Evidence for the elimination of viral hepatitis B and C in Egypt: Results of a nationwide survey in 2022

INTRODUCTION

Viral hepatitis C (HCV) and B (HBV) were at the top of Egypt's most significant public health challenges, with an estimated 14.7% of its population having antibodies to HCV in 2008. Egypt issued an ambitious action plan in 2014 to eliminate viral hepatitis through strengthening infection control and improving patient care. In 2018, an extensive HCV mass screening campaign was conducted for the entire country's population with treating more than 4 million patients with antivirals. This study aimed to evaluate the current prevalence of viral hepatitis in Egypt after all these efforts.

METHODS

A cross-sectional household cluster survey was conducted in all 27 Egyptian governorates to obtain a representative sample of Egypt's population. Subjects aged 1-70 years were interviewed using a standardised questionnaire that included demographics, viral hepatitis knowledge, previous infection and risk factors data. Laboratory testing was performed for all subjects for anti-HCV and HBsAg using chemiluminescence. Subjects positive for anti-HCV were further tested for HCV-RNA by RT-PCR. Prevalence rates were calculated by demographic groups and compared to the demographic health survey 2015 results.

RESULTS

Of 20 881 subjects interviewed, 48.8% were males, 20.2% were children <15 years of age, and 53.7% were residents of rural areas. Of all subjects, 92 (0.4%) were HCV-infected, 1577 (7.6%) were anti-HCV positive and 177 (0.8%) were HBV-chronically infected, including one patient who had mixed HBV and HCV current infection. The prevalence of HCV-current and HBV chronic infections decreased by 93% and 20%, respectively, compared to 2015.

CONCLUSIONS

Egypt achieved the elimination of the viral hepatitis goal. To maintain low rates of viral hepatitis, community health education, in addition to maintaining infection control and blood safety programs, is essential.

Comparative analysis of COVID-19 and influenza prevalence among Egyptian pilgrims returning from Hajj and Umrah in 2022: epidemiology, clinical characteristics, and genomic sequencing

PURPOSE

To describe the changes that occurred in the SARS-CoV-2 and influenza Prevalence, epidemiology, clinical picture, and prevalent genotypes among the Egyptian pilgrims returning from Hajj and Umrah 2022 seasons.

METHODS

Pilgrims were contacted at the airport and invited to participate in the survey. Pilgrims who consented were interviewed using a standardized line list that included participant demographics, respiratory symptoms if any, previous COVID-19 infection, influenza vaccination whereas COVID-19 vaccination information were collected from vaccination cards. Participants were asked to provide throat and nasopharyngeal swabs for SARS-CoV-2 and influenza testing using RT-PCR and a subset of isolates were sequenced. Descriptive data analysis was performed to describe the epidemiology and clinical symptoms of SARS-CoV-2 and influenza. Prevalence rates of SARS-CoV-2 and influenza during Hajj were calculated and compared to Umrah surveys using chi2 and t-test with a significance level < 0.05.

RESULTS

Overall, 3,862 Egyptian pilgrims enrolled, their mean age was 50.5 ± 47 years, half of them were > 50 years of age and 58.2% were males. Of them, 384 (9.9%) tested positive for SARS-CoV-2 and 51 (1.3%) for influenza viruses. Prevalence of SARS-CoV-2 infections (vaccine breakthrough) increased significantly between the Umrah and Hajj surveys (6.7% vs. 9.9%, p < 0.001), and variants of the virus varied considerably. Whereas no significant difference was found in influenza prevalence, vaccine coverage and vaccine breakthrough infection rates (11.7 vs. 9.2%, 26.9 vs. 26.8%, and 1.4 vs. 1.1% respectively).

CONCLUSIONS

SARS-CoV-2 prevalence among Egyptian pilgrims returning from Hajj in July increased with reduced vaccine effectiveness compared to Umrah in March 2022 suggesting a possible wave of SARS-CoV-2 in the upcoming winter.

Multicenter study to describe viral etiologies, clinical profiles, and outcomes of hospitalized children with severe acute respiratory infections, Egypt 2022

In late 2022, severe acute respiratory infections (SARI) surveillance reported an abrupt increase in non-COVID-19 infections among children after three years of drastic reductions. Signals of increased absenteeism due to respiratory symptoms among primary and preparatory school children were detected by Event-Based Surveillance. We conducted a hospital-based survey of children who were admitted with SARI to identify the causative pathogen(s) and estimate the burden of infection. A survey was conducted among children < 16 years in 21 referral hospitals in the three governorates with the highest SARI rates. Patients' demographics, clinical symptoms, and severity were collected from medical records using a line list. Patients were swabbed and tested for a panel of 33 respiratory pathogens by RT-PCR at the Central Laboratory in Cairo. Descriptive data analysis was performed for demographic data. Patients' characteristics were compared by causative agents' clinical picture and severity using Chi2 with a p < 0.05 significance. Overall, 317 patients were enrolled, 58.3% were ≤ 1 year of age, 61.5% were males. Of 229 (72.7%) of positively tested patients, viruses caused 92.1% including RSV 63.8%, Rhinovirus 10.0%, Influenza 9.2%, Adenovirus 5.2%, and 1.3% co-infected with two viruses. Bacteria caused 3.5% of cases and 4.4% had mixed viral-bacterial infections. Rhinovirus was the most common cause of death among children with SARI, followed by RSV (8.7% and 1.4%), whereas influenza and Adenovirus did not result in any deaths. Patients with viral-bacterial infections are more likely to be admitted to ICU and die at the hospital than bacterial or viral infections (60% and 20% vs. 31.8% and 1.9% vs. 12.5% and 12.5%, p < 0.001). Viruses particularly RSV are the leading cause of SARI causing significant health problem among children < 16 years in Egypt. Bacterial on top of viral infection can worsen disease courses and outcomes. Studies are required to estimate the SARI burden accurately among Egyptian children and a comprehensive approach tailored to Egypt is necessary to reduce its burden.

Comparison of SARS-Cov-2 omicron variant with the previously identified SARS-Cov-2 variants in Egypt, 2020-2022: insight into SARS-Cov-2 genome evolution and its impact on epidemiology, clinical picture, disease severity, and mortality

BACKGROUND

The o severe acute respiratory coronavirus 2 (SARS-CoV-2) pandemic has killed millions of people and caused widespread concern around the world. Multiple genetic variants of SARS-CoV-2 have been identified as the pandemic continues. Concerns have been raised about high transmissibility and lower vaccine efficacy against omicron. There is an urgent need to better describe how omicron will impact clinical presentation and vaccine efficacy. This study aims at comparing the epidemiologic, clinical, and genomic characteristics of the omicron variant prevalent during the fifth wave with those of other VOCs between May 2020 and April 2022.

METHODS

Epidemiological data were obtained from the National Electronic Diseases Surveillance System. Secondary data analysis was performed on all confirmed COVID-19 patients. Descriptive data analysis was performed for demographics and patient outcome and the incidence of COVID-19 was calculated as the proportion of SARS-CoV-2 confirmed patients out of the total population of Egypt. Incidence and characteristics of the omicron cohort from January- April 2022, were compared to those confirmed from May 2020-December 2021. We performed the whole-genome sequencing of SARS-CoV-2 on 1590 specimens using Illumina sequencing to describe the circulation of the virus lineages in Egypt.

RESULTS

A total of 502,629 patients enrolled, including 60,665 (12.1%) reported in the fifth wave. The incidence rate of omicron was significantly lower than the mean of incidences in the previous subperiod (60.1 vs. 86.3/100,000 population, p < 0.001). Symptoms were reported less often in the omicron cohort than in patients with other variants, with omicron having a lower hospitalization rate and overall case fatality rate as well. The omicron cohort tended to stay fewer days at the hospital than did those with other variants. We analyzed sequences of 2433 (1590 in this study and 843 were obtained from GISAID platform) Egyptian SARS-CoV-2 full genomes. The first wave that occurred before the emergence of global variants of concern belonged to the B.1 clade. The second and third waves were associated with C.36. Waves 4 and 5 included B.1.617.2 and BA.1 clades, respectively.

CONCLUSIONS

The study indicated that Omicron-infected patients had milder symptoms and were less likely to be hospitalized; however, patients hospitalized with omicron had a more severe course and higher fatality rates than those hospitalized with other variants. Our findings demonstrate the importance of combining epidemiological data and genomic analysis to generate actionable information for public health decision-making.

Resurgence of influenza and respiratory syncytial virus in Egypt following two years of decline during the COVID-19 pandemic: outpatient clinic survey of infants and children, October 2022

INTRODUCTION

Two years after unprecedented low rates of circulation of most common respiratory viruses (SARS-CoV-2), the Egyptian ARI surveillance system detected an increase in acute respiratory infections (ARIs) with a reduced circulation of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), especially among school children. A national survey was conducted to estimate the burden and identify the viral causes of ARIs among children < 16 years of age.

METHODS

A one-day survey was carried out in 98 governmental outpatient clinics distributed all over Egypt 26 governorates. The four largest referral hospitals in each governorate where most influenza-like illness (ILI) patients seek care were selected. Using the WHO case definition, the first five patients < 16 years of age with ILI symptoms visiting the selected outpatient clinics on the survey day were enrolled. Basic demographic and clinical data of patients were collected using a linelist. Patients were swabbed and tested for SARS-CoV-2, influenza, and Respiratory Syncytial virus (RSV) by RT-PCR at the Central Laboratory in Cairo.

RESULTS

Overall, 530 patients enrolled, their mean age was 5.8 ± 4.2, 57.1% were males, and 70.2% reside in rural or semi-rural areas. Of all patients, 134 (25.3%) had influenza, 111 (20.9%) RSV, and 14 (2.8%) coinfections. Influenza-positive children were older compared to RSV, (7.2 ± 4.1, 4.3 ± 4.1, p < 0.001), with more than half of them (53.0%) being school students. Dyspnea was reported in RSV more than in influenza (62.2% vs. 49.3%, p < 0.05). Among RSV patients, children < 2 years had a higher rate of dyspnea than others (86.7% vs. 53.1%, < 0.001).

CONCLUSIONS

A resurgence of influenza and RSV was detected in Egypt in the 2022-2023 winter season. Influenza caused a higher rate of infection than RSV, while RSV caused more severe symptoms than influenza. Monitoring a broader range of respiratory pathogens is recommended to estimate the ARI burden and risky groups for severe disease in Egypt.

COVID-19 vaccination coverage in Egypt: a large-scale national survey - to help achieving vaccination target, March-May, 2022

BACKGROUND

Only 57 countries have vaccinated 70% of their population against COVID-19, most of them in high-income countries, whereas almost one billion people in low-income countries remained unvaccinated. In March-May 2022, Egypt's Ministry of Health and Population (MoHP) conducted a nationwide community-based survey to determine COVID-19 vaccine coverage and people's perceptions of vaccination in order to improve COVID-19 vaccination uptake and confidence among Egyptians, as well as to prioritize interventions.

METHODS

A cross-sectional population-based household survey among Egyptians ≥ 18 years of age was implemented in two phases using a multistage random sampling technique in all of Egypt's 27 governorates. A sample of 18,000 subjects divided into 450 clusters of 20 households each was calculated in proportion to each governorate and the main occupation of the population. Participants were interviewed using a semistructured questionnaire that included demographics, vaccination information from the vaccination card, history of COVID-19 infection, reasons for vaccine refusal among the unvaccinated, and vaccination experience among vaccinated subjects. Vaccination coverage rates were calculated by dividing numbers by the total number of participants. Bivariate and multivariate analyses were performed by comparing the vaccinated and unvaccinated to identify the risk factors for low vaccine uptake.

RESULTS

Overall 18,107 were interviewed, their mean age was 42 ± 16 years and 58.8% were females. Of them, 8,742 (48.3%) had COVID-19 vaccine and 8,020 (44.3%) were fully vaccinated. Factors associated with low vaccination uptake by multivariate analysis included: age groups (18-29 and 30-39) (ORs 2.0 (95% C.I. 1.8-2.2) and 1.3 (95% C.I.1.2-1.4), respectively), residences in urban or frontier governorates (ORs 1.6 (95% C.I. 1.5-1.8) and 1.2 (95% C.I. 1.1-1.4), respectively), housewives and self-employed people (ORs 1.3 (95% C.I. 1.2-1.4) and 1.2 (95% C.I. 1.1-1.4), respectively), married people (ORs 1.3 (95% C.I. 1.2-1.4), and primary and secondary educated (ORs 1.1 (95% C.I. 1.01-1.2) and 1.1(1.04-1.2) respectively). Vaccine hesitancy was due to fear of adverse events (17.5%), mistrust of vaccine (10.2%), concern over safety during pregnancy and lactation (6.9%), and chronic diseases (5.0%).

CONCLUSIONS

Survey identified lower vaccination coverage in Egypt compared to the WHO 70% target. Communication programs targeting the groups with low vaccine uptake are needed to eliminate barriers related to vaccination convenience, side effects, and safety to effectively promote vaccine uptake. Findings from the survey could contribute significantly to vaccination promotion by guiding decision-making efforts on the risky groups and preventing vaccine hesitancy.

Adapting an integrated acute respiratory infections sentinel surveillance to the COVID-19 pandemic requirements, Egypt, 2020-2022

Objectives

In Egypt, an integrated surveillance for acute respiratory infections (ARIs) was established in 2016 to identify the causes of ARIs. The surveillance system includes 19 governmental hospitals. In response to the coronavirus disease 2019 (COVID-19) pandemic, the World Health Organisation (WHO) requested surveillance adaptation to address the emerging challenges. This study aims to describe the experience in Egypt of adapting ARI surveillance to the COVID-19 pandemic.

Methods

WHO case definitions were used to identify patients with ARIs. Nasopharyngeal/oropharyngeal swabs were collected for SARS-CoV-2 and influenza testing. Demographic and clinical information were obtained by interviewing patients at the hospitals. During the COVID-19 pandemic, the first two outpatients daily and every fifth admitted patient were enrolled in the study. To determine the status of ARIs in Egypt during the pandemic, patient demographic, clinical and laboratory data from 2020 to 2022 were obtained and descriptive analyses were performed.

Results

Overall, 18,160 patients were enrolled in the study, including 7923 (43.6%) seen at outpatient clinics and 10,237 (56.4%) inpatients. Of the study participants, 6453 (35.5%) tested positive for ARIs, including 5620 (87.1%) for SARS-CoV-2, 781 (12.1%) for influenza and 52 (0.8%) for SARS-CoV-2/influenza coinfection. SARS-CoV-2 was the cause for 95.3% of admitted patients and 65.4% of outpatients. Influenza subtypes included A/H3 (55.7%), Influenza-B (29.1%) and H1/pdm09 (14.2%). Compared with influenza, SARS-CoV-2 tended to infect the elderly, in warm weather and in urban governorates, and resulted in more hospitalisations, longer hospital stays and higher case fatalities (16.3% vs 6.6%, p < 0.001).

Conclusions

ARI surveillance in Egypt was successfully adapted to the COVID-19 pandemic and effectively described the clinical characteristics and severity of circulating viruses. Surveillance reported the re-emergence of influenza with a severe course and high fatality. Surveillance is essential for monitoring the activity of respiratory viruses with the aim of guiding clinical management, including preventative and control measures.

Incidence, risk factors, and whole-genome sequence of SARs-CoV-2 and influenza virus among the Egyptian pilgrims returning from Umrah mass gathering in Saudi Arabia, April-May 2022

BACKGROUND

Ramadan Umrah is the second largest Islamic pilgrimage with 2.75 million pilgrims allowed in 2022. This report presents the results of a survey among Egyptian pilgrims returning from Ramadan Umrah to monitor SARS-CoV-2 and influenza activity and identify prevalent SARS-CoV-2 variants after this mass gathering.

METHODS

Cross-sectional survey conducted at Cairo airport from 30th April 2022-5 th May 2022. Pilgrims were invited to participate voluntarily. After consenting, participants interviewed using questionnaire including demographics, health status, and vaccination information and asked to provide NP/OP swabs for SARS-CoV-2 and influenza testing by RT-PCR. Whole-genome sequencing performed for 29 SARS-CoV-2 isolates. Incidence calculated, descriptive data analysis performed, and SARS-CoV-2 patients were compared to negatively tested participants using chi2 and p value< 0.05.

RESULTS

Overall, 1003 subjects participated, their mean age 50.9 ± 13 years, 594 (59.2%) were males. Of them, 76(7.6%) tested positive including 67(6.7%) SARS-CoV-2, 7(0.7%) influenza and 2(0.2%) SARS-CoV-2/influenza coinfection. Omicron sublineage BA.2 was the prevalent variant with no difference in severity identified between BA.1 and BA.2. No difference was identified between COVID-19 incidence among receivers of different vaccine types or between fully vaccinated and booster dose receivers.

CONCLUSIONS

Survey indicated a low incidence of SARs-CoV-2 and influenza among Egyptian pilgrims returning from Ramadan Umrah. Patients had mild or no symptoms with no hospitalization or deaths reported. Full vaccination and booster doses of COVID-19 vaccines proved equally effective. Enhancing COVID-19 and influenza vaccination before mass gatherings and close monitoring of respiratory viruses among pilgrims returning from Hajj and Umrah are crucial for outbreak early detection and mitigation.

The value of contact tracing and isolation in mitigation of COVID-19 epidemic: findings from outbreak investigation of COVID-19 onboard Nile Cruise Ship, Egypt, March 2020

WHO informed Egypt health authorities of individuals of different nationalities who proved positive for COVID-19 after returning from Egypt. Patients were among touristic group who visited Cairo and spent 1-week onboard Nile cruise ship. Investigation performed to confirm outbreak, detect source, and implement containment measures. Active case finding and contact tracing performed among contacts of the index cases and their contacts. Contacts defined as anyone within 6 feet from confirmed or suspected COVID-19 case for ≥15 min. Overall, 331 contacts, including 201 ship boarders and 130 hotel guests, were listed and interviewed using semistructured questionnaire and tested for COVID-19 by PCR. Among them, 136 (41.1%) were close contacts of index cases and 195 (58.9%) contacted secondary cases. Their mean age was 34.6±11.5 years, 251 (75.8%) were males and 126 (38.1%) non-Egyptians. Of them, 67 (20.2%) tested positive for COVID-19, including 57 (28.4%) ship boarders and 10 (7.7%) hotel guests. Per cent positive was significantly higher in: contacts of index cases, Egyptians, ship boarders and in males than corresponding categories (35.3% vs 9.7%, 22.9% vs 15.9%, 27.4% vs 7.7%, 24.7% vs 6.3%), respectively. Of all positive cases, 40 (59.7%) were asymptomatic where ship boarders, non-Egyptians, >50 years old and females were more likely to be asymptomatic than corresponding categories (85.0 vs 48.9%, 72.7 vs 54.5%, 100.0 vs 56.5%), respectively. COVID-19 patients among group of tourists triggered an outbreak onboard Nile ship and hotel in Egypt. Outbreak quickly contained through lab testing, case isolation, strict infection control measures and contact tracing which proved effective in reducing COVID-19 transmission early in pandemic.

Functional and mental health affection (depression, anxiety, stress) among Egyptian rheumatic diseases patients during COVID-19 pandemic

OBJECTIVE

Psychological distress caused by the SARS-CoV-2 outbreak has had deleterious effects on patients with chronic rheumatic disease, as those patients were highly susceptible for COVID-19 infection due to their chronicity, in addition to use of immunosuppressive drugs. Therefore, they underwent to more isolation than other people and develop more stress and depression. This study aimed at evaluating level of depression, anxiety, stress symptoms and physical health status in Egyptian patients with various rheumatic diseases during COVID-19 pandemic.

PATIENTS AND METHODS

This is a cross-sectional study conducted in Gharbia Governorate, Egypt. It included 440 diagnosed cases of rheumatic diseases from 1st to the end of March 2021. Depression, Anxiety and Stress Scale-21 (DASS21) and RAPID3/MDHAQ test were used to assess the pandemic's psychological and functional effect on participants.

RESULTS

RAPID3 test results showed that during the COVID-19 outbreak the 40% of patients had a moderate severity functional affection and 20% had high severity. DASS21 depression scoring showed mild to moderate depression (33% and 35%, respectively), while severe depression was detected in only 3.2% of cases. Moderate anxiety was reported in 49% of cases, 29% had severe anxiety while 1% showed extremely severe anxiety. Mild to moderate stress was reported in 17% and 16%, respectively. Female and cases aged more than 45 years had significantly more severe functional affection recorded by RAPID3 test, moderate stress and severe anxiety. On the other hand, severe depression was significantly higher in male and young patients younger than 45 years old.

CONCLUSIONS

Rheumatic disease patients have been highly susceptible to functional affection and psychological distress related to COVID-19 pandemic. Planning and implementation of programs to enforce coping strategies for these patients are required.

Effects of bisphenol A on pancreas and thyroid gland of young and adult female Sprague Dawlеy rats

Bisphenol A (BPA), a chemical involved in formation of plastic vessels, is one of the most widespread endocrine disrupting chemicals. The study was designed to investigate the effect of BPA on pancreas and thyroid gland of young and adult female Sprague Dawley rats. The rats were exposed to 330 mg/kg BPA orally every other day for 12 weeks; control rats were exposed orally to ethyl alcohol and corn oil. Samples were collected at 4, 8 and 12 weeks for hormonal, biochemical assays and histopathological examination. The insulin hormone in exposed young rats was decreased, but its level in adult ones was increased; the biochemical assay for blood sugar level showed a significant increase in young rats and decrease in adult ones. T3 hormone was increased in treated young and adult rats; T4 hormone was increased in treated adults, while calcium level was decreased in treated adult rats. The histopathological findings of pancreas revealed vacuolation in its endocrine parts in young rats, while in adult ones there was intralobular fatty infiltration - a typical picture of diabetes. The thyroid gland in treated young female rats showed increased cellularity of parafollicular cells; moreover there was parafollicular haemorrhage, and in adult ones - desquamation in lining epithelium of follicular cells. In conclusion, exposure of young and adult female rats to BPA resulted in changes in the pancreatic and thyroid gland cells manifested by morphological, hormonal and biochemical parameters.

Public health workers' knowledge, attitude and practice regarding COVID-19: the impact of Field Epidemiology Training Program in the Eastern Mediterranean Region

BACKGROUND

This study aimed to compare knowledge, attitude and practice (KAP) regarding COVID-19 between public health workers (PHWs) attended field epidemiology training program (FETP-trained) and those who did not attend FETP (non-FETP trained).

METHODS

Multi-country cross-sectional survey was conducted among PHWs who participated in COVID-19 pandemic in 10 countries at EMR. Online questionnaire that included demographic information, KAP regarding COVID-19 pandemic was distributed among HCWs. Scoring system was used to quantify the answers, bivariate and Multivariate analysis performed to compare FETP-trained with non-FETP trained PHWs.

RESULTS

Overall, 1337 PHWs participated, with 835 (62.4%) < 40 years of age, and 851 (63.6%) males. Of them, 423 (31.6%) had FETP, including that 189 (44.7%) had advanced level, 155 (36.6%) intermediate and 79 (18.7%) basic level training. Compared with non-FETP trained, FETP trained were older, having higher KAP scores. FETP participation was low in infection control, and PH laboratories. KAP mean scores for intermediate level attendees are comparable to advanced level.

CONCLUSIONS

FETP-trained are having better KAP than non-FETP PHWs. Expanding the intermediate level, maintain the Rapid Response training and introduce the laboratory component are recommended to maximize the benefit from FETP. Infection control, antimicrobial resistance and coordination are areas where training should include.

COVID-19 outcomes among pregnant and nonpregnant women at reproductive age in Egypt

BACKGROUND

To describe demographic, clinical and epidemiological characteristics of pregnant and nonpregnant women with confirmed COVID-19 at reproductive age and determine risk factors of COVID-19 severe outcomes during pregnancy.

METHODS

A retrospective study for females aged 18-49 with confirmed COVID-19 by RT-PCR in Egypt, February-July 2020. Data were obtained from Egypt National Surveillance, bivariate and multivariate analysis for demographic and clinical characteristics and outcomes of COVID-19 between pregnant and nonpregnant women including ICU admission, need for ventilator and death was performed.

RESULTS

A total of 23 095 females were identified, with mean (SD) age of 35.1 (8.1) year. Of those, 408 (1.8%) were pregnant, with mean (SD) age of 29.3 (8.1) years. Compared to nonpregnant, pregnant patients were more likely to be admitted to hospital (OR = 1.7 CI = 1.4-2.1), ICU (OR = 2.4, CI = 1.3-4.3), need ventilator (OR = 3.9, CI = 2.1-7.4) and have severe outcome (OR = 3.0, CI = 1.9-4.7). Factors associated with severe outcome included: pregnancy, age > 30 years, underlying medical conditions, and living in rural areas.

CONCLUSION

Pregnant women with COVID-19 are at higher risk of severe symptoms and outcome including ICU admission, requiring ventilator and death. To reduce risk of severe outcome, counseling about for seeking medical care and health education about COVID-19 preventive measures should be performed.

Mental health impacts of COVID-19 on healthcare workers in the Eastern Mediterranean Region: a multi-country study

Background

Healthcare workers (HCWs) fighting against the COVID-19 pandemic are under incredible pressure, which puts them at risk of developing mental health problems. This study aimed to determine the prevalence of depression, anxiety, and stress among HCWs responding to COVID-19 and its associated factors.

Methods

A multi-country cross-sectional study was conducted during July–August 2020 among HCWs responding to COVID-19 in nine Eastern Mediterranean Region (EMR) countries. Data were collected using an online questionnaire administered using KoBo Toolbox. Mental problems were assessed using the Depression, Anxiety, and Stress Scale (DASS-21).

Results

A total of 1448 HCWs from nine EMR countries participated in this study. About 51.2% were male and 52.7% aged ≤ 30 years. Of all HCWs, 57.5% had depression, 42.0% had stress, and 59.1% had anxiety. Considering the severity, 19.2%, 16.1%, 26.6% of patients had severe to extremely severe depression, stress, and anxiety, respectively. Depression, stress, anxiety, and distress scores were significantly associated with participants’ residency, having children, preexisting psychiatric illness, and being isolated for COVID-19. Furthermore, females, those working in a teaching hospital, and specialists had significantly higher depression and stress scores. Married status, current smoking, diabetes mellitus, having a friend who died with COVID-19, and high COVID-19 worry scores were significantly associated with higher distress scores.

Conclusions

Mental problems were prevalent among HCWs responding to COVID-19 in EMR. Therefore, special interventions to promote mental well-being among HCWs responding to COVID-19 need to be immediately implemented.

Risk Factors of COVID-19 Critical Outcomes in the Eastern Mediterranean Region: A Multicountry Retrospective Study

BACKGROUND

The establishment of empirical evidence in the Eastern Mediterranean Region (EMR) necessitates the implementation of wide-scale studies to describe the demographic, clinical features, and severity profile of COVID-19 patients.

OBJECTIVE

This study aimed to assess the patterns of COVID-19 severity and mortality in seven countries and to determine the risk factors of COVID-19 severity and mortality.

METHODS

This multi-country study was based on a retrospective review of medical records of hospitalized patients confirmed to have COVID-19. This study included data from Iraq, Pakistan, Sudan, Somalia, Morocco, Egypt, and Yemen. All demographic and clinical data were extracted from hospital records (paper files) by trained data collectors.

RESULTS

A total of 4141 patients were included in this study from seven countries. Comorbidities were reported by nearly half of the patients, with hypertension (HT) (24.7%) and diabetes (22.7%) being the most common. Older age, diabetes mellitus, hypertension, and heart diseases were significantly associated with COVID-19 severity and mortality. Ever smoking and renal diseases were significantly associated with severity but not mortality, while male gender, respiratory diseases, and malignancy were significantly associated with mortality but not severity.

CONCLUSIONS

The study confirmed the role of comorbidities and demographic features on the severity and mortality of COVID-19. Understanding the contributing factors ensures attentive care and informs clinical management of patients with poorer prognoses in the early stages of diseases.

Risk Factors of COVID-19 Critical Outcomes in the Eastern Mediterranean Region: Multicountry Retrospective Study (Preprint).. [DOI: 10.2196/preprints.32831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

The establishment of empirical evidence in the Eastern Mediterranean Region necessitates the implementation of wide-scale studies to describe the demographic, clinical features, and severity profile of patients with COVID-19.

OBJECTIVE

This study aims to assess the patterns of COVID-19 severity and mortality in seven countries, and to determine the risk factors of COVID-19 severity and mortality.

METHODS

This multicountry study was based on a retrospective review of medical records of hospitalized patients confirmed to have COVID-19. This study includes data from Iraq, Pakistan, Sudan, Somalia, Morocco, Egypt, and Yemen. All demographic and clinical data were extracted from hospital records (paper files) by trained data collectors.

RESULTS

A total of 4141 patients were included in this study from seven countries. Comorbidities were reported by nearly half of the patients, with hypertension (n=1021, 24.7%) and diabetes (n=939, 22.7%) being the most common. Older age, diabetes mellitus, hypertension, and heart diseases were significantly associated with COVID-19 severity and mortality. Ever smoking and renal diseases were significantly associated with severity but not mortality, while male gender, respiratory diseases, and malignancy were significantly associated with mortality but not severity.

CONCLUSIONS

The study confirms the role of comorbidities and demographic features on the severity and mortality of COVID-19. Understanding the contributing factors ensures attentive care and informs clinical management of patients with poorer prognoses in the early stages of diseases.

Epidemiology and outcome of influenza-associated infections among hospitalized patients with acute respiratory infections, Egypt national surveillance system, 2016-2019

Introduction

Egypt has established different types of surveillance systems to monitor influenza activities, early detect outbreaks, and tailor efficient prevention and control strategies. This is the first study to describe epidemiology and outcome of influenza‐associated infections among hospitalized patients using the National Electronic Disease Surveillance System (NEDSS) data, 2016‐2019.

Methods

Data reported from 284 hospitals all over Egypt were extracted from the NEDSS. Data of hospitalized patients with Acute Respiratory Infections (ARI), 2016‐2019, were included in the analysis. Laboratory testing for influenza by RT‐PCR according to US CDC testing protocol was used to confirm influenza type and subtype.

Results

Overall 46 417 patients hospitalized with ARI were identified, their mean age was 30.9 ± 26 and 52.9% were males. Among 41 512 (89.4%) laboratory‐tested patients, 7167 (17.3%) were positive for one or more types of influenza viruses. Influenza viruses circulated in all ages and throughout the year, with higher rates in winter, late childhood, and middle ages. Mortality from influenza was significantly higher than other causes of ARIs (5.0% vs 3.8%, P < .001), and it was associated with older ages, December‐May, delay in hospital admission, residence in urban and frontier governorates and infection with A/H1N1 virus. The distribution of influenza subtype by time shows alternate pattern between A/H1N1 and H3N2, each subtype peaks every other year with a high peak of A/H1N1 in 2016.

Conclusions

The national Egyptian surveillance succeeded to describe the epidemiology of hospitalized patients with ARIs and influenza in Egypt over time. Surveillance with strain‐specific laboratory testing and annual assessment of associated severity might be useful to guide influenza prevention and control strategies including vaccination and case management.

The Impact of Implementing the Egypt Pandemic Preparedness Plan for Acute Respiratory Infections in Combating the Early Stage of the COVID-19 Pandemic, February-July 2020: Viewpoint

This article briefly describes Egypt’s acute respiratory infection (ARI) epidemic preparedness and containment plan and illustrates the impact of implementation of the plan on combating the early stage of the COVID-19 epidemic in Egypt. Pillars of the plan include crisis management, enhancing surveillance systems and contact tracing, case and hospital management, raising community awareness, and quarantine and entry points. To identify the impact of the implementation of the plan on epidemic mitigation, a literature review was performed of studies published from Egypt in the early stage of the pandemic. In addition, data for patients with COVID-19 from February to July 2020 were obtained from the National Egyptian Surveillance system and studied to describe the situation in the early stage of the epidemic in Egypt. The lessons learned indicated that the single most important key to success in early-stage epidemic containment is the commitment of all partners to a predeveloped and agreed-upon preparedness plan. This information could be useful for other countries in the region and worldwide in mitigating future anticipated ARI epidemics and pandemics. Postepidemic evaluation is needed to better assess Egypt’s national response to the COVID-19 epidemic.

Coinfection With SARS-CoV-2 and Influenza A(H1N1) in a Patient Seen at an Influenza-like Illness Surveillance Site in Egypt: Case Report

Background

Sentinel surveillance of influenza-like illness (ILI) in Egypt started in 2000 at 8 sentinel sites geographically distributed all over the country. In response to the COVID-19 pandemic, SARS-CoV-2 was added to the panel of viral testing by polymerase chain reaction for the first 2 patients with ILI seen at one of the sentinel sites. We report the first SARS-CoV-2 and influenza A(H1N1) virus co-infection with mild symptoms detected through routine ILI surveillance in Egypt.

Objective

This report aims to describe how the case was identified and the demographic and clinical characteristics and outcomes of the patient.

Methods

The case was identified by Central Public Health Laboratory staff, who contacted the ILI sentinel surveillance officer at the Ministry of Health. The case patient was contacted through a telephone call. Detailed information about the patient’s clinical picture, course of disease, and outcome was obtained. The contacts of the patient were investigated for acute respiratory symptoms, disease confirmation, and outcomes.

Results

Among 510 specimens collected from patients with ILI symptoms from October 2019 to August 2020, 61 (12.0%) were COVID-19–positive and 29 (5.7%) tested positive for influenza, including 15 (51.7%) A(H1N1), 11 (38.0%) A(H3N2), and 3 (10.3%) influenza B specimens. A 21-year-old woman was confirmed to have SARS-CoV-2 and influenza A(H1N1) virus coinfection. She had a high fever of 40.2 °C and mild respiratory symptoms that resolved within 2 days with symptomatic treatment. All five of her family contacts had mild respiratory symptoms 2-3 days after exposure to the confirmed case, and their symptoms resolved without treatment or investigation.

Conclusions

This case highlights the possible occurrence of SARS-CoV-2/influenza A(H1N1) coinfection in younger and healthy people, who may resolve the infection rapidly. We emphasize the usefulness of the surveillance system for detection of viral causative agents of ILI and recommend broadening of the testing panel, especially if it can guide case management.

Beyond Ruxolitinib: Fedratinib and Other Emergent Treatment Options for Myelofibrosis

Myelofibrosis (MF) is a myeloproliferative neoplasm characterized by clonal proliferation of differentiated myeloid cells leading to bone marrow fibrosis, cytopenias and extramedullary hematopoiesis. In late 2019, the FDA approved the highly selective JAK2 inhibitor, fedratinib, for intermediate-2 or high-risk primary or secondary MF, making it the second drug approved for MF after ruxolitinib, a JAK1/2 inhibitor, which was approved for MF in 2011. The approval of fedratinib was based on phase II trials and the phase III JAKARTA trial, in which the drug significantly reduced splenomegaly and symptom burden compared to placebo, including some patients previously treated with ruxolitinib. The main side effects of fedratinib include anemia, gastrointestinal symptoms, and elevations in liver transaminases. Fedratinib also has ablack box warning for encephalopathy, although this occurred only in about 1% of the treated patients, most of which were ultimately felt not to represent Wernicke’s encephalopathy. Nonetheless, monitoring of thiamine levels and supplementation are recommended especially in high-risk patients. This concern has led to a prolonged clinical hold and delayed the drug approval by several years during which the drug exchanged manufacturers, highlighting the need for meticulous investigation and adjudication of serious, but rare, adverse events in drug development that could end up preventing drugs with favorable risk/benefit ratio from being approved. In this review, we discuss the pharmacokinetic data and efficacy, as well as the toxicity results of clinical trials of fedratinib. We also review ongoing trials of JAK inhibitors in MF and explore future treatment options for MF patients who are refractory to ruxolitinib.

2688. The Clinical Impact of Early De-escalation of Broad-Spectrum Antibiotics in Acute Myeloid Leukemia Patients with Febrile Neutropenia

Background

In patients with febrile neutropenia (FN) the initiation of broad-spectrum antibiotics (BSA), an anti-pseudomonal agent +/− vancomycin, is recommended by national guidelines. BSA should be continued until absolute neutrophil count (ANC) recovery (ANC > 500 cells/mm3). With increasing antimicrobial resistance, clinicians are reassessing the need to continue BSA until count recovery; new data are emerging that patients may be able to have their BSA de-escalated if stable and afebrile. At our institution, some patients are de-escalated from BSA to a fluoroquinolone before ANC recovery and others are continued on BSA. The purpose of this study was to evaluate the efficacy and safety of early de-escalation compared with the standard of care.

Methods

We retrospectively reviewed acute myeloid leukemia patients receiving induction chemotherapy who developed FN while at Yale New Haven Hospital from March 2013 to August 2018. Patients were excluded if they developed a culture documented infection, received incomplete or multiple induction chemotherapy treatments, or died from underlying disease during hospitalization. The primary outcome was recurrent fever during admission and secondary outcomes included incidence of breakthrough infections (BI), duration of hospital stay, early discharge (discharge before ANC recovery), duration of BSA, and readmission within 7 days of discharge.

Results

A total of 210 patients were evaluated and 91 patients were included (de-escalation, n = 45; BSA, n = 46). Baseline characteristics are noted in Table 1. There was no statistical difference in rate of recurrent fever in patients who were de-escalated from BSA compared with those that were continued (P = 0.05). De-escalated patients had a shorter duration of BSA therapy (P < 0.05), earlier discharge (P = 0.05) and no difference in readmission rates (P = 0.39) (Table 2). There was no difference in rate of BI between both groups and all BI were bacteremias. (Table 3) No patients who experienced a BI died from infection.

Conclusion

The results of this study revealed no difference in the primary outcome of recurrent fever between the BSA and de-escalation groups. De-escalation led to a reduced duration of BSA and facilitated earlier discharge without increasing readmission rates and BI.

Disclosures

All authors: No reported disclosures.

An educational intervention to promote appropriate antibiotic use for acute respiratory infections in a district in Egypt- pilot study

Background

Antibiotic overuse is the most important modifiable factor contributing to antibiotic resistance. We conducted an educational campaign in Minya, Egypt targeting prescribers and the public through communications focused on appropriate antibiotic use for acute respiratory infections (ARIs).

Methods

The entire population of Minya was targeted by the campaign. Physicians and pharmacists were invited to participate in the pre-intervention assessments. Acute care hospitals and a sample of primary healthcare centers in Minya were randomly selected for a pre-intervention survey and all patients exiting outpatient clinics on the day of the survey were invited to participate. The same survey methodology was conducted for the post-intervention assessments. Descriptive comparisons were made through three assessments conducted pre- and post-intervention. We quantitated antibiotic prescribing through a survey administered to patients with an ARI exiting outpatient clinics. Additionally, physicians, pharmacists, and patients were interviewed regarding their attitudes and beliefs towards antibiotic prescribing. Finally, physicians were tested on three clinical scenarios (cold, bronchitis, and sinusitis) to measure their knowledge on antibiotic use.

Results

Post-intervention patient exit surveys revealed a 23.1% decrease in antibiotic prescribing for ARIs in this population (83.7 to 64.4%) and physicians and pharmacists self-reported less frequently prescribing antibiotics for ARIs on their follow-up surveys. We also found an increase in correct responses to the clinical scenarios and in attitude and belief scores for physicians, pharmacists, and patients regarding antibiotic use in the post-intervention sample.

Conclusions

Overall, the samples surveyed after the community-based educational campaign reported a lower frequency of antibiotic prescribing and improved knowledge and attitudes regarding antibiotic misuse compared to the samples surveyed before the campaign. Ongoing interventions educating providers and patients are needed to decrease antibiotic misuse and reduce the spread of antibiotic resistance in Egypt.

Evidence of sustained reductions in the relative risk of acute hepatitis B and C virus infections, and the increasing burden of hepatitis a virus infection in Egypt: comparison of sentinel acute viral hepatitis surveillance results, 2001-17

BACKGROUND

Egypt ranks fifth for the burden of viral hepatitis worldwide. As part of Egypt's renewed national strategy for the elimination of viral hepatitis, surveillance for acute viral hepatitis (AVH) was re-established during 2014-2017 to describe the current epidemiology and associated risk factors, and changes from surveillance conducted during 2001-2004.

METHODS

Patients with suspected AVH were enrolled, completed a questionnaire, and provided blood for testing for hepatitis viruses A (HAV), B (HBV), C (HCV), D, and E (HEV) infections by enzyme-linked immunosorbent assay. Odds ratios and Chi2 were used to detect differences between hepatitis types by patient characteristics and exposures. Newcombe-Wilson method was used to compare results between surveillance periods 2001-2004 and 2014-2017.

RESULTS

Between 2014 and 2017, among 9321 patients enrolled, 8362 (89.7%) had one or more markers of AVH including 7806 (93.4%) HAV, 252 (3.0%) HCV, 238 (2.8%) HBV, and 31 (0.4%) HEV infection. HAV infection occurred most commonly among children < 16 years age, while HBV infection occurred among ages 16-35 years and HCV infection in ages greater than 45 years. Healthcare-associated exposures were significantly associated with HBV and HCV infections compared to HAV infection including receiving therapeutic injections, surgery, wound suture, or urinary catheter and IV line insertions, while significant lifestyle exposures included exposure to blood outside the healthcare system, IV drug use, or incarceration. Exposures significantly associated with HAV infection were attending nursery or pre-school, contact with person attending nursery or pre-school, having meals outside the home, or contact with HAV case. Compared with AVH surveillance during 2001-2004, there was a significant increase in the proportion of HAV infections from 40.2 to 89.7% (RR = 2.3) with corresponding reductions in the proportions of HBV and HCV infections from 30.0 to 2.8% (RR = 0.1) and 29.8 to 3.0% (RR = 0.1), respectively.

CONCLUSIONS

Healthcare-associated exposures were significantly association with and remain the greatest risk for HBV and HCV infections in Egypt. Additional studies to evaluate factors associated with the reductions in HBV and HCV infections, and cost effectiveness of routine HAV immunization might help Egypt guide and evaluate control measures.

Role of Histone Deacetylase Inhibitors in Relapsed Refractory Multiple Myeloma: A Focus on Vorinostat and Panobinostat

Multiple myeloma is a neoplastic plasma cell disorder that is characterized by clonal proliferation of plasma cells in the bone marrow, monoclonal protein in the blood and/or urine, and associated organ dysfunction and biomarkers. There have been multiple recent advances in the relapsed and refractory setting. Major steps forward include the introduction of proteasome inhibitors (bortezomib and carfilzomib) and immunomodulatory drugs (thalidomide, lenalidomide, and pomalidomide) in various combinations. These drugs have changed the management of multiple myeloma and have extended overall survival in the past decade. Established curative therapy is not yet available for patients diagnosed with multiple myeloma, supporting the development of new treatment targets. Histone deacetylase inhibitors have multiple proposed mechanisms of action in the treatment of multiple myeloma. Both vorinostat and panobinostat have demonstrated some activity against multiple myeloma, and due to the benefits reported with panobinostat, the U.S. Food and Drug Administration has recently approved the drug for the treatment of relapsed and refractory multiple myeloma. In this article, we describe the pharmacology, efficacy, and toxicity profile of vorinostat and panobinostat and their possible place in therapy.

Immunotherapy: A New Approach to Treating Multiple Myeloma with Daratumumab and Elotuzumab

OBJECTIVE

To review the clinical pharmacology, efficacy, and safety of daratumumab and elotuzumab for the treatment of relapsed refractory multiple myeloma (RRMM).

DATA SOURCES

A literature search of MEDLINE, PubMed, the US National Institutes of Health Clinicaltrials.gov, the Food and Drug administration, and relevant meeting abstracts was conducted using the terms daratumumab, elotuzumab, multiple myeloma, anti-CD38, HuMax-CD38, HuLuc63, SLAMF7, and anti-CS1 STUDY SELECTION/DATA EXTRACTION: Human and animal studies describing the pharmacology, pharmacokinetics, efficacy, and safety of daratumumab and elotuzumab for MM were identified.

DATA SYNTHESIS

Daratumumab (anti-CD38) and elotuzumab (anti-CS1) have been recently FDA approved for the treatment of RRMM after showing efficacy in clinical trials. Elotuzumab approval was based on phase III data, and daratumumab gained accelerated approval based on phase I/II trials. Daratumumab has demonstrated significant single-agent activity, with an overall response rate (ORR) of 36% in patients with a median of 4 prior lines of therapy. Elotuzumab has not been shown to have single-agent activity. But the efficacy of both these antibodies in combination with lenalidomide and dexamethasone in RRMM showed an ORR exceeding 80%. Tolerability of elotuzumab and daratumumab seems to be acceptable, with the most common adverse event being infusion reactions.

CONCLUSION

Daratumumab and elotuzumab have shown encouraging results in RRMM that led to their FDA approval. Both are well tolerated with minimal toxicities. Phase III clinical trials will define optimal combination and place in therapy of daratumumab and elotuzumab.

Is climate change a threat for water uses in the Mediterranean region? Results from a survey at local scale

Water scarcity and water security are linked, not only through the direct effects of water shortages on each water users' access to water, but also because of water conflicts generated. Climate change is predicted to raise temperatures in the Mediterranean region and reduce rainfall, leading to a reduction in water yield and possibly worsening the situation of water resource shortages that Mediterranean regions are already experiencing. In its dissemination strategy, the EU FP7 CLIMB project addressed water security threats through an analysis of water uses and water use rivalries within a few target catchments distributed over the Mediterranean region. The present work explores whether climate change is locally perceived by stakeholders (water users and managers) as a key issue for their water uses and water security. Individual interviews, meetings, and compilation of questionnaires were conducted at five sites located in the Mediterranean region. The methodology permitted an analysis of water use and its evolution in the water management context, an identification of the state of awareness of local stakeholders and of the pressures on water use and water use rivalries, and a prioritization of water uses. Currently, the main response to increasing water demand in the Mediterranean region, while not yet considering climate change as a driving force, is a progressive externalization of water resources, with limits represented by national borders and technological possibilities. Overall, 'climate change' was not mentioned by stakeholders during both interviews and in answers to the questionnaires. Even the prospect of decreasing precipitation was not considered a relevant or threatening issue in the coming 20years. This confirms the need to continue all efforts to disseminate the state of knowledge on climate change impacts in the Mediterranean region, such as water scarcity, especially to local water managers, as initiated by various research programs of the European Commission.

Upfront plerixafor plus G-CSF versus cyclophosphamide plus G-CSF for stem cell mobilization in multiple myeloma: efficacy and cost analysis study

Cyclophosphamide plus G-CSF (C+G-CSF) is one of the most widely used stem cell (SC) mobilization regimens for patients with multiple myeloma (MM). Plerixafor plus G-CSF (P+G-CSF) has demonstrated superior SC mobilization efficacy when compared with G-CSF alone and has been shown to rescue patients who fail mobilization with G-CSF or C+G-CSF. Despite the proven efficacy of P+G-CSF in upfront SC mobilization, its use has been limited, mostly due to concerns of high price of the drug. However, a comprehensive comparison of the efficacy and cost effectiveness of SC mobilization using C+G-CSF versus P+G-CSF is not available. In this study, we compared 111 patients receiving C+G-CSF to 112 patients receiving P+G-CSF. The use of P+G-CSF was associated with a higher success rate of SC collection defined as ⩾5 × 10(6) CD34+ cells/kg (94 versus 83%, P=0.013) and less toxicities. Thirteen patients in the C+G-CSF arm were hospitalized owing to complications while none in the P+G-CSF group. C+G-CSF was associated with higher financial burden as assessed using institutional-specific costs and charges (P<0.001) as well as using Medicare reimbursement rates (P=0.27). Higher rate of hospitalization, increased need for salvage mobilization, and increased G-CSF use account for these differences.

Characterization of Mycobacterium tuberculosis isolated from cancer patients with suspected tuberculosis infection in Egypt: identification, prevalence, risk factors and resistance pattern

Data are sparse on Mycobacterium tuberculosis infection among patients with cancer in Egypt. We sought to detect the presence of tuberculosis (TB) disease among patients with malignant conditions and suspected TB and to study the main risk factors. Also, we compared different diagnostic procedures and detected the antimicrobial susceptibility of M. tuberculosis isolates against rifampin and isoniazid. One hundred patients were included in this study, all of them had malignant conditions and were suspected by the clinicians of having TB. Identification of M. tuberculosis in different specimens was performed by smear microscopy, followed by Lowenstein-Jensen medium and Mycobacterium growth indicator tube (MGIT) cultures and artus(®) real-time PCR. In addition, an indirect MGIT anti-TB susceptibility test was carried out against rifampin and isoniazid. A total of 76% of studied cases were found to be TB positive. The frequencies of TB-positive cases in the bronchogenic, haematological and solid tumour malignancy groups were 21%, 25% and 30%, respectively. Significant differences between pulmonary and extrapulmonary TB in different malignancy groups were recorded. Real-time PCR showed the highest overall diagnostic efficiency. Multidrug-resistance of M. tuberculosis to both rifampin and isoniazid was detected in 28.6% of examined isolates. Infection in cancer patients with TB was significantly more often recorded among elderly patients and those suffering from poverty. Pulmonary TB is more common than extrapulmonary TB in patients with malignancy. Real-time PCR is the most accurate and rapid method for TB diagnosis. MGIT-rifampin resistance may be used as a reliable marker for detection of multidrug-resistant TB. Diagnosis and instituting treatment course for active or latent TB infection are crucial before starting anticancer therapy.

Pandemic (H1N1) 2009 and Hajj Pilgrims who received Predeparture Vaccination, Egypt

In Egypt, vaccination against pandemic (H1N1) 2009 virus was required of pilgrims departing for the 2009 Hajj. A survey of 551 pilgrims as they returned to Egypt found 542 (98.1% [weighted]) reported receiving the vaccine; 6 (1.0% [weighted]) were infected with influenza virus A (H3N2) but none with pandemic (H1N1) 2009 virus.

Effects of hand hygiene campaigns on incidence of laboratory-confirmed influenza and absenteeism in schoolchildren, Cairo, Egypt

To evaluate the effectiveness of an intensive hand hygiene campaign on reducing absenteeism caused by influenza-like illness (ILI), diarrhea, conjunctivitis, and laboratory-confirmed influenza, we conducted a randomized control trial in 60 elementary schools in Cairo, Egypt. Children in the intervention schools were required to wash hands twice each day, and health messages were provided through entertainment activities. Data were collected on student absenteeism and reasons for illness. School nurses collected nasal swabs from students with ILI, which were tested by using a qualitative diagnostic test for influenza A and B. Compared with results for the control group, in the intervention group, overall absences caused by ILI, diarrhea, conjunctivitis, and laboratory-confirmed influenza were reduced by 40%, 30%, 67%, and 50%, respectively (p<0.0001 for each illness). An intensive hand hygiene campaign was effective in reducing absenteeism caused by these illnesses.

Sentinel surveillance for patients with acute hepatitis in Egypt, 2001-04

Viral hepatitis is a major problem in Egypt. To define the epidemiology of the disease, sentinel surveillance was established in 5 hospitals in diverse areas of the country in 2001. Data were completed for patients meeting the case definition for viral hepatitis. Of a total of 5909 patients evaluated, 4189 (70.9%) showed positive antibody markers for hepatitis. Out of those, 40.2% had evidence of hepatitis A virus (HAV) infection, 30.0% hepatitis B virus (HBV) and 29.8% hepatitis C virus (HCV) infection. This surveillance system was useful in identifying the variable endemicity of acute HAV infection in different regions and for better understanding the epidemiology of HBV and HCV infection.

Laboratory-based surveillance of patients with bacterial meningitis in Egypt (1998–2004)

Laboratory-based surveillance for bacterial meningitis was conducted in a network of infectious disease hospitals in Egypt to better understand the epidemiology of this infection. Healthcare and laboratory personnel were trained in basic surveillance and microbiologic processing of cerebrospinal fluid (CSF) specimens. All bacterial isolates from CSF were confirmed and tested for antimicrobial susceptibility. PCR testing was performed on a random subset of purulent, culture-negative CSF specimens. Of 11,070 patients who met criteria for the case definition, 843 (8%) were culture positive (42% positive for Streptococcus pneumoniae, 20% for Haemophilus influenzae serotype b, 17% for each of Neisseria meningitidis and Mycobacterium tuberculosis, and 6% for other bacteria). Of 1,784 (46%) CSF specimens tested by PCR, 232 (13%) were positive for the first three major pathogens. Of N. meningitidis isolates, 52% belonged to serogroup A, 35% to serogroup B, and 4% to serogroup W135. S. pneumoniae isolates comprised 46 different serotypes, of which 6B, 1, 19A, 23F, and 6A were the most predominant. The overall case-fatality rate for culture-positive cases was 26% and was highest among patients with M. tuberculosis (47%). Factors significantly associated with death (p < 0.05) included admission to rural hospitals, long prodromal period, referral from other hospitals, antibiotic treatment prior to admission, and clear CSF (<100 cells/mm3). Susceptibility to ampicillin and ceftriaxone was observed in 44 and 100% of H. influenzae serotype b isolates and in 52 and 94% of S. pneumoniae isolates, respectively. This surveillance highlights the significant mortality and morbidity associated with bacterial meningitis in Egypt. Decision makers need to review current treatment guidelines and introduce appropriate vaccines for prevention and control of the disease.

Hospital-based surveillance for acute febrile illness in Egypt: a focus on community-acquired bloodstream infections

Acute febrile illness (AFI) is a common syndrome in Egypt. However its etiologies are not well characterized. To determine the relative frequency of pathogen etiologies and possibly improve diagnostic, clinical management and public health measures, we implemented laboratory-based surveillance in a network of infectious disease hospitals throughout Egypt. Admitted patients with AFI provided background details and a blood sample for bacterial culture and serologic analysis. Case definitions were based on laboratory results. Of 10,130 patients evaluated between 1999 and 2003, 5% were culture positive for Salmonella enterica serogroup Typhi, 3% for Brucella, and 2% for other pathogens. An additional 18% of patients had positive serologic results for typhoid and 11% for brucellosis. Risk factor analysis identified availability of municipal water to be significantly (P < 0.05) associated with protection against typhoid. Animal contact and consumption of raw dairy products were significantly associated with brucellosis. The surveillance network identified typhoid fever and brucellosis as the most common bacterial causes of AFI in Egypt, allowed better description of their epidemiology, and may lead to the development of targeted prevention strategies.

Neonatal sepsis in Egypt associated with bacterial contamination of glucose-containing intravenous fluids

BACKGROUND

Rates of sepsis exceeding 50% in a neonatal intensive care unit (NICU) in Cairo, Egypt, were not controlled by routine antimicrobial therapy. We investigated these conditions in September 2001.

METHODS

Case series and retrospective cohort studies were conducted on 2 groups of NICU infants admitted to an academic medical center between February 12 and July 31, 2001. Observation of clinical practices led us to culture in-use intravenous (i.v.) fluids and medications. We monitored rates of i.v. fluid contamination, clinical sepsis and mortality after interventions to establish new procedures for handling and disposal of i.v. fluids, infection control training and improved clinical laboratory capacity.

RESULTS

Among infants in the retrospective cohort group, 88 (77%) of 115 had clinical sepsis, and 59 (51%) died. In the case series group, we documented the time of initial positive blood culture; 21 (64%) of 33 were septic <24 hours after birth. Klebsiella pneumoniae accounted for 24 (73%) of 33 isolates; 14 (58%) of 24 were extended spectrum beta-lactamase-producing and aminoglycoside-resistant. On admission, all neonates received glucose-containing i.v. fluids; i.v. bottles (500 mL) were divided among multiple infants. The i.v. fluids were prepared at the bedside; poor hand hygiene and poor adherence to aseptic techniques were observed. K. pneumoniae was isolated from 13 (65%) of 20 in-use glucose-containing i.v. fluids. Fluid contamination, sepsis and mortality rates declined significantly after intervention.

CONCLUSION

Extrinsically contaminated i.v. fluids resulted in sepsis and deaths. Standard infection control precautions significantly improve mortality and sepsis rates and are prerequisites for safe NICU care.