Infection control in the management of highly pathogenic infectious diseases: consensus of the European Network of Infectious Disease

Laboratory biosafety: A visual analysis in the web of science database from 2000 to 2022: A review

To conduct a visual analysis of institutional publications, individual publications and publication keywords in the field of laboratory biosafety using the Web of Science database from 2000 to 2022.VOSviewer 1.6.18 was used to study the relation between paper authors, and CiteSpace 6.1.R6 was used to visualize the collaboration between the paper institutions, the paper keywords and the timeline. The main research institutions included the Centers for Disease Control and Prevention (USA), and the University of Chinese Academy of Sciences (China). The collaboration between the research institutions was limited and dispersed. Each of the main study teams is led by Feldmann Heinz, Peter B. Jahrling, Roger Hewson, and Li Na. Infection, identification, and outbreak are the keywords that appear more often and are also of higher importance in publications. The citation burst of keywords varies over time: outbreak, resistance, and polymerase chain reaction from 2004 to 2012; gene, cells, and Ebola from 2013 to 2017; and spread, safety, coronavirus, and African swine fever from 2018 to 2022. The centralization of research teams and individuals in laboratory biosafety is not conducive to the growth of disciplinary diversity. These publication keywords are mainly align with significant social events, scientific and technological development trends, and national strategic needs. This paper advocates for a more balanced allocation of resources and collaboration opportunities to foster diversity and address emerging challenges in the field of laboratory biosafety.

Building a High-Level Isolation Unit in Rwanda and Establishing a Training Program for the Medical Management of Patients With High-Consequence Infectious Diseases

Rwanda is a country in East Africa, a region characterized by highly mobile populations and outbreaks of high-consequence infectious diseases occurring on a regular basis. To increase the level of outbreak preparedness in the region, the Rwandan government and the German Ministry of Health signed a joint agreement to construct a new high-level isolation unit in Rwanda, the first in East Africa, and implement a training program for Rwandan healthcare workers to equip them with the necessary skills and knowledge for medical management of patients under high-level isolation conditions, including intensive care treatment. To better understand the scope and format of the planned training program, a needs assessment was performed based on findings from a standardized survey of 4 intensive care units in Rwanda as well as observations from 2 members of a German high-level isolation unit who completed clinical internships at Rwandan hospitals. In this case study, we describe the necessary steps to promote the sustainability and capabilities of the new high-level isolation unit in Kigali and ensure the successful implementation of the training program.

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.

Implementing paediatric appropriate use criteria for endotracheal suction to reduce complications in mechanically ventilated children with respiratory infections

BACKGROUND

Endotracheal suction is used to maintain endotracheal tube patency. There is limited guidance to inform clinical practice for children with respiratory infections.

OBJECTIVE

The objective of this study was to determine whether implementation of a paediatric endotracheal suction appropriate use guideline Paediatric AirWay Suction (PAWS) is associated with an increased use of appropriate and decreased use of inappropriate suction interventions.

METHODS

A mixed-method, pre-implementation-post-implementation study was conducted between September 2021 and April 2022. Suction episodes in mechanically ventilated children with a respiratory infection were eligible. Using a structured approach, we implemented the PAWS guideline in a single paediatric intensive care unit. Evaluation included clinical (e.g., suction intervention appropriateness), implementation (e.g., acceptability), and cost outcomes (implementation costs). Associations between implementation of the PAWS guideline and appropriateness of endotracheal suction intervention use were investigated using generalised linear models.

RESULTS

Data from 439 eligible suctions were included in the analysis. Following PAWS implementation, inappropriate endotracheal tube intervention use reduced from 99% to 58%, an absolute reduction (AR) of 41% (95% confidence interval [CI]: 25%, 56%). Reductions were most notable for open suction systems (AR: 48%; 95% CI: 30%, 65%), 0.9% sodium chloride use (AR: 23%; 95% CI: 8%, 38%) and presuction and postsuction manual bagging (38%; 95% CI: 16%, 60%, and 86%; 95% CI: 73%, 99%), respectively. Clinicians perceived PAWS as acceptable and suitable for use.

CONCLUSIONS

Implementation of endotracheal tube suction appropriate use guidelines in a mixed paediatric intensive care unit was associated with a large reduction in inappropriate suction intervention use in paediatric patients with respiratory infections.

Resilient Hospital Design: From Crimean War to COVID-19

OBJECTIVES

Serious COVID-19 nosocomial infection has demonstrated a need to design our health services in a different manner. Triggered by the current crisis and the interest in rapid deployable hospital, this article discusses how hospital building layouts can be improved to streamline the patient pathways and thus to reduce the risk of hospital-related infections. Another objective of this work is to explore the possibility to develop flexible and scalable hospital building layouts through modular construction. This enables hospitals to better cope with different future demands and thereby enhance the resilience of the healthcare facilities.

BACKGROUND

During the first wave of COVID-19, approximate one-seventh to one-fifth COVID-19 patients and majority of infected healthcare workers acquired the disease in NHS hospitals. Similar issues emerged during the Crimean War (1853-1856) when more soldiers died from infectious diseases rather than of battlefield casualties in Scutari Hospital. This led to an important collaborative work between Florence Nightingale, who looked into this problem statistically, and Isambard Kingdom Brunel, who designed the rapid deployment Renkioi Hospital which yielded a death rate 90% lower than that in Scutari Hospital. While contemporary medical research and practice have moved beyond Nightingale's concept of contagion, challenges of optimizing hospital building layouts to support healing and effectively combat nosocomial infections still pose elusive problems that require further investigation.

METHODS

Through case study investigations, this article evaluates the risk of nosocomial infections of airborne transmissions under different building layouts, and this provides essential data for infection control in the new-build or refurbished healthcare projects.

RESULTS

Improved hospital layout can be achieved through reconfiguration of rooms and concourse. Design interventions through evidence-based infection risk analysis can reduce congestion and provide extra separation and compartmentalization which will contribute the reduced nosocomial infection rate.

CONCLUSIONS

A resilient hospital shall be able to cope with unexpected circumstances and be flexible to change when new challenges arise, without compromising the safety and well-being of frontline medical staff and other patients. Such an organizational resilience depends on not only flexible clinical protocols but also flexible hospital building layouts. The latter allows hospitals to get better prepared for rapidly changing patient expectations, medical advances, and extreme weather events. The reconfigurability of an existing healthcare facility can be further enhanced through modular construction, standardization of building components, and additional space considered.

Emergence of Marburg virus: a global perspective on fatal outbreaks and clinical challenges

The Marburg virus (MV), identified in 1967, has caused deadly outbreaks worldwide, the mortality rate of Marburg virus disease (MVD) varies depending on the outbreak and virus strain, but the average case fatality rate is around 50%. However, case fatality rates have varied from 24 to 88% in past outbreaks depending on virus strain and case management. Designated a priority pathogen by the National Institute of Allergy and Infectious Diseases (NIAID), MV induces hemorrhagic fever, organ failure, and coagulation issues in both humans and non-human primates. This review presents an extensive exploration of MVD outbreak evolution, virus structure, and genome, as well as the sources and transmission routes of MV, including human-to-human spread and involvement of natural hosts such as the Egyptian fruit bat (Rousettus aegyptiacus) and other Chiroptera species. The disease progression involves early viral replication impacting immune cells like monocytes, macrophages, and dendritic cells, followed by damage to the spleen, liver, and secondary lymphoid organs. Subsequent spread occurs to hepatocytes, endothelial cells, fibroblasts, and epithelial cells. MV can evade host immune response by inhibiting interferon type I (IFN-1) synthesis. This comprehensive investigation aims to enhance understanding of pathophysiology, cellular tropism, and injury sites in the host, aiding insights into MVD causes. Clinical data and treatments are discussed, albeit current methods to halt MVD outbreaks remain elusive. By elucidating MV infection's history and mechanisms, this review seeks to advance MV disease treatment, drug development, and vaccine creation. The World Health Organization (WHO) considers MV a high-concern filovirus causing severe and fatal hemorrhagic fever, with a death rate ranging from 24 to 88%. The virus often spreads through contact with infected individuals, originating from animals. Visitors to bat habitats like caves or mines face higher risk. We tailored this search strategy for four databases: Scopus, Web of Science, Google Scholar, and PubMed. we primarily utilized search terms such as "Marburg virus," "Epidemiology," "Vaccine," "Outbreak," and "Transmission." To enhance comprehension of the virus and associated disease, this summary offers a comprehensive overview of MV outbreaks, pathophysiology, and management strategies. Continued research and learning hold promise for preventing and controlling future MVD outbreaks. GRAPHICAL ABSTRACT.

A narrative review of high-level isolation unit operational and infrastructure features

High-level isolation units (HLIUs) are specially designed facilities for care and management of patients with suspected or confirmed high-consequence infectious diseases (HCIDs), equipped with unique infrastructure and operational features. While individual HLIUs have published on their experiences caring for patients with HCIDs and two previous HLIU consensus efforts have outlined key components of HLIUs, we aimed to summarise the existing literature that describes best practices, challenges and core features of these specialised facilities. A narrative review of the literature was conducted using keywords associated with HLIUs and HCIDs. A total of 100 articles were used throughout the manuscript from the literature search or from alternate methods like reference checks or snowballing. Articles were sorted into categories (eg, physical infrastructure, laboratory, internal transport); for each category, a synthesis of the relevant literature was conducted to describe best practices, experiences and operational features. The review and summary of HLIU experiences, best practices, challenges and components can serve as a resource for units continuing to improve readiness, or for hospitals in early stages of developing their HLIU teams and planning or constructing their units. The COVID-19 pandemic, a global outbreak of mpox, sporadic cases of viral haemorrhagic fevers in Europe and the USA, and recent outbreaks of Lassa fever, Sudan Ebolavirus, and Marburg emphasise the need for an extensive summary of HLIU practices to inform readiness and response.

A Restructured Hospital Into a One-Building Organization for COVID-19 Patients: A Resilient and Effective Response to the Pandemic

The COVID-19 pandemic is a unique crisis challenging healthcare institutions as it rapidly overwhelmed hospitals due to a large influx of patients. This major event forced all the components of the healthcare systems to adapt and invent new workflows. Thus, our tertiary care hospital was reorganized entirely. During the cruising phase, additional staff was allocated to a one-building organization comprising an intensive care unit (ICU), an acute care unit, a physical medicine and rehabilitation unit, and a COVID-19 screening area. The transfer of patients from a ward to another was more efficient due to these organizations and pavilion structure. The observed mortality was low in the acute care ward, except in the palliative unit. No nosocomial infection with SARS-CoV-2 was reported in any other building of the hospital since this organization was set up. This type of one-building organization, integrating all the components for comprehensive patient care, seems to be the most appropriate response to pandemics.

Appropriate use criteria for endotracheal suction interventions in mechanically ventilated children: The RAND/UCLA development process

OBJECTIVES

Endotracheal suction is an invasive airway clearance technique used in mechanically ventilated children. This article outlines the methods used to develop appropriate use criteria for endotracheal suction interventions in mechanically ventilated paediatric patients.

METHODS

The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop paediatric appropriate use criteria. This included the following sequential phases of defining scope and key terms, a literature review and synthesis, expert multidisciplinary panel selection, case scenario development, and appropriateness ratings by an interdisciplinary expert panel over two rounds. The panel comprised experts in the fields of paediatric and neonatal intensive care, respiratory medicine, infectious diseases, critical care nursing, implementation science, retrieval medicine, and education. Case scenarios were developed iteratively by interdisciplinary experts and derived from common applications or anticipated intervention uses, as well as from current clinical practice guidelines and results of studies examining interventions efficacy and safety. Scenarios were rated on a scale of 1 (harm outweighs benefit) to 9 (benefit outweighs harm), to define appropriate use (median: 7 to 9), uncertain use (median: 4 to 6), and inappropriate use (median: 1 to 3) of endotracheal suction interventions. Scenarios were than classified as a level of appropriateness.

CONCLUSIONS

The RAND Corporation/University of California, Los Angeles Appropriateness Method provides a thorough and transparent method to inform development of the first appropriate use criteria for endotracheal suction interventions in paediatric patients.

Capabilities of global high-level isolation units: A pre-workshop survey

OBJECTIVE

To assess experience, physical infrastructure, and capabilities of high-level isolation units (HLIUs) planning to participate in a 2018 global HLIU workshop hosted by the US National Emerging Special Pathogens Training and Education Center (NETEC).

DESIGN

An electronic survey elicited information on general HLIU organization, operating costs, staffing models, and infection control protocols of select global units.

SETTING AND PARTICIPANTS

The survey was distributed to site representatives of 22 HLIUs located in the United States, Europe, and Asia; 19 (86%) responded.

METHODS

Data were coded and analyzed using descriptive statistics.

RESULTS

The mean annual reported budget for the 19 responding units was US$484,615. Most (89%) had treated a suspected or confirmed case of a high-consequence infectious disease. Reported composition of trained teams included a broad range of clinical and nonclinical roles. The mean number of HLIU beds was 6.37 (median, 4; range, 2-20) for adults and 4.23 (median, 2; range, 1-10) for children; however, capacity was dependent on pathogen.

CONCLUSIONS

Responding HLIUs represent some of the most experienced HLIUs in the world. Variation in reported unit infrastructure, capabilities, and procedures demonstrate the variety of HLIU approaches. A number of technical questions unique to HLIUs remain unanswered related to physical design, infection prevention and control procedures, and staffing and training. These key areas represent potential focal points for future evidence and practice guidelines. These data are important considerations for hospitals considering the design and development of HLIUs, and there is a need for continued global HLIU collaboration to define best practices.

Training in infectious diseases across europe in 2021 - A survey on training delivery, content and assessment

OBJECTIVES

To define the status of Infectious Diseases (ID) as an approved specialty in Europe; to enumerate the number of specialists (in general and in relation to the overall population) and specialist trainees and describe the content, delivery, and evaluation of postgraduate training in ID in different countries.

METHODS

Structured web-based questionnaire surveys in March 2021 of responsible national authorities, specialist societies and individual country representatives to the Section of Infectious Diseases of the European Union for Medical Specialties. Descriptive analysis of quantitative and qualitative responses.

RESULTS

In responses received from 33/35 (94.3%) countries, ID is recognised as a specialty in 24 and as a subspecialty of general internal medicine (GIM) in 8, but it is not recognised in Spain. The number of ID specialists per country varies from <5 per million inhabitants to 78 per million. Median length of training is 5 (IQR 4.0 - 6.0) years with variable amounts of preceding and/or concurrent GIM. Only 21.2% of countries (7/33) provide the minimum recommended training of 6 months in microbiology and 30% cover competencies such as palliative care, team working and leadership, audit, and quality control. Training is monitored by personal logbook or e-portfolio in 75% (25/33) and assessed by final exams in 69.7% (23/33) of countries, but yearly reviews with trainees only occur in 54.5% (18/33) of countries.

CONCLUSIONS

There are substantial gaps in modernisation of ID training in many countries to match current European Training Requirements. Joint training with clinical microbiology and in multidisciplinary team working should be extended. Training/monitoring trainers should find greater focus, together with regular feedback to trainees within many national training programmes.

Training and assessment of medical specialists in clinical microbiology and infectious diseases in Europe

BACKGROUND

There is wide variation in the availability and training of specialists in the diagnosis and management of infections across Europe.

OBJECTIVES

To describe and reflect on the current objectives, structure and content of European curricula and examinations for the training and assessment of medical specialists in Clinical (Medical) Microbiology (CM/MM) and Infectious Diseases (ID).

SOURCES

Narrative review of developments over the past two decades and related policy documents and scientific literature.

CONTENT

Responsibility for curricula and examinations lies with the European Union of Medical Specialists (UEMS). The ID Section of UEMS was inaugurated in 1997 and the MM Section separated from Laboratory Medicine in 2008. The sections collaborate closely with each other and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). Updated European Training Requirements (ETR) were approved for MM in 2017 and ID in 2018. These comprehensive curricula outline the framework for delivery of specialist training and quality control for trainers and training programmes, emphasizing the need for documented, regular formative reviews of progress of trainees. Competencies to be achieved include both specialty-related and generic knowledge, skills and professional behaviours. The indicative length of training is typically 5 years; a year of clinical training is mandated for CM/MM trainees and 6 months of microbiology laboratory training for ID trainees. Each Section is developing examinations using multiple choice questions to test the knowledge base defined in their ETR, to be delivered in 2022 following pilot examinations in 2021.

IMPLICATIONS

The revised ETRs and European examinations for medical specialists in CM/MM and ID provide benchmarks for national authorities to adapt or adopt locally. Through harmonization of postgraduate training and assessment, they support the promotion and recognition of high standards of clinical practice and hence improved care for patients throughout Europe, and improved mobility of trainees and specialists.

Viewpoint of a WHO Advisory Group Tasked to Consider Establishing a Closely-monitored Challenge Model of Coronavirus Disease 2019 (COVID-19) in Healthy Volunteers

WHO convened an Advisory Group (AG) to consider the feasibility, potential value, and limitations of establishing a closely-monitored challenge model of experimental severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19) in healthy adult volunteers. The AG included experts in design, establishment, and performance of challenges. This report summarizes issues that render a COVID-19 model daunting to establish (the potential of SARS-CoV-2 to cause severe/fatal illness, its high transmissibility, and lack of a "rescue treatment" to prevent progression from mild/moderate to severe clinical illness) and it proffers prudent strategies for stepwise model development, challenge virus selection, guidelines for manufacturing challenge doses, and ways to contain SARS-CoV-2 and prevent transmission to household/community contacts. A COVID-19 model could demonstrate protection against virus shedding and/or illness induced by prior SARS-CoV-2 challenge or vaccination. A limitation of the model is that vaccine efficacy in experimentally challenged healthy young adults cannot per se be extrapolated to predict efficacy in elderly/high-risk adults.

Impact of admission to high-risk isolation room on patients' and healthcare workers' perceptions: A qualitative cross-assessment Approach

•

The consequences of hospital admission of high-risk infectious patients into special rooms have been only rarely investigated.

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Our work is based on semi-structured interviews of 14 patients and 16 Health Care Workers and shows that patients housed with specific precautions have a negative representation of these spaces and a feeling of confinement as opposed to those admitted without precautions.

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Health Care Workers also have a negative view of these rooms.

Introduction

High-risk isolation units (HRIU) house patients at high risk of transmitting infectious agents, notably patients with suspected viral hemorrhagic fever or smear-positive tuberculosis. Admission to HRIU can alter the quality of care and impact patients’ and healthcare workers’ (HCWs) anxiety and dissatisfaction.

Methods

The Infectious Diseases Department of the Bichat Claude Bernard Hospital in Paris houses a 7–bed HRIU. We conducted a qualitative study based on individual semi-structured interviews to assess the perceptions of both patients and HCWs.

Results

We interviewed 14 patients and 16 HCWs routinely working in the HRIU. All 8 patients subject to isolation precautions and 1 of the 6 patients not subject to isolation precautions expressed a negative representation of the room with a feeling of confinement, stigma, and mistrust. They also reported a lack of information from healthcare staff and a need for entertainment, activities, and visits from relatives. HCWs did not like working in this unit because of the anteroom's technical constraints and a loss of frequent contact with patients. They also expressed a feeling of insecurity working in these units despite the use of interphones.

Conclusion

Placing patients in an HRIU not only affects their emotions, but also impacts HCWs both emotionally and organizationally. Alert systems, intercoms, and videoconferencing systems can improve safety and security as well as exchanges with patients and their relatives. Psychological support is needed for patients who are subject to isolation precautions and for their attending HCWs.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed.

OBJECTIVES

To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020.

SELECTION CRITERIA

We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate.

MAIN RESULTS

Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants) coveralls were more difficult to doff than isolation gowns (very low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). According to three studies that tested more recently introduced full-body PPE ensembles, there may be no difference in contamination. Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only.

AUTHORS' CONCLUSIONS

We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed.

OBJECTIVES

To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020.

SELECTION CRITERIA

We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate.

MAIN RESULTS

Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants), people with a long gown had less contamination than those with a coverall, and coveralls were more difficult to doff (low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only.

AUTHORS' CONCLUSIONS

We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort, and may therefore even lead to more contamination. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.

Crimean-Congo hemorrhagic fever: An update

Crimean-Congo hemorrhagic fever (CCHF) is a severe form of hemorrhagic fever caused by a virus of the genus Nairovirus. The amplifying hosts are various mammal species that remain asymptomatic. Humans are infected by tick bites or contact with animal blood. CCHF has a broad geographic distribution and is endemic in Africa, Asia (in particular the Middle East) and South East Europe. This area has expanded in recent years with two indigenous cases reported in Spain in 2016 and 2018. The incubation period is short with the onset of symptoms in generally less than a week. The initial symptoms are common to other infectious syndromes with fever, headache, myalgia and gastrointestinal symptoms. The hemorrhagic syndrome occurs during a second phase with sometimes major bleeding in and from the mucous membranes and the skin. Strict barrier precautionary measures are required to prevent secondary and nosocomial spread. CCHF may be documented by PCR detection of the virus genome during the first days after the onset of illness, and then by serological testing for IgM antibodies as from the 2nd week after infection. Patient management is mainly based on supportive care. Despite a few encouraging retrospective reports, there is no confirmed evidence that supports the use of ribavirin for curative treatment. Nevertheless, the World Health Organization continues to recommend the use of ribavirin to treat CCHF, considering the limited medical risk related to short-term treatment. The prescription of ribavirin should however be encouraged post-exposure for medical professionals, to prevent secondary infection.

Caring for patients with Ebola virus disease: Are U.S. biocontainment centers ready for the next outbreak?

The 2014 West African Ebola virus disease (EVD) outbreak is the largest and deadliest EVD epidemic to date, resulting in fivefold more cases than all other outbreaks combined. This outbreak was particularly devastating to healthcare workers in West Africa and resulted in several EVD patients being medically evacuated for treatment in the U.S. and Europe. Governmental agencies provide recommendations for triaging and testing patients with EVD, however best laboratory practices are still unknown and are very resource dependent.

Biocontainment Units: Moving to the Next Phase of Evolution

The concept and belief in the idea of "biocontainment" has undergone significant evolution during the past 20 years. The authors believe that the time is right to move to the next phase of this evolution to reassess establishment of formal standards for what constitutes a biocontainment unit and what diseases might be considered for admission to a biocontainment unit.

U.S. Medical Examiner/Coroner capability to handle highly infectious decedents

In the United States of America, Medical Examiners and Coroners (ME/Cs) investigate approximately 20% of all deaths. Unexpected deaths, such as those occurring due to a deceased person under investigation for a highly infectious disease, are likely to fall under ME/C jurisdiction, thereby placing the ME/C and other morgue personnel at increased risk of contracting an occupationally acquired infection. This survey of U.S. ME/Cs' capabilities to address highly infectious decedents aimed to determine opportunities for improvement at ME/C facilities serving a state or metropolitan area. Data for this study was gathered via an electronic survey. Of the 177 electronic surveys that were distributed, the overall response rate was N = 108 (61%), with 99 of those 108 respondents completing all the questions within the survey. At least one ME/C responded from 47 of 50 states, and the District of Columbia. Select results were: less than half of respondents (44%) stated that their office had been involved in handling a suspected or confirmed highly infectious remains case and responses indicated medical examiners. Additionally, ME/C altered their personal protective equipment based on suspected versus confirmed highly infectious remains rather than taking an all-hazards approach. Standard operating procedures or guidelines should be updated to take an all-hazards approach, best-practices on handling highly infectious remains could be integrated into a standardized education, and evidence-based information on appropriate personal protective equipment selection could be incorporated into a widely disseminated learning module for addressing suspected or confirmed highly infectious remains, as those areas were revealed to be currently lacking.

Therapeutic management of Crimean-Congo haemorrhagic fever

Crimean-Congo haemorrhagic fever has been reported in more than 30 countries in Africa, Asia, the Middle East and Eastern Europe, with an increasing incidence in recent years, especially in Europe. Because no specific treatments have demonstrated efficacy, supportive treatment is essential, as well as the provision of a centre with the appropriate means to guarantee the safety of its healthcare professionals. Laboratory monitoring of thrombocytopenia, severe coagulopathy or liver failure is of critical importance. Patients with Crimean-Congo haemorrhagic fever should be admitted to High Level Isolation Units where appropriate biocontainment procedures can prevent nosocomial transmission through infected fluids or accidents with contaminated material. In case of high-risk exposures, early administration of ribavirin should be considered.

Therapeutic management of Crimean-Congo haemorrhagic fever

Crimean-Congo haemorrhagic fever has been reported in more than 30 countries in Africa, Asia, the Middle East and Eastern Europe, with an increasing incidence in recent years, especially in Europe. Because no specific treatments have demonstrated efficacy, supportive treatment is essential, as well as the provision of a centre with the appropriate means to guarantee the safety of its healthcare professionals. Laboratory monitoring of thrombocytopenia, severe coagulopathy or liver failure is of critical importance. Patients with Crimean-Congo haemorrhagic fever should be admitted to High Level Isolation Units where appropriate biocontainment procedures can prevent nosocomial transmission through infected fluids or accidents with contaminated material. In case of high-risk exposures, early administration of ribavirin should be considered.

Highly infectious diseases in the Mediterranean Sea area: Inventory of isolation capabilities and recommendations for appropriate isolation

Epidemics such as viral haemorrhagic fevers, severe acute respiratory syndrome, Middle East respiratory syndrome coronavirus or yet unknown ones have few chances of disappearing. Globalization, worldwide travel, climate change, social conflicts and wars, among others, are likely to favor the emergence of epidemics. Preparedness of hospitals to prevent the spread of these outbreaks is among the prioritized political programmes of many countries. The EuroNHID network has in the past drawn a map of features and equipment of hospitals across Europe to take care of highly contagious patients. We update the data regarding isolation capabilities and recommendations, with an emphasis on Mediterranean countries.

Immuno Nanosensor for the Ultrasensitive Naked Eye Detection of Tuberculosis

In the present study, a beneficial approach for the ultrasensitive and affordable naked eye detection and diagnosis of tuberculosis (TB) by utilizing plasmonic enzyme-linked immunosorbent assay (ELISA) via antibody-antigen interaction was studied. Here, the biocatalytic cycle of the intracellular enzymes links to the formation and successive growth of the gold nanoparticles (GNPs) for ultrasensitive detection. The formation of different colored solutions by the plasmonic nanoparticles in the presence of enzyme labels links directly to the existence or non-existence of the TB analytes in the sample solutions. For disease detection, the adapted protocol is based mainly on the conventional ELISA procedure that involves catalase-labeled antibodies, i.e., the enzymes consume hydrogen peroxide and further produce GNPs with the addition of gold (III) chloride. The amount of hydrogen peroxide remaining in the solution determines whether the GNPs solution is to be formed in the color blue or the color red, as it serves as a confirmation for the naked eye detection of TB analytes. However, the conventional ELISA method only shows tonal colors that need a high concentration of analyte to achieve high confidence levels for naked eye detection. Also, in this research, we proposed the incorporation of protein biomarker, Mycobacterium tuberculosis ESAT-6-like protein esxB (CFP-10), as a means of TB detection using plasmonic ELISA. With the use of this technique, the CFP-10 detection limit can be lowered to 0.01 &micro;g/mL by the naked eye. Further, our developed technique was successfully tested and confirmed with sputum samples from patients diagnosed with positive TB, thereby providing enough evidence for the utilization of our technique in the early diagnosis of TB disease.

Building an Intelligent Hospital to Fight Contagion

The idea of building hospitals to fight contagion was born with the lazarettos. At the time when the microorganisms were not yet known, the mechanisms of transmission of contagion were already well apprehended. Based on the same knowledge but thanks to new technologies, such hospitals have now been built downtown, next to the most highly performing technological plateau. Regrouping patient care, diagnostics, research, and development, the University Hospital Institute Méditerranée Infection building offers a wonderful tool to contain and understand contagion, in a well-designed setting, creating excellent working conditions that are attractive for interested scientists.

Viral Hemorrhagic Fever Preparedness

The 2014–2016 outbreak of Ebola virus disease (EVD) in West Africa marked the 25th such occurrence but was noteworthy in its massive scope, causing more human morbidity and mortality than the previous 24 recorded outbreaks combined. As of April 2016, there were 28,652 cases resulting in at least 11,325 deaths, nearly all in the three nations of Guinea, Liberia, and Sierra Leone (Centers for Disease Control and Prevention. http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html. Accessed 2 June 2016). Moreover, the 2014–2016 outbreak was the first in which patients, albeit few in number, were afforded sophisticated intensive care in the United States and in Europe. This “high-level containment care” (HLCC) was provided in specially designed purpose-built biocontainment units (BCUs). In this chapter, we explore the history and evolution of biocontainment, discuss its unique engineering and infection control modalities, and offer recommendations for the clinical and operational management of Ebola and other viral hemorrhagic fevers (VHFs).

The French Infectious Diseases Society's readiness and response to epidemic or biological risk-the current situation following the Middle East respiratory syndrome coronavirus and Ebola virus disease alerts

CONTEXT

In 2012, the French Infectious Diseases Society (French acronym SPILF) initiated the "Coordination of epidemic and biological risk" (SPILF-COREB - Emergences [SCE]) group to support the readiness and response of healthcare workers (HCWs) to new alerts.

OBJECTIVE

To present the SCE group, its functioning, and the main support it provided for frontline HCWs.

METHODS

A multidisciplinary group of heads of infectious disease departments from reference hospitals was created to build a network of clinical expertise for care, training, and research in the field of epidemic and biological risk (EBR). The network developed a set of standardized operational procedures (SOPs) to guide interventions to manage EBR-suspect patients.

RESULTS

A working group created the SOP aimed at frontline HCWs taking care of patients. Priority was given to the development of a generic procedure, which was then adapted according to the current alert. Five key steps were identified and hierarchized: detecting, protecting, caring for, alerting, and referring the EBR patient. The interaction between clinicians and those responsible for the protection of the community was crucial. The SOPs validated by the SPILF and its affiliates were disseminated to a wide range of key stakeholders through various media including workshops and the SPILF's website.

CONCLUSION

SPILF can easily adapt and timely mobilize the EBR expertise in case of an alert. The present work suggests that sharing and discussing this experience, initiated at the European level, can generate a new collective expertise and needs to be further developed and strengthened.

Enabling Rapid Response to the 2014-2016 Ebola Epidemic: The Experience and the Results of the National Institute for Infectious Diseases Lazzaro Spallanzani

The unprecedented epidemic of Ebola virus disease (EVD) in West Africa highlighted the need for stronger systems for disease surveillance, response, and prevention worldwide. Tackling an epidemic event today requires a broader view, not only limited to medical management of the patients, but which also includes heroic efforts by clinicians and public health personnel.Since its foundation in 1936, INMI has been devoted to the prevention, diagnosis and care for infectious diseases. In 2009, INMI became a WHO collaborative center for clinical care, diagnosis, response and training on Highly Infectious Diseases. This paper is aimed to present the activities and the challenging issues encountered by INMI during the 2014-2015 EVD outbreak in terms of preparedness and response to the epidemiological, clinical, diagnostic and research controversial aspects of EVD, both in Italy and in the field.

Preparedness at Japan's Hospitals Designated for Patients with Highly Infectious Diseases

In 2015, in order to assess the preparedness of Japan's special hospitals that have been designated to admit and treat patients with highly infectious diseases, we conducted a cross-sectional study of all 47 hospitals with this designation, using a self-report questionnaire that addressed 5 issues: (1) hospital characteristics and the occupation of the respondents; (2) the availability and content of the hospital guidelines for managing patients with suspected or confirmed viral hemorrhagic fever; (3) the implementation of preparedness activities in the context of the recent Ebola crisis; (4) characteristics of admission rooms for patients; and (5) human resources and occupational issues. Although our study found that most of Japan's designated hospitals were well-equipped, several areas of concern were also identified, including the lack of an effective clinical protocol, problems with management of human resources, and occupational issues. Developing a more feasible response protocol to any possible outbreak of new or reemergent infectious diseases is essential not only for Japan but for the global community in view of the threat posed by highly infectious diseases.

The critical care response to a hospital outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: an observational study

Background

Middle East respiratory syndrome coronavirus (MERS-CoV) has caused several hospital outbreaks, including a major outbreak at King Abdulaziz Medical City, a 940-bed tertiary-care hospital in Riyadh, Saudi Arabia (August–September 2015). To learn from our experience, we described the critical care response to the outbreak.

Methods

This observational study was conducted at the Intensive Care Department which covered 5 ICUs with 60 single-bedded rooms. We described qualitatively and, as applicable, quantitatively the response of intensive care services to the outbreak. The clinical course and outcomes of healthcare workers (HCWs) who had MERS were noted.

Results

Sixty-three MERS patients were admitted to 3 MERS-designated ICUs during the outbreak (peak census = 27 patients on August 25, 2015, and the last new case on September 13, 2015). Most patients had multiorgan failure. Eight HCWs had MERS requiring ICU admission (median stay = 28 days): Seven developed acute respiratory distress syndrome, four were treated with prone positioning, four needed continuous renal replacement therapy and one had extracorporeal membrane oxygenation. The hospital mortality of ICU MERS patients was 63.4 % (0 % for the HCWs). In response to the outbreak, the number of negative-pressure rooms was increased from 14 to 38 rooms in 3 MERS-designated ICUs. Patients were managed with a nurse-to-patient ratio of 1:0.8. Infection prevention practices were intensified. As a surrogate, surface disinfectant and hand hygiene gel consumption increased by ~30 % and 17 N95 masks were used per patient/day on average. Family visits were restricted to 2 h/day. Although most ICU staff expressed concerns about acquiring MERS, all reported to work normally. During the outbreak, 27.0 % of nurses and 18.4 % of physicians working in the MERS-designated ICUs reported upper respiratory symptoms, and were tested for MERS-CoV. Only 2/196 (1.0 %) ICU nurses and 1/80 (1.3 %) physician tested positive, had mild disease and recovered fully. The total sick leave duration was 138 days for nurses and 30 days for physicians.

Conclusions

Our hospital outbreak of MERS resulted in 63 patients requiring organ support and prolonged ICU stay with a high mortality rate. The ICU response required careful facility and staff management and proper infection control and prevention practices.

A Brief History of Biocontainment

The concept of clinical biocontainment, otherwise known as high-level containment care (HLCC), had its birth among a confluence of near-simultaneous events in 1969. The U.S. Army's Medical Research Institute of Infectious Diseases (USAMRIID) began construction of the first modern biocontainment unit that year, and opened the two-bed facility, often referred to as "the Slammer" in 1971. Over its 41-year existence, 21 persons exposed to highly hazardous infectious diseases were admitted to the Slammer, but none ever contracted the disease to which they had been exposed. Owing, in part, to this underutilization, some questioned the utility of HLCC units. This concern notwithstanding, Emory University and the University of Nebraska opened HLCC units in civilian academic medical centers in 2004 and 2005, respectively. These units, distinct from conventional infectious disease isolation wards found in most major medical centers, proved their worth during the West African Ebola Virus Disease (EVD) outbreak of 2014-2015. It is our opinion that such units, as well as the parallel high-level containment transport systems necessary to move patients to them, will continue to play an important role in the global response to emerging and highly hazardous contagious pathogens. Moreover, we feel that the lessons derived from their successful operation will lead to improvements in infection control procedures and practices throughout the healthcare system.

Lassa fever: another threat from West Africa

Lassa fever, a zoonotic viral infection, is endemic in West Africa. The disease causes annual wide spread morbidity and mortality in Africa, and can be imported by travelers. Possible importation of Lassa fever and the potential for the use of Lassa virus as an agent of bioterrorism mandate clinicians in Israel and other countries to be vigilant and familiar with the basic characteristics of this disease. The article reviews the basis of this infection and the clinical management of patients with Lassa fever. Special emphasis is given to antiviral treatment and infection control.

A healthy degree of suspicion: A discussion of the implementation of transmission based precautions in the emergency department

Background

Emergency department (ED) presentations have increased significantly domestically and internationally. Swift identification and implementation of transmission based precautions (TBP) for patients known or suspected of having an epidemiologically important pathogen is important. ED staff, particularly triage nurses, are pivotal in detecting and preventing infection, including healthcare associated infections (HAI).

Methods

MEDLINE, CINAHL, PubMed and Ovid were searched for articles published between 2004 and 2015 using key search terms: infection control/prevention and emergency department(s), triage, and transmission based precautions and emergency department(s), and triage, to identify common themes for discussion. Systematic review/meta-analysis was not in the scope of this exploration.

Findings

Themes were identified relating to HAI and ED practices and grouped into: assisted detection of conditions for which TBP is required, ED and TBP, mass-causality event/bioterrorism/pandemic/epidemic, infection control not TBP and multi-resistant organisms not TBP. The literature is heavily influenced by worldwide epidemic/pandemics and bioterrorist risks resulting in increased awareness of the importance of swift identification of syndromes that require TBP, but only in these situations.

Conclusion

Implementation of appropriate TBP, changing triage practices, training and measures to assist decision-making could assist in preventing HAI in the ED context. A systematic quantitative review of the literature is recommended to guide practice change research.

Management of infections in critically ill returning travellers in the intensive care unit-I: considerations on infection control and transmission of resistance

•

Person-to-person transmission is the most important means of transmission.

•

Malaria remains by far the most important cause of death.

•

Surveillance strategies based on epidemiological data (country visited, duration of travel, and time elapsed since return) and clinical syndromes associated with a systematic search policy are usually mandatory to limit the risk of an outbreak.

•

Hospitalization in a single-bed room and isolation according to symptoms should be the rule while awaiting laboratory test results.

Depending on their destinations and activities, international travellers are at a significant risk of contracting both communicable and non-communicable diseases. On return to their home countries, such travellers may require intensive care. The emergence of severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV), and more recently Ebola haemorrhagic fever, has highlighted the risks. Other well-known communicable pathogens such as methicillin-resistant Staphylococcus aureus and carbapenemase-producing Enterobacteriaceae have been described previously. However, malaria remains by far the most important cause of death. The issues related to imported antibiotic resistance and protection from highly contagious diseases are reviewed here. Surveillance strategies based on epidemiological data (country visited, duration of travel, and time elapsed since return) and clinical syndromes, together with systematic search policies, are usually mandatory to limit the risk of an outbreak. Single-bed hospital rooms and isolation according to symptoms should be the rule while awaiting laboratory test results. Because person-to-person contact is the main route of transmission, healthcare workers should implement specific prevention strategies.

Preparing for imported Ebola cases in Israel, 2014 to 2015

During the current outbreak of Ebola virus disease (EVD) in West Africa, preventing exportation of the disease posed many challenges for economically more developed countries. In Israel, although the risk of importing single cases was assumed to be low, the implications of local transmission were great. This article describes the EVD preparedness plan of the Israeli Ministry of Health. Key elements were a sensitive case definition, designation of a single treatment centre for suspected and confirmed cases, construction of a mobile unit using customised negative-pressure tents and a vigorous national training programme. There were no patients with EVD in Israel, but a few suspected cases were assessed. The Israeli plan may provide a template for emergency infectious disease response in other geographically small countries.

Ebola virus disease complicated with viral interstitial pneumonia: a case report

Background

In the current Ebola epidemic in Western Africa, many healthcare workers have become infected. Some of these have been medically evacuated to hospitals in Europe and the USA. These clinical experiences provide unique insights into the course of Ebola virus disease under optimized condition within high level isolation units.

Case presentation

A 50-year-old Caucasian male physician contracted Ebola virus diseases in Sierra Leone and was medically evacuated to Italy. Few days after the admission the course of the illness was characterized by severe gastro-intestinal symptoms followed by respiratory failure, accompanied by pulmonary infiltration and high Ebola viral load in the bronchial aspirate and Plasmodium vivax co-infection. The patient received experimental antiviral therapy with favipiravir, convalescent plasma and ZMAb. Ebola viral load started to steadily decrease in the blood after ZMAb administration and became undetectable by day 19 after admission, while it persisted longer in urine samples. No temporal association was observed between viral load decay in plasma and administration of favipiravir. The patient completely recovered and was discharged 39 days after admission.

Conclusions

This is the first case of Ebola-related interstitial pneumonia documented by molecular testing of lung fluid specimens. This reports underlines the pivotal role of fluid replacement and advanced life support with mechanical ventilation in the management of patients with Ebola virus diseases respiratory failure. Beside our finding indicates a close temporal association between administration of cZMAb and Ebola virus clearance from blood.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1169-4) contains supplementary material, which is available to authorized users.

Mathematical and computational approaches to epidemic modeling: a comprehensive review

Mathematical and computational approaches are important tools for understanding epidemic spread patterns and evaluating policies of disease control. In recent years, epidemiology has become increasingly integrated with mathematics, sociology, management science, complexity science, and computer science. The cross of multiple disciplines has caused rapid development of mathematical and computational approaches to epidemic modeling. In this article, we carry out a comprehensive review of epidemic models to provide an insight into the literature of epidemic modeling and simulation. We introduce major epidemic models in three directions, including mathematical models, complex network models, and agent-based models. We discuss the principles, applications, advantages, and limitations of these models. Meanwhile, we also propose some future research directions in epidemic modeling.

A 2009 cross-sectional survey of procedures for post-mortem management of highly infectious disease patients in 48 isolation facilities in 16 countries: data from EuroNHID

Purpose

The handling of human remains may pose a risk for transmission of highly infectious agents. The use of appropriate biosafety measures is very important in case of management of patients deceased from highly infectious diseases (HIDs), such as Ebola virus disease. This paper presents the capabilities and resources in this field in 16 European countries, and suggests indications for the safe post-mortem management of HID patients.

Methods

The European Network for Highly Infectious Diseases conducted in 2009 a survey in 48 isolation facilities in 16 European countries. A set of standardized checklists, filled during on-site visits, have been used for data collection.

Results

Thirty-nine facilities (81.2 %) reported to have written procedures for the management of human remains, and 27 (56.2 %) for the performance of autopsies in HID patients. A Biosafety Level 3 autopsy room was available in eight (16.6 %) facilities, other technical devices for safe autopsies were available in nine (18.7 %). Overall, four facilities (8.3 %) reported to have all features explored for the safe management of human remains. Conversely, in five (10.4 %) none of these features were available.

Conclusions

The level of preparedness of surveyed isolation facilities in the field of post-mortem management in case of HIDs was not satisfactory, and improvements are needed.

[Structural requirements for the management of patients with highly contagious life-threatening infectious diseases: update 2015]

The care of highly contagious life-threatening infectious diseases (HLID) requires specialized treatment facilities that are capable of strict isolation measures and appropriate medical treatment. The German approach to the management of these diseases, which is maintained by the Permanent Working Group of Medical Competence and Treatment Centers for Highly Contagious and Life-Threatening Diseases (STAKOB) is adjusted in the present publication with regards to recent experiences and upcoming needs. Clear synergies in using infrastructures and bundling of resources have led to similar efforts at the European level. The German concept, therefore, has a pioneering role. This update is intended to improve professional patient care and also minimize the risk of disease spread and transmission.

[Specialized clinical facilities for the treatment of highly contagious, life-threatening infectious diseases : a comparison between Germany and 15 European nations]

BACKGROUND

Patients suffering from highly contagious, life-threatening infections should be treated in specialized clinical facilities that follow the highest infection control standards. Consensus statements defining technical equipment and operational procedures have been published in recent years, but the level of adherence to these has not been evaluated.

METHODS

Data summarized here comparing German and European isolation facilities are the partial results of a cross-sectional analysis conducted by the "European Network for Highly Infectious Diseases" that included 48 clinical care facilities in 16 European nations. Data collection was conducted using questionnaires and on-site visits, focussing on aspects of infrastructure, technical equipment, and the availability of trained personnel.

RESULTS

Although all centres enrolled were listed as "isolation units", all aspects evaluated differed broadly. Eighteen facilities fulfilled the definition of a 'High Level Isolation Unit', as 6/8 enrolled German facilities did. In contrast, 24 facilities could not operate independently from their co-located hospital.

DISCUSSION

Within and between nations contributing data disparities regarding the fulfilment of guidelines published were seen. German isolation facilities mostly fulfilled all criteria evaluated and performed on a high technical level. However, data presented do not reflect the current situation in Germany due to the time that has elapsed since the study was conducted. Hence, longitudinal data collection and harmonisation of terminology at least on national level needs to be implemented.

Transportation capacity for patients with highly infectious diseases in Europe: a survey in 16 nations

Highly infectious diseases (HIDs) are defined as being transmissible from person to person, causing life-threatening illnesses and presenting a serious public health hazard. In most European Union member states specialized isolation facilities are responsible for the management of such cases. Ground ambulances are often affiliated with those facilities because rapid relocation of patients is most desirable. To date, no pooled data on the accessibility, technical specifications and operational procedures for such transport capacities are available. During 2009, the ‘European Network for HIDs’ conducted a cross-sectional analysis of hospitals responsible for HID patients in Europe including an assessment of (a) legal aspects; (b) technical and infrastructure aspects; and (c) operational procedures for ground ambulances used for HID transport. Overall, 48 isolation facilities in 16 European countries were evaluated and feedback rates ranged from 78% to 100% (n = 37 to n = 48 centres). Only 46.8% (22/47) of all centres have both national and local guidelines regulating HID patient transport. If recommended, specific equipment is found in 90% of centres (9/10), but standard ambulances in only 6/13 centres (46%). Exclusive entrances (32/45; 71%) and pathways (30/44; 68.2%) for patient admission, as well as protocols for disinfection of ambulances (34/47; 72.3%) and equipment (30/43; 69.8%) exist in most centres. In conclusion, the availability and technical specifications of ambulances broadly differ, reflecting different preparedness levels within the European Union. Hence, regulations for technical specifications and operational procedures should be harmonized to promote patient and healthcare worker safety.

Radiographic imaging for patients with contagious infectious diseases: how to acquire chest radiographs of patients infected with the Ebola virus

OBJECTIVE

Contagious infectious diseases add a new dimension to radiology and pose many unanswered questions. In particular, what is the safest way to image patients with contagious and potentially lethal infectious diseases? Here, we describe protocols used by Emory University to successfully acquire chest radiographs of patients with Ebola virus disease.

CONCLUSION

Radiology departments need to develop new protocols for various modalities used in imaging patients with contagious and potentially lethal infectious diseases.

Personal Protective Equipment Management and Policies: European Network for Highly Infectious Diseases Data from 48 Isolation Facilities in 16 European Countries

Objective.

To collect data about personal protective equipment (PPE) management and to provide indications for improving PPE policies in Europe.

Design.

Descriptive, cross-sectional survey.

Setting and Participants.

Data were collected in 48 isolation facilities in 16 European countries nominated by National Health Authorities for the management of highly infectious diseases (HIDs).

Methods.

Data were collected through standardized checklists at on-site visits during February-November 2009. Indications for adequate PPE policies were developed on the basis of a literature review, partners' expert opinions, and the collected data.

Results.

All facilities have procedures for the selection of PPE in case of HID, and 44 have procedures for the removal of PPE. In 40 facilities, different levels of PPE are used according to a risk assessment process, and in 8 facilities, high-level PPE (eg, positive-pressure complete suits or Trexler units) is always used. A fit test is performed at 25 of the 40 facilities at which it is applicable, a seal check is recommended at 25, and both procedures are used at 17. Strategies for promoting and monitoring the correct use of PPE are available at 42 facilities. In case of a sudden increase in demand, 44 facilities have procedures for rapid supply of PPE, whereas 14 facilities have procedures for decontamination and reuse of some PPE.

Conclusions.

Most isolation facilities devote an acceptable level of attention to PPE selection and removal, strategies for the promotion of the correct use of PPE, and ensuring adequate supplies of PPE. Fit test and seal check procedures are still not widely practiced. Moreover, policies vary widely between and within European countries, and the development of common practice procedures is advisable.

Infect Control Hosp Epidemiol 2012;33(10):1008-1016

Isolation facilities for highly infectious diseases in Europe--a cross-sectional analysis in 16 countries

BACKGROUND

Highly Infectious Diseases (HIDs) are (i) easily transmissible form person to person; (ii) cause a life-threatening illness with no or few treatment options; and (iii) pose a threat for both personnel and the public. Hence, even suspected HID cases should be managed in specialised facilities minimizing infection risks but allowing state-of-the-art critical care. Consensus statements on the operational management of isolation facilities have been published recently. The study presented was set up to compare the operational management, resources, and technical equipment among European isolation facilities. Due to differences in geography, population density, and national response plans it was hypothesized that adherence to recommendations will vary.

METHODS AND FINDINGS

Until mid of 2010 the European Network for Highly Infectious Diseases conducted a cross-sectional analysis of isolation facilities in Europe, recruiting 48 isolation facilities in 16 countries. Three checklists were disseminated, assessing 44 items and 148 specific questions. The median feedback rate for specific questions was 97.9% (n = 47/48) (range: n = 7/48 (14.6%) to n = 48/48 (100%). Although all facilities enrolled were nominated specialised facilities' serving countries or regions, their design, equipment and personnel management varied. Eighteen facilities fulfilled the definition of a High Level Isolation Unit'. In contrast, 24 facilities could not operate independently from their co-located hospital, and five could not ensure access to equipment essential for infection control. Data presented are not representative for the EU in general, as only 16/27 (59.3%) of all Member States agreed to participate. Another limitation of this study is the time elapsed between data collection and publication; e.g. in Germany one additional facility opened in the meantime.

CONCLUSION

There are disparities both within and between European countries regarding the design and equipment of isolation facilities. With regard to the International Health Regulations, terminology, capacities and equipment should be standardised.

Mathematical modeling of pathogen trajectory in a patient care environment

OBJECTIVE

Minimizing healthcare worker exposure to airborne infectious pathogens is an important infection control practice. This study utilized mathematical modeling to evaluate the trajectories and subsequent concentrations of particles following a simulated release in a patient care room.

DESIGN

Observational study.

SETTING

Biocontainment unit patient care room at a university-affiliated tertiary care medical center.

METHODS

Quantitative mathematical modeling of airflow in a patient care room was achieved using a computational fluid dynamics software package. Models were created on the basis of a release of particles from various locations in the room. Computerized particle trajectories were presented in time-lapse fashion over a blueprint of the room. A series of smoke tests were conducted to visually validate the model.

RESULTS

Most particles released from the head of the bed initially rose to the ceiling and then spread across the ceiling and throughout the room. The highest particle concentrations were observed at the head of the bed nearest to the air return vent, and the lowest concentrations were observed at the foot of the bed.

CONCLUSIONS

Mathematical modeling provides clinically relevant data on the potential exposure risk in patient care rooms and is applicable in multiple healthcare delivery settings. The information obtained through mathematical modeling could potentially serve as an infection control modality to enhance the protection of healthcare workers.

Recommended precaution procedures protect healthcare workers from Crimean-Congo hemorrhagic fever virus

OBJECTIVES

The Crimean-Congo hemorrhagic fever (CCHF) virus can spread from person to person and may cause nosocomial outbreaks among healthcare workers (HCWs). The US Centers for Disease Control and Prevention have recommended the use of personal protective equipment (PPE). We investigated the compliance of HCWs with PPE usage during the follow-up of patients, and also the number of risky contacts that occurred between patients and HCWs. We also aimed to determine the seroprevalence of CCHF virus in HCWs.

METHODS

This study was conducted at Cumhuriyet University Education and Research Hospital, a medical center located in a highly endemic area for CCHF where a total of 1284 confirmed CCHF patients were followed-up between 2002 and 2012. All HCWs who were at risk of CCHF virus contact and infection were included in the study. The compliance of the HCWs with PPE usage and the number of contacts that had occurred were recorded. HCW serum samples were analyzed for CCHF virus IgM and IgG by ELISA.

RESULTS

The total rates of PPE usage were 93.7% for gowns, 77.4% for gloves, and 38.9% for masks; the highest compliance was detected in the infectious diseases ward: 100%, 88.6%, and 82.9%, respectively. A total of four HCWs had a history of high-risk contact with contaminated material (two percutaneous exposure and two mucosal contacts), but the number of low-risk contacts was quite high. The total seroprevalence rate was only 0.53%.

CONCLUSIONS

Although the HCWs at our medical center have dealt with an extremely high number of CCHF patients during the last decade, the total seropositivity for CCHFV IgG was only 0.53%. This low rate may be a result of high compliance with PPE usage and also regular education programs.

Virulence attenuation during an influenza A/H5N1 pandemic

More than 15 years after the first human cases of influenza A/H5N1 in Hong Kong, the world remains at risk for an H5N1 pandemic. Preparedness activities have focused on antiviral stockpiling and distribution, development of a human H5N1 vaccine, operationalizing screening and social distancing policies, and other non-pharmaceutical interventions. The planning of these interventions has been done in an attempt to lessen the cumulative mortality resulting from a hypothetical H5N1 pandemic. In this theoretical study, we consider the natural limitations on an H5N1 pandemic's mortality imposed by the virus' epidemiological–evolutionary constraints. Evolutionary theory dictates that pathogens should evolve to be relatively benign, depending on the magnitude of the correlation between a pathogen's virulence and its transmissibility. Because the case fatality of H5N1 infections in humans is currently 60 per cent, it is doubtful that the current viruses are close to their evolutionary optimum for transmission among humans. To describe the dynamics of virulence evolution during an H5N1 pandemic, we build a mathematical model based on the patterns of clinical progression in past H5N1 cases. Using both a deterministic model and a stochastic individual-based simulation, we describe (i) the drivers of evolutionary dynamics during an H5N1 pandemic, (ii) the range of case fatalities for which H5N1 viruses can successfully cause outbreaks in humans, and (iii) the effects of different kinds of social distancing on virulence evolution. We discuss two main epidemiological–evolutionary features of this system (i) the delaying or slowing of an epidemic which results in a majority of hosts experiencing an attenuated virulence phenotype and (ii) the strong evolutionary pressure for lower virulence experienced by the virus during a period of intense social distancing.