Diagnostic stewardship in infectious diseases: a scoping review.

Introduction. The term 'diagnostic stewardship' is relatively new, with a recent surge in its use within the literature. Despite its increasing popularity, a precise definition remains elusive. Various attempts have been made to define it, with some viewing it as an integral part of antimicrobial stewardship. The World Health Organization offers a broad definition, emphasizing the importance of timely, accurate diagnostics. However, inconsistencies in the use of this term still persist, necessitating further clarification.Gap Statement. There are currently inconsistencies in the definition of diagnostic stewardship used within the academic literature.Aim. This scoping review aims to categorize the use of diagnostic stewardship approaches and define this approach by identifying common characteristics and factors of its use within the literature.Methodology. This scoping review undertook a multi-database search from date of inception until October 2022. Any observational or experimental study where the authors define the intervention to be diagnostic stewardship from any clinical area was included. Screening of all papers was undertaken by a single reviewer with 10% verification by a second reviewer. Data extraction was undertaken by a single reviewer using a pre-piloted form. Given the wide variation in study design and intervention outcomes, a narrative synthesis approach was applied. Studies were clustered around common diagnostic stewardship interventions where appropriate.Results. After duplicate removal, a total of 1310 citations were identified, of which, after full-paper screening, 105 studies were included in this scoping review. The classification of an intervention as taking a diagnostic stewardship approach is a relatively recent development, with the first publication in this field dating back to 2017. The majority of research in this area has been conducted within the USA, with very few studies undertaken outside this region. Visual inspection of the citation map reveals that the current evidence base is interconnected, with frequent references to each other's work. The interventions commonly adopt a restrictive approach, utilizing hard and soft stops within the pre-analytical phase to restrict access to testing. Upon closer examination of the outcomes, it becomes evident that there is a predominant focus on reducing the number of tests rather than enhancing the current test protocol. This is further reflected in the limited number of studies that report on test performance (including protocol improvements, specificity and sensitivity).Conclusion. Diagnostic stewardship seems to have deviated from its intended course, morphing into a rather rudimentary instrument wielded not to enhance but to constrict the scope of testing. Despite the World Health Organization's advocacy for an ideology that promotes a more comprehensive approach to quality improvement, it may be more appropriate to consider alternative regional narratives when categorizing these types of quality improvement interventions.

Temporal shifts in 24 notifiable infectious diseases in China before and during the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic, along with the implementation of public health and social measures (PHSMs), have markedly reshaped infectious disease transmission dynamics. We analysed the impact of PHSMs on 24 notifiable infectious diseases (NIDs) in the Chinese mainland, using time series models to forecast transmission trends without PHSMs or pandemic. Our findings revealed distinct seasonal patterns in NID incidence, with respiratory diseases showing the greatest response to PHSMs, while bloodborne and sexually transmitted diseases responded more moderately. 8 NIDs were identified as susceptible to PHSMs, including hand, foot, and mouth disease, dengue fever, rubella, scarlet fever, pertussis, mumps, malaria, and Japanese encephalitis. The termination of PHSMs did not cause NIDs resurgence immediately, except for pertussis, which experienced its highest peak in December 2023 since January 2008. Our findings highlight the varied impact of PHSMs on different NIDs and the importance of sustainable, long-term strategies, like vaccine development.

Social contacts patterns relevant to the transmission of infectious diseases in Suzhou, China following the COVID-19 epidemic.

BACKGROUND: The COVID-19 pandemic has profoundly affected human social contact patterns, but there is limited understanding regarding the post-pandemic social contact patterns. Our objective is to quantitatively assess social contact patterns in Suzhou post-COVID-19. METHODS: We employed a diary design and conducted social contact surveys from June to October 2023, utilizing paper questionnaires. A generalized linear model was utilized to analyze the relationship between individual contacts and covariates. We examined the proportions of contact type, location, duration, and frequency. Additionally, age-related mixed matrices were established. RESULTS: The participants reported an average of 11.51 (SD 5.96) contact numbers and a total of 19.78 (SD 20.94) contact numbers per day, respectively. The number of contacts was significantly associated with age, household size, and the type of week. Compared to the 0-9 age group, those in the 10-19 age group reported a higher number of contacts (IRR = 1.12, CI: 1.01-1.24), while participants aged 20 and older reported fewer (IRR range: 0.54-0.67). Larger households (5 or more) reported more contacts (IRR = 1.09, CI: 1.01-1.18) and fewer contacts were reported on weekends (IRR = 0.95, CI: 0.90-0.99). School had the highest proportion of contact durations exceeding 4 h (49.5%) and daily frequencies (90.4%), followed by home and workplace. The contact patterns exhibited clear age-assortative mixing, with Q indices of 0.27 and 0.28. CONCLUSIONS: We assessed the characteristics of social contact patterns in Suzhou, which are essential for parameterizing models of infectious disease transmission. The high frequency and intensity of contacts among school-aged children should be given special attention, making school intervention policies a crucial component in controlling infectious disease transmission.

Unmasking the NLRP3 inflammasome in dendritic cells as a potential therapeutic target for autoimmunity, cancer, and infectious conditions.

Proper and functional immune response requires a complex interaction between innate and adaptive immune cells, which dendritic cells (DCs) are the primary actors in this coordination as professional antigen-presenting cells. DCs are armed with numerous pattern recognition receptors (PRRs) such as nucleotide-binding and oligomerization domain-like receptors (NLRs) like NLRP3, which influence the development of their activation state upon sensation of ligands. NLRP3 is a crucial component of the immune system for protection against tumors and infectious agents, because its activation leads to the assembly of inflammasomes that cause the formation of active caspase-1 and stimulate the maturation and release of proinflammatory cytokines. But, when NLRP3 becomes overactivated, it plays a pathogenic role in the progression of several autoimmune disorders. So, NLRP3 activation is strictly regulated by diverse signaling pathways that are mentioned in detail in this review. Furthermore, the role of NLRP3 in all of the diverse immune cells' subsets is briefly mentioned in this study because NLRP3 plays a pivotal role in modulating other immune cells which are accompanied by DCs' responses and subsequently influence differentiation of T cells to diverse T helper subsets and even impact on cytotoxic CD8+ T cells' responses. This review sheds light on the functional and therapeutic role of NLRP3 in DCs and its contribution to the occurrence and progression of autoimmune disorders, prevention of diverse tumors' development, and recognition and annihilation of various infectious agents. Furthermore, we highlight NLRP3 targeting potential for improving DC-based immunotherapeutic approaches, to be used for the benefit of patients suffering from these disorders.

Nanobodies in the fight against infectious diseases: repurposing nature's tiny weapons.

Nanobodies are the smallest known antigen-binding molecules to date. Their small size, good tissue penetration, high stability and solubility, ease of expression, refolding ability, and negligible immunogenicity in the human body have granted them excellence over conventional antibodies. Those exceptional attributes of nanobodies make them promising candidates for various applications in biotechnology, medicine, protein engineering, structural biology, food, and agriculture. This review presents an overview of their structure, development methods, advantages, possible challenges, and applications with special emphasis on infectious diseases-related ones. A showcase of how nanobodies can be harnessed for applications including neutralization of viruses and combating antibiotic-resistant bacteria is detailed. Overall, the impact of nanobodies in vaccine design, rapid diagnostics, and targeted therapies, besides exploring their role in deciphering microbial structures and virulence mechanisms are highlighted. Indeed, nanobodies are reshaping the future of infectious disease prevention and treatment.

Sample-to-result molecular diagnostic platforms and their suitability for infectious disease testing in low- and middle-income countries.

INTRODUCTION: Diagnostics are an essential, undervalued part of the health-care system. For many diseases, molecular diagnostics are the gold standard, but are not easy to implement in Low- and Middle-Income Countries (LMIC). Sample-to-result (S2R) platforms combining all procedures in a closed system could offer a solution. In this paper, we investigated their suitability for implementation in LMIC. AREAS COVERED: A scorecard was used to evaluate different platforms on a range of parameters. Most platforms scored fairly on the platform itself, ease-of-use and test consumables; however, shortcomings were identified in cost, distribution and test panels tailored to LMIC needs. The diagnostic coverage for common infectious diseases was found to have a wider coverage in high-income countries (HIC) than LMIC. A literature study showed that in LMIC, these platforms are mainly used as diagnostic tools or evaluation of diagnostic performance, with a minority assessing the operational characteristics or the clinical utility. In this narrative review, we identified various points for adaptation of S2R platforms to LMIC conditions. EXPERT OPINION: For S2R platforms to be suitable for implementation in LMIC some modifications by the manufacturers could be considered. Furthermore, strengthening health systems and digitalization are vital; as are smaller, cheaper, faster, and sustainable technologies.

Regulation of immune responses to infection through interaction between stem cell-derived exosomes and toll-like receptors mediated by microRNA cargoes.

Infectious diseases are among the factors that account for a significant proportion of disease-related deaths worldwide. The primary treatment approach to combat microbial infections is the use of antibiotics. However, the widespread use of these drugs over the past two decades has led to the emergence of resistant microbial species, making the control of microbial infections a serious challenge. One of the most important solutions in the field of combating infectious diseases is the regulation of the host's defense system. Toll-like receptors (TLRs) play a crucial role in the first primary defense against pathogens by identifying harmful endogenous molecules released from dying cells and damaged tissues as well as invading microbial agents. Therefore, they play an important role in communicating and regulating innate and adaptive immunity. Of course, excessive activation of TLRs can lead to disruption of immune homeostasis and increase the risk of inflammatory reactions. Targeting TLR signaling pathways has emerged as a new therapeutic approach for infectious diseases based on host-directed therapy (HDT). In recent years, stem cell-derived exosomes have received significant attention as factors regulating the immune system. The regulation effects of exosomes on the immune system are based on the HDT strategy, which is due to their cargoes. In general, the mechanism of action of stem cell-derived exosomes in HDT is by regulating and modulating immunity, promoting tissue regeneration, and reducing host toxicity. One of their most important cargoes is microRNAs, which have been shown to play a significant role in regulating immunity through TLRs. This review investigates the therapeutic properties of stem cell-derived exosomes in combating infections through the interaction between exosomal microRNAs and Toll-like receptors.

Modelling the impact of precaution on disease dynamics and its evolution.

In this paper, we introduce the notion of practically susceptible population, which is a fraction of the biologically susceptible population. Assuming that the fraction depends on the severity of the epidemic and the public's level of precaution (as a response of the public to the epidemic), we propose a general framework model with the response level evolving with the epidemic. We firstly verify the well-posedness and confirm the disease's eventual vanishing for the framework model under the assumption that the basic reproduction number R 0 < 1 . For R 0 > 1 , we study how the behavioural response evolves with epidemics and how such an evolution impacts the disease dynamics. More specifically, when the precaution level is taken to be the instantaneous best response function in literature, we show that the endemic dynamic is convergence to the endemic equilibrium; while when the precaution level is the delayed best response, the endemic dynamic can be either convergence to the endemic equilibrium, or convergence to a positive periodic solution. Our derivation offers a justification/explanation for the best response used in some literature. By replacing "adopting the best response" with "adapting toward the best response", we also explore the adaptive long-term dynamics.

Why We Need to Change How We Talk About Infectious Disease.

This article builds a case for raising occupational consciousness by critically questioning ahistorical and apolitical uses of battle language, especially when referring to infectious diseases. Words such as invasion, colonization, and resistance are particularly ethically troubling, and this article considers why the social practices our language brings about matter in health care. Dynamic relationships among humans and microbes, as well as metaphor, are considered here in historical context and through the lens of Derrida's portmanteau hostipitality, which invites reconsideration of an infectious disease notion of host and how conceptions of hospitality have been institutionalized and commodified. This article argues that language used in infectious disease care settings should be informed by coexistence as a guiding value of clinical and ethical relevance.

A risk-induced dispersal strategy of the infected population for a disease-free state in the SIS epidemic model.

This article proposes a dispersal strategy for infected individuals in a spatial susceptible-infected-susceptible (SIS) epidemic model. The presence of spatial heterogeneity and the movement of individuals play crucial roles in determining the persistence and eradication of infectious diseases. To capture these dynamics, we introduce a moving strategy called risk-induced dispersal (RID) for infected individuals in a continuous-time patch model of the SIS epidemic. First, we establish a continuous-time n-patch model and verify that the RID strategy is an effective approach for attaining a disease-free state. This is substantiated through simulations conducted on 7-patch models and analytical results derived from 2-patch models. Second, we extend our analysis by adapting the patch model into a diffusive epidemic model. This extension allows us to explore further the impact of the RID movement strategy on disease transmission and control. We validate our results through simulations, which provide the effects of the RID dispersal strategy.

The burden of infectious diseases throughout and after the COVID-19 pandemic (2020-2023) and Russo-Ukrainian war migration.

Understanding how the infectious disease burden was affected throughout the COVID-19 pandemic is pivotal to identifying potential hot spots and guiding future mitigation measures. Therefore, our study aimed to analyze the changes in the rate of new cases of Poland's most frequent infectious diseases during the entire COVID-19 pandemic and after the influx of war refugees from Ukraine. We performed a registry-based population-wide study in Poland to analyze the changes in the rate of 24 infectious disease cases from 2020 to 2023 and compared them to the prepandemic period (2016-2019). Data were collected from publicly archived datasets of the Epimeld database published by national epidemiological authority institutions. The rate of most of the studied diseases (66.6%) revealed significantly negative correlations with the rate of SARS-CoV-2 infections. For the majority of infectious diseases, it substantially decreased in 2020 (in case of 83%) and 2021 (63%), following which it mostly rebounded to the prepandemic levels and, in some cases, exceeded them in 2023 when the exceptionally high annual rates of new cases of scarlet fever, Streptococcus pneumoniae infections, HIV infections, syphilis, gonococcal infections, and tick-borne encephalitis were noted. The rate of Clostridioides difficile enterocolitis was two-fold higher than before the pandemic from 2021 onward. The rate of Legionnaires' disease in 2023 also exceeded the prepandemic threshold, although this was due to a local outbreak unrelated to lifted COVID-19 pandemic restrictions or migration of war refugees. The influx of war migrants from Ukraine could impact the epidemiology of sexually transmitted diseases. The present analysis indicates that continued efforts are needed to prevent COVID-19 from overwhelming healthcare systems again and decreasing the control over the burden of other infectious diseases. It also identifies the potential tipping points that require additional mitigation measures, which are also discussed in the paper, to avoid escalation in the future.

Contagion dynamics in time-varying metapopulation networks with node's activity and attractiveness.

The metapopulation network model is a mathematical framework used to study the spatial spread of epidemics with individuals' mobility. In this paper, we develop a time-varying network model in which the activity of a population is correlated with its attractiveness in mobility. By studying the spreading dynamics of the SIR (susceptible-infectious-recovered)-type disease in different correlated networks based on the proposed model, we theoretically derive the mobility threshold and numerically observe that increasing the correction between activity and attractiveness results in a reduced mobility threshold but suppresses the fraction of infected subpopulations. It also introduces greater heterogeneity in the spatial distribution of infected individuals. Additionally, we investigate the impact of nonpharmaceutical interventions on the spread of epidemics in different correlation networks. Our results show that the simultaneous implementation of self-isolation and self-protection is more effective in negatively correlated networks than that in positively correlated or non-correlated networks. Both self-isolation and self-protection strategies enhance the mobility threshold and, thus, slow down the spread of the epidemic. However, the effectiveness of each strategy in reducing the fraction of infected subpopulations varies in different correlated networks. Self-protection is more effective in positively correlated networks, whereas self-isolation is more effective in negatively correlated networks. Our study will provide insights into epidemic prevention and control in large-scale time-varying metapopulation networks.

Mortality Associated with Priority Diseases in Flood-Affected Areas Using District Health Information System (DHIS2) During September-December 2022: Pakistan Experience.

OBJECTIVES: To quantify the burden of communicable diseases and characterize the most reported infections during public health emergency of floods in Pakistan. METHODS: The study's design is a descriptive trend analysis. The study utilized the disease data reported to District Health Information System (DHIS2) for the 12 most frequently reported priority diseases under the Integrated Disease Surveillance and Response (IDSR) system in Pakistan. RESULTS: In total, there were 1,532,963 suspected cases during August to December 2022 in flood-affected districts (n = 75) across Pakistan; Sindh Province reported the highest number of cases (n = 692,673) from 23 districts, followed by Khyber Pakhtunkhwa (KP) (n = 568,682) from 17 districts, Balochistan (n = 167,215) from 32 districts, and Punjab (n = 104,393) from 3 districts. High positivity was reported for malaria (79,622/201,901; 39.4%), followed by acute diarrhea (non-cholera) (23/62; 37.1%), hepatitis A and E (47/252; 18.7%), and dengue (603/3245; 18.6%). The crude mortality rate was 11.9 per 10 000 population (1824/1,532,963 [deaths/cases]). CONCLUSION: The study identified acute respiratory infection, acute diarrhea, malaria, and skin diseases as the most prevalent diseases. This suggests that preparedness efforts and interventions targeting these diseases should be prioritized in future flood response plans. The study highlights the importance of strengthening the IDSR as a Disease Early Warning System through the implementation of the DHIS2.

Medical knowledge of ChatGPT in public health, infectious diseases, COVID-19 pandemic, and vaccines: multiple choice questions examination based performance.

Background: At the beginning of the year 2023, the Chatbot Generative Pre-Trained Transformer (ChatGPT) gained remarkable attention from the public. There is a great discussion about ChatGPT and its knowledge in medical sciences, however, literature is lacking to evaluate the ChatGPT knowledge level in public health. Therefore, this study investigates the knowledge of ChatGPT in public health, infectious diseases, the COVID-19 pandemic, and its vaccines. Methods: Multiple Choice Questions (MCQs) bank was established. The question's contents were reviewed and confirmed that the questions were appropriate to the contents. The MCQs were based on the case scenario, with four sub-stems, with a single correct answer. From the MCQs bank, 60 MCQs we selected, 30 MCQs were from public health, and infectious diseases topics, 17 MCQs were from the COVID-19 pandemic, and 13 MCQs were on COVID-19 vaccines. Each MCQ was manually entered, and tasks were given to determine the knowledge level of ChatGPT on MCQs. Results: Out of a total of 60 MCQs in public health, infectious diseases, the COVID-19 pandemic, and vaccines, ChatGPT attempted all the MCQs and obtained 17/30 (56.66%) marks in public health, infectious diseases, 15/17 (88.23%) in COVID-19, and 12/13 (92.30%) marks in COVID-19 vaccines MCQs, with an overall score of 44/60 (73.33%). The observed results of the correct answers in each section were significantly higher (p = 0.001). The ChatGPT obtained satisfactory grades in all three domains of public health, infectious diseases, and COVID-19 pandemic-allied examination. Conclusion: ChatGPT has satisfactory knowledge of public health, infectious diseases, the COVID-19 pandemic, and its vaccines. In future, ChatGPT may assist medical educators, academicians, and healthcare professionals in providing a better understanding of public health, infectious diseases, the COVID-19 pandemic, and vaccines.

Scenario-based assessment of emergency management of urban infectious disease outbreaks.

Infectious diseases pose a severe threat to human health and are accompanied by significant economic losses. Studies of urban outbreaks of infectious diseases are diverse. However, previous studies have neglected the identification of critical events and the evaluation of scenario-based modeling of urban infectious disease outbreak emergency management mechanisms. In this paper, we aim to conduct an empirical analysis and scenario extrapolation using a questionnaire survey of 18 experts, based on the CIA-ISM method and scenario theory, to identify the key factors influencing urban infectious disease outbreaks. Subsequently, we evaluate the effectiveness of urban infectious disease outbreak emergency management mechanisms. Finally, we compare and verify the actual situation of COVID-19 in China, drawing the following conclusions and recommendations. (1) The scenario-based urban infectious disease emergency management model can effectively replicate the development of urban infectious diseases. (2) The establishment of an emergency command center and the isolation and observation of individuals exposed to infectious diseases are crucial factors in the emergency management of urban outbreaks of infectious disease.

Persistence and Variation of the Indirect Effects of COVID-19 Restrictions on the Spectrum of Notifiable Infectious Diseases in China: Analysis of National Surveillance Among Children and Adolescents From 2018 to 2021.

BACKGROUND: Beyond the direct effect of COVID-19 infection on young people, the wider impact of the pandemic on other infectious diseases remains unknown. OBJECTIVE: This study aims to assess changes in the incidence and mortality of 42 notifiable infectious diseases during the pandemic among children and adolescents in China, compared with prepandemic levels. METHODS: The Notifiable Infectious Disease Surveillance System of China was used to detect new cases and fatalities among individuals aged 5-22 years across 42 notifiable infectious diseases spanning from 2018 to 2021. These infectious diseases were categorized into 5 groups: respiratory, gastrointestinal and enterovirus, sexually transmitted and blood-borne, zoonotic, and vector-borne diseases. Each year (2018-2021) was segmented into 4 phases: phase 1 (January 1-22), phase 2 (January 23-April 7), phase 3 (April 8-August 31), and phase 4 (September 1-December 31) according to the varying intensities of pandemic restrictive measures in 2020. Generalized linear models were applied to assess the change in the incidence and mortality within each disease category, using 2018 and 2019 as the reference. RESULTS: A total of 4,898,260 incident cases and 3701 deaths were included. The overall incidence of notifiable infectious diseases decreased sharply during the first year of the COVID-19 pandemic (2020) compared with prepandemic levels (2018 and 2019), and then rebounded in 2021, particularly in South China. Across the past 4 years, the number of deaths steadily decreased. The incidence of diseases rebounded differentially by the pandemic phase. For instance, although seasonal influenza dominated respiratory diseases in 2019, it showed a substantial decline during the pandemic (percent change in phase 2 2020: 0.21, 95% CI 0.09-0.50), which persisted until 2021 (percent change in phase 4 2021: 1.02, 95% CI 0.74-1.41). The incidence of gastrointestinal and enterovirus diseases decreased by 33.6% during 2020 but rebounded by 56.9% in 2021, mainly driven by hand, foot, and mouth disease (percent change in phase 3 2021: 1.28, 95% CI 1.17-1.41) and infectious diarrhea (percent change in phase 3 2020: 1.22, 95% CI 1.17-1.28). Sexually transmitted and blood-borne diseases were restrained during the first year of 2021 but rebounded quickly in 2021, mainly driven by syphilis (percent change in phase 3 2020: 1.31, 95% CI 1.23-1.40) and gonorrhea (percent change in phase 3 2020: 1.10, 95% CI 1.05-1.16). Zoonotic diseases were not dampened by the pandemic but continued to increase across the study period, mainly due to brucellosis (percent change in phase 2 2020: 0.94, 95% CI 0.75-1.16). Vector-borne diseases showed a continuous decline during 2020, dominated by hemorrhagic fever (percent change in phase 2 2020: 0.68, 95% CI 0.53-0.87), but rebounded in 2021. CONCLUSIONS: The COVID-19 pandemic was associated with a marked decline in notifiable infectious diseases in Chinese children and adolescents. These effects were not sustained, with evidence of a rebound to prepandemic levels by late 2021. To effectively address the postpandemic resurgence of infectious diseases in children and adolescents, it will be essential to maintain disease surveillance and strengthen the implementation of various initiatives. These include extending immunization programs, prioritizing the management of sexually transmitted infections, continuing feasible nonpharmaceutical intervention projects, and effectively managing imported infections.