Differences in the distribution of pathogens and antimicrobial resistance in bloodstream infections in migrants compared with non-migrants in Denmark

BACKGROUND

We wish to study disparities in bloodstream infections in migrants and non-migrants by comparing the distribution of pathogens and their resistance patterns in long-term migrants with that in non-migrants in Denmark.

METHODS

The study is based on a cohort of migrants, who received residency in Denmark between 1993 and 2015 and a control group of non-migrants. The cohort was linked to a database of bloodstream infections from 2000 to 2015 covering two regions in Denmark. First-time bloodstream infections in individuals ≥18 years of age at the time of sampling were included. We calculated odds ratios adjusted for age, sex, year of sampling, comorbidity, and place of acquisition (hospital- or community-acquired).

RESULTS

We identified 4,703 bloodstream infection cases. Family-reunified migrants and refugees had higher odds of Escherichia coli than non-migrants (OR 1.89 95%CI: 1.46-2.44 and OR 1.55 95%CI: 1.25-1.92) and lower odds of Streptococcus pneumoniae (OR 0.38 95%CI: 0.21-0.67 and OR 0.52 95%CI: 0.34-0.81). Differences in pathogen distribution were only prevalent in community-acquired bloodstream infections. Refugees had higher odds of Escherichia coli resistant to piperacillin-tazobactam, ciprofloxacin, and gentamicin compared with non-migrants. Family-reunified migrants had higher odds of Escherichia coli and other Enterobacterales resistant to ciprofloxacin.

CONCLUSIONS

Migrants had a higher proportion of community-acquired bloodstream infections with Escherichia coli as well as higher odds of bloodstream infections with resistant Escherichia coli compared with non-migrants. These novel results are relevant for improving migrant health by focussing on preventing and treating infections especially with Escherichia coli such as urinary tract and abdominal infections.

Pathogen distribution and antimicrobial resistance in infections in migrants and nonmigrants in Denmark, a cross-sectional study

OBJECTIVE

To investigate differences in bacterial distribution and resistance patterns of relevant pathogens in skin and tissue infections among migrants compared to nonmigrants.

METHODS

The population is based on a cohort of migrants who obtained residence as refugees or family-reunited migrants in Denmark between January 1993 and December 2015. The cohort was linked to positive swabs and tissue cultures collected from hospitals and general practitioners between the years 2000 and 2016 at the Department of Microbiology, University Hospital Hvidovre, Denmark. We calculated odds ratios for pathogen distribution and resistance patterns using logistic regression by comparing migrants with nonmigrants.

RESULTS

In total, 43,770 pathogens from 37,276 individuals were included, with Staphylococcus aureus being the most common bacterium. Migrants had higher odds of infections with Enterobacterales than nonmigrants (OR 1.42, 95%CI: 1.23-1.63) and lower odds of beta-haemolytic Streptococci (OR 0.79, 95%CI: 0.73-0.86). Family-reunited migrants and refugees had higher odds of methicillin-resistant Staphylococcus aureus (MRSA) than nonmigrants (OR 5.01, 95%CI: 2.61-5.13 and OR 3.66, 95%CI: 2.61-5.13). This was more pronounced in female migrants. The odds of ciprofloxacin-resistant Enterobacterales were higher in both family-reunited migrants and refugees than in nonmigrants (OR 2.21, 95%CI: 1.34-3.64 and OR 2.17, 95%CI: 1.34-3.52).

CONCLUSIONS

The prevalence of MRSA and ciprofloxacin-resistant Enterobacterales was higher among family-reunited migrants and refugees than in nonmigrants. Our findings suggest an increased awareness for AMR in migrants.

COVID-19 preventive measures coincided with a marked decline in other infectious diseases in Denmark, spring 2020

We aimed to descriptively analyse the possible impact of the national COVID-19 interventions on the incidence of common infectious diseases in Denmark during spring and summer 2020. This observational study focused on national register data on infections caused by 16 different bacterial and viral pathogens. We included new cases registered between 1 January 2016 and 31 July 2020. The weekly number of new cases were analysed with respect to the COVID-19-related interventions introduced during 2020. We found a marked decrease in infections associated with droplet transmission coinciding with the COVID-19 interventions in spring and summer 2020. These included decreases in both viral and bacterial airway infections and also decreases in invasive infections caused by Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis. There was also a reduction in cases associated with foodborne transmission during the COVID-19 lockdown period. We found no effect of the lockdown on infections by invasive beta-haemolytic streptococci group B, C and G, Staphylococcus aureus bacteraemia, Neisseria gonorrhoeae or Clostridioides difficile. In conclusion, we found that the widespread interventions such as physical distancing, less travel, hygiene measures and lockdown of schools, restaurants and workplaces together coincided with a marked decline in respiratory infections and, to a smaller extent, some foodborne-transmitted infections.

Molecular epidemiology of the SARS-CoV-2 variant Omicron BA.2 sub-lineage in Denmark, 29 November 2021 to 2 January 2022

Following emergence of the SARS-CoV-2 variant Omicron in November 2021, the dominant BA.1 sub-lineage was replaced by the BA.2 sub-lineage in Denmark. We analysed the first 2,623 BA.2 cases from 29 November 2021 to 2 January 2022. No epidemiological or clinical differences were found between individuals infected with BA.1 versus BA.2. Phylogenetic analyses showed a geographic east-to-west transmission of BA.2 from the Capital Region with clusters expanding after the Christmas holidays. Mutational analysis shows distinct differences between BA.1 and BA.2.

Decrease in All-Cause 30-Day Mortality after Bacteraemia over a 15-Year Period: A Population-Based Cohort Study in Denmark in 2000-2014

INTRODUCTION

Bacteraemia is a frequent infectious condition that strongly affects morbidity and mortality. The incidence is increasing worldwide. This study explores all-cause 30-day mortality after bacteraemia in two out of Denmark's five healthcare regions with approximately 2.4 million inhabitants.

METHODS

Clinically significant bacteraemia episodes (n = 55,257) were identified from a geographically well-defined background population between 2000 and 2014, drawing on population-based data regarding bacterial species and vital status. All-cause 30-day mortality was assessed in relation to bacteraemia episodes, number of patients with analysed blood cultures and the background population.

RESULTS

We observed a decreasing trend of all-cause 30-day mortality between 2000 and 2014, both in relation to the number of bacteraemia episodes and the background population. Mortality decreased from 22.7% of the bacteraemia episodes in 2000 to 17.4% in 2014 (annual IRR [95% CI]: 0.983 [0.979-0.987]). In relation to the background population, there were 41 deaths per 100,000 inhabitants in 2000, decreasing to 39 in 2014 (annual IRR [95% CI]: 0.988 [0.982-0.993]). Numbers of inhabitants, bacteraemia episodes, and analysed persons having BCs increased during the period.

CONCLUSIONS

All-cause 30-day mortality in patients with bacteraemia decreased significantly over a 15-year period.

Strengthening screening for infectious diseases and vaccination among migrants in Europe: What is needed to close the implementation gaps?

Migration to the European Union (EU)/European Economic Area (EEA) affects the epidemiology of infectious diseases, including tuberculosis (TB), HIV, hepatitis B/C, and parasitic diseases. Some sub-populations of migrants are also considered to be an under-immunised group and thus at risk of vaccine-preventable diseases. Providing high-risk migrants access to timely and efficacious screening and vaccination, and understanding how best to implement more integrated screening and vaccination programmes into European health systems ensuring linkage to care and treatment, is key to improving the health of migrants and their communities, alongside meeting national and regional targets for infection surveillance, control, and elimination. The European Centre for Disease Prevention and Control (ECDC) has responded to calls to action to improve migrant health and strengthen universal health coverage by developing evidence-based guidance for policy makers, public health experts, and front-line healthcare professionals on how to approach screening and vaccination in newly arrived migrants within the EU/EEA. In this Commentary, we provide a perspective towards developing efficacious screening and vaccination of newly arrived migrants, with a focus on defining implementation challenges and evidence gaps in high-migrant receiving EU/EEA countries. There is a need now to leverage the increasing momentum around migrant health to both strengthen the evidence-base and to advocate for universal access to health care for all migrants in the EU/EEA, including undocumented migrants. This should include voluntary, confidential, and non-stigmatising screening and vaccination that should be free of charge and facilitate linkage to appropriate care and treatment.

Fatal Septicemia Linked to Transmission of MRSA Clonal Complex 398 in Hospital and Nursing Home, Denmark

We describe 2 fatal cases of methicillin-resistant Staphylococcus aureus (MRSA) clonal complex 398 septicemia in persons who had no contact with livestock. Whole-genome sequencing of the isolated MRSA strains strongly suggest that both were of animal origin and that the patients had been infected through 2 independent person-to-person transmission chains.

Norovirus Genotypes in Hospital Settings: Differences Between Nosocomial and Community-Acquired Infections

BACKGROUND

Norovirus (NoV) is a major cause of gastroenteritis and hospital outbreaks, leading to substantial morbidity and direct healthcare expenses as well as indirect societal costs. The aim of the study was to estimate the proportion of nosocomial NoV infections among inpatients testing positive for NoV in Denmark, 2002-2010, and to study the distribution of NoV genotypes among inpatients with nosocomial and community-acquired NoV infections, respectively.

METHODS

Admission and stool sampling dates from 3656 NoV-infected patients were used to estimate the proportion of nosocomial infections. The associations between nosocomial infection and patient age, sex, and NoV genotype GII.4 were examined.

RESULTS

Of the 3656 inpatients, 63% were classified as having nosocomial infections. Among these, 9 capsid and 8 polymerase NoV genotypes were detected, whereas in the smaller group of inpatients with community-acquired infections, 12 capsid and 9 polymerase genotypes were detected. Nosocomial NoV infections were associated with age ≥60 years and infections with genotype GII.4.

CONCLUSIONS

The majority of NoV infections in hospitalized patients were nosocomial. Nosocomial infection was mainly associated with older age but also with the specific genotype GII.4. The genotypes in community-acquired NoV infections were more heterogeneous than in nosocomial infections.

Sequence analysis of the capsid gene during a genotype II.4 dominated norovirus season in one university hospital: identification of possible transmission routes

Norovirus (NoV) is a leading cause of gastroenteritis and genotype II.4 (GII.4) is responsible for the majority of nosocomial NoV infections. Our objective was to examine whether sequencing of the capsid gene might be a useful tool for the hospital outbreak investigation to define possible transmission routes. All NoV positive samples submitted from one university hospital during the 2007/8 season were selected. Genotyping of selected samples by partial polymerase gene sequencing had shown that the majority belonged to the GII.4 variant Den Haag 2006b and had identical polymerase sequences. Sequences of the capsid gene (1412 nucleotides) were obtained from the first available sample from 55 patients. From six immunocompromised patients with persistent infections a second sample was also included. As a control for a point-source outbreak, five samples from a foodborne outbreak caused by the same GII.4 variant were analyzed. Forty-seven of the inpatients (85%) were infected with the GII.4 variant Den Haag 2006b. Phylogenetic analysis of the Den Haag 2006b sequences identified four distinct outbreaks in different departments and a fifth outbreak with possible inter-department spread. In addition, a more heterogeneous cluster with evidence of repeated introductions from the community, but also possible inter-department spread was observed. In all six patients with paired sequences, evidence for in vivo evolution of the virus was found. Capsid gene sequencing showed substantial sequence variation among NoV GII.4 variant Den Haag 2006b strains from one single institution during a nine months' period. This method proved useful to understand the local epidemiology and, when used promptly, has the potential to make infection control measures more targeted.

Social autopsy: INDEPTH Network experiences of utility, process, practices, and challenges in investigating causes and contributors to mortality

BACKGROUND

Effective implementation of child survival interventions depends on improved understanding of cultural, social, and health system factors affecting utilization of health care. Never the less, no standardized instrument exists for collecting and interpreting information on how to avert death and improve the implementation of child survival interventions.

OBJECTIVE

To describe the methodology, development, and first results of a standard social autopsy tool for the collection of information to understand common barriers to health care, risky behaviors, and missed opportunities for health intervention in deceased children under 5 years old.

METHODS

Under the INDEPTH Network, a social autopsy working group was formed to reach consensus around a standard social autopsy tool for neonatal and child death. The details around 434 child deaths in Iganga/Mayuge Health and Demographic Surveillance Site (HDSS) in Uganda and 40 child deaths in Dodowa HDSS in Ghana were investigated over 12 to 18 months. Interviews with the caretakers of these children elicited information on what happened before death, including signs and symptoms, contact with health services, details on treatments, and details of doctors. These social autopsies were used to assess the contributions of delays in care seeking and case management to the childhood deaths.

RESULTS

At least one severe symptom had been recognized prior to death in 96% of the children in Iganga/Mayuge HDSS and in 70% in Dodowa HDSS, yet 32% and 80% of children were first treated at home, respectively. Twenty percent of children in Iganga/Mayuge HDSS and 13% of children in Dodowa HDSS were never taken for care outside the home. In both countries most went to private providers. In Iganga/Mayuge HDSS the main delays were caused by inadequate case management by the health provider, while in Dodowa HDSS the main delays were in the home.

CONCLUSION

While delay at home was a main obstacle to prompt and appropriate treatment in Dodowa HDSS, there were severe challenges to prompt and adequate case management in the health system in both study sites in Ghana and Uganda. Meanwhile, caretaker awareness of danger signs needs to improve in both countries to promote early care seeking and to reduce the number of children needing referral. Social autopsy methods can improve this understanding, which can assist health planners to prioritize scarce resources appropriately.

The burden of headache in a patient population from a specialized headache centre

The aim was to characterize the individual and socio-economic impact of headache in a patient population from The Danish Headache Centre. This was a cross-sectional study using a structured interview, prospective headache diaries and standardized self-administered questionnaires using the ICHD-II criteria. Fifty-five subjects (12 male and 43 female) with a median age of 41 years and a median headache frequency of 15 days/month participated. Very high utilization of the healthcare system and a high absence rate due to headache of 12 days/year were reported. Eighty-one percent experienced a marked decrease in work effectiveness. Overall, 91% felt hampered by their headache on a daily basis and 98% had had expenses for headache medication. Frequent headache disorders are highly costly, especially due to indirect costs. Prevention, early intervention or effective treatment strategies for headache disorders may therefore be highly cost effective, not only for the individual but also for society.

[Mobile extracorporeal shock wave lithotripsy of urinary calculi performed in the county of Ringkjobing]

Experiences with mobile extracorporeal shock wave lithotripsy (ESWL) of urinary calculi using a third generation lithotriptor are reported. A total of 146 renal units in 132 patients received 204 ESWL treatments with mobile lithotriptor for renal and ureteric stones. Treatments were given once a month at Holstebro Hospital and Herning Hospital alternately, with six to eight treatments per day. The overall success was 82% (53% stone-free). Success with renal stones was 89% (51% stone-free) and that with ureteric stones 66% (59% stone-free). Retrograde manipulation appeared to be a safe and effective treatment for patients with obstructing upper ureteric stones. Treatment of other ureteric stones in situ gave unsatisfactory results (success 52%, stone-free 51%). There were no serious complications.

[Ischemic stenosis of the small intestine after blunt abdominal trauma]

A case of posttraumatic ischaemic stenosis is presented. The patient, a five year-old girl, was admitted to hospital with physical and radiological signs of small bowel obstruction about two weeks after sustaining blunt abdominal trauma in a car accident. At laparotomy two lesions of the distal jejunum were found. Proximal to this the small intestine was dilated. A segment of 25 cms. of small bowel including the two lesions was resected. Microscopic examination showed two ulcers with adjacent fibrosis consistent with ischaemic stenosis. The patient recovered completely after the operation. The entity of "seat belt syndrome" is presented.

Computer-generated graphical presentations: use of multimedia to enhance communication

Personal computers may be used to create, store, and deliver graphical presentations. With computer-generated combinations of the five media (text, images, sound, video, and animation)--that is, multimedia presentations--the effectiveness of message delivery can be greatly increased. The basic tools are (1) a personal computer; (2) presentation software; and (3) a projector to enlarge the monitor images for audience viewing. Use of this new method has grown rapidly in the business-conference world, but has yet to gain widespread acceptance at medical meetings. We review herein the rationale for multimedia presentations in medicine (vis-à-vis traditional slide shows) as an improved means for increasing audience attention, comprehension, and retention. The evolution of multimedia is traced from earliest times to the present. The steps involved in making a multimedia presentation are summarized, emphasizing advances in technology that bring the new method within practical reach of busy physicians. Specific attention is given to software, digital image processing, storage devices, and delivery methods. Our development of a urology multimedia presentation--delivered May 4, 1996, before the Society for Urology and Engineering and now Internet-accessible at http://www.usrf.org--was the impetus for this work.

[Evaluation of sex education and contraception instruction at the contraception clinic in Odense]

The aim of the study was to evaluate 1 1/2 hours of lessons on contraception given to 9. and 10. grade students at the Contraception Clinic in Odense, Denmark. The lessons are a supplement to the traditional sexual education given at the school. The study included 148 pupils in the period from August 1991 to January 1992. The median age was 15 years for both girls and boys. The pupils answered two identical questionnaires; one just before the lessons were given and the other ten to 13 weeks after the visit to the clinic. The article presents the answers given about male and female sexual function, knowledge/own choice of contraception, pregnancy, abortion and HIV. The extra lessons improved the knowledge among the pupils, but there were still some boys with inadequate knowledge. The article gives suggestions for improving the teaching of contraception, such as having both male and female teachers. This would also emphasize that both sexes have a common responsibility. If the pupils answer a simple questionnaire before the lessons, it is possible to goal-direct the education to individual requirements. The pupils are introduced to the Contraception Clinic, where they easily can seek advice in the future.