body height, at age 25 years, was used as reference for calculation of VC (mean +/- SD: 93.6% +/- 15.3% in patients with osteoporosis v 105.6% +/- 15.1% in patients with CLBP). FEV1 was significantly (p < 0.05) lower in patients with osteoporosis when previous body height was considered, in comparison with patients with CLBP (mean +/- SD: 85.0% +/- 14.2% in patients with osteoporosis v 92.4% +/- 13.6% in patients with CLBP). In patients with osteoporosis VC (standardized on previous body height) was significantly negatively correlated with SDI-anterior (r = -0.4, p < 0.03). Furthermore, VC standardized on previous body height showed a weak but significant negative correlation with some clinical measures of osteoporosis (height reduction vs %VC: r = -0.34, p < 0.05; distance from the lowest ribs to iliac crest vs %VC: r = 0.35, p < 0.04). In conclusion, we found that pulmonary function is significantly diminished in patients with spinal osteoporotic fractures as compared with CLBP patients without evidence of manifest osteoporosis. Reduction of pulmonary function is correlated significantly with clinical and radiological measures of severity of spinal deformation due to osteoporotic fractures.

[European Study of Vertebral Osteoporosis (EVOS): cooperation of participants and selection bias in Germany]. / Die europäische Studie zur vertebralen Osteoporose (EVOS): Teilnahmebereitschaft und Selektionsverzerrung in Deutschland.

BACKGROUND: In population-based studies non-participation rates of about one third of the sample can be expected. The number of refusals may even be higher, if personal attendance of the subjects is requested. A different participation behaviour of the diseased and non-diseased may affect the prevalence estimation of a disease as well as the risk factor association. METHODS AND RESULTS: The European Vertebral Osteoporosis Study (EVOS) is an international, multicenter, cross-sectional survey in men and women aged 50 to 79 years. Within Europe 36 centres recruited 17,342 participants. The 8 German centres contribute about one forth of the data. In Germany subjects were recruited in several steps: random sample drawing from population registries, initial postal questionnaire, medical interview, lateral X-rays of the thoracic and lumbar spine. Depending on the extent of participation a variable amount of sociodemographic data and information on subjective health is available from the non-reachable, non-responders, and responders with incomplete and with complete examination. A comparison of the different participation groups showed, that especially old women were lost from the study. Compared to those, who only answered to an initial questionnaire, subjects, who were interviewed and X-rayed, more often suffered from back pain but reported a better functional capacity. This could be a hint on a selection of a population of the "worried well". CONCLUSION: On the whole the selection processes seem to have a minor influence on the outcome. The initial postal questionnaire turned out to be effective in collecting basic information from those who refused to attend a personal examination.

Clinical grading of spinal osteoporosis: quality of life components and spinal deformity in women with chronic low back pain and women with vertebral osteoporosis.

Clinical consequences of osteoporotic vertebral fractures, such as back pain, functional limitations, and impairment of mood, are often cited as justification for prevention and therapy. But these symptoms are poorly characterized, and a clinical grading system is not available. The aim of this study was to compare clinical measures for spinal deformation and quality of life components between patients with osteoporosis and patients with chronic low back pain (CLBP) and to determine the relationship between spinal deformation and quality of life components. A total of 130 female patients (63 osteoporotic patients, 65 +/- 7.9 years, and 77 CLBP patients, 56 +/- 6.5 years) had a standardized interview on quality of life components (pain, activities of daily life, mood) and clinical measures of spinal deformation (height reduction [HR], distance from occiput to wall [DOW], and distance from iliac crest to ribs [DIR]). Spinal X-rays were reviewed in all patients for the evidence of vertebral fractures. In osteoporotic patients, vertebral deformity was quantified by the spine deformity index (SDI) on X-rays. It was assessed whether subgroups could be identified by a combination of indices for spinal deformation (SDI, HR, DOW) using a cluster analysis. Back pain was a major complaint in both groups, without differences in pain intensity and frequency. Impairment of general well being and mood was found in about one-third of the patients in both groups. Independent of age, the disability score was significantly higher in patients with osteoporosis than in patients with CLBP. Both groups differed with respect to clinical measures of spinal deformity (HR, DOW, DIR). Among osteoporotic patients, parameters of quality of life were not linearly related to the degree of radiologically assessed vertebral deformity, but osteoporotic patients with two or more vertebral fractures tended to have more functional limitations than those with only one fracture. There was, however, a significant linear relationship between components of quality of life (disability score, pain) and clinical measures of spinal deformation (HR, DOW, DIR). The osteoporotic patients were subdivided into three clusters. The first group was characterized by low spinal deformation (decreases SDI, decreases HR, decreases DOW) and little impairment of quality of life. The second group had significantly greater spinal deformation (increases SDI, increases HR, increases DOW) and significantly more pain and functional limitations. The third group was characterized by increased kyphosis, mainly caused by nonskeletal dysfunction (decreases SDI, decreases HR, increases DOW), but pain and functional limitations were impaired to the same degree as in the second group with severe skeletal spinal deformation. We conclude that with respect to quality of life components, functional limitation is the most specific to spinal osteoporosis and is related to clinical measures of spinal deformation. Furthermore, spinal deformation and the clinical course of osteoporosis appears to be insufficiently reflected by radiological indices of vertebral deformity (such as SDI) alone. For grading the disease and for therapeutical concepts, radiological measures and clinical evaluation should be considered in combination.