Associations of pre-existing comorbidities and COVID-19 in-hospital mortality: an unCoVer analyses

Background

Accumulated evidence on risk factors for adverse COVID-19 outcomes revealed that old age and male sex are main associates, next to pre-existing comorbidities, as analysed from scattered single cohorts of hospitalised COVID-19 patients of accessible electronic medical records. Hence, evidence from federated analyses is called for to provide a more comprehensive and robust analyses of risk factors.

Methods

Using the unCoVer network, i.e., a research platform of 29 partners for the expert use of patient data as routinely gathered in real-world healthcare settings, present analyses restricted to available data of four hospitals from Spain, Slovakia, Romania and Bosnia and Herzegovina covering 8,287 hospitalised COVID-19 patients. In-hospital death after COVID-19 diagnosis was examined in relation to common pre-existing comorbidities using virtual pooling of logistic regression models adjusted for age and sex.

Results

Patients were on average 60.1 (± 20.9) years, 50.7% were male, almost half (43.3%) had at least one pre-existing comorbidity (17.4% having obesity, 21.9% hypertension, 18.0% diabetes and 13.7% cardiovascular diseases (CVD)), and 12.6% died during hospitalisation. Patients with comorbidities had a higher risk of mortality that was increasing with the number of comorbidities: from a virtual pooled odds ratio of 1.16 (95%CI: 0.96, 1.40) for one vs none to 1.30 (1.04, 1.64) and 2.14 (1.64, 2.79) for two and three or more comorbidities, respectively. Of the comorbidities, highest risk was seen for CVD (1.68; 1.40, 2.01), followed by hypertension (1.40; 1.19, 1.64) and diabetes (1.27; 1.07, 1.50), and the lowest for obesity (1.13; 0.94, 1.37).

Conclusions

By federated analyses, this study confirmed that the number of comorbidities was a strong risk factor for in-hospital death after COVID-19, in particular CVD. The unCoVer platform pursues using scattered data sources by innovative computational resources and integrated information for enhanced impact.

Key messages

Comparing health insurance and survey data in estimating prevalence of chronic diseases

Background

Population prevalence of chronic conditions can be estimated from national health surveys and from administrative data sources such as insurance records. This study evaluated the agreement between the Belgian Health Interview Survey (BHIS) and the Belgian compulsory health insurance data (BCHI) in ascertaining chronic hypertension, hypercholesterolemia and diabetes in Belgium.

Methods

The most recent cycle of BHIS (2018) provided the self-reported prevalence of diabetes, hypertension, and hypercholesterolemia among a representative sample of Belgian adults. For BCHI, the chronic conditions were attributed for every individual in the BHIS reviewing the medication prescription records identified using the ATC/DDD system. These two data sources were linked through unique identifiers by STATBEL. Disease prevalence, measures of agreement, and measures of concordance were estimated. Logistic regression was performed to determine the factors affecting agreement between BHIS and BCHI’s disease classifications.

Results

Data linkage was done for 9,753 individuals aged 15 years and older. From the sample, BHIS and BCHI respectively identified 5.9% and 5.6% diabetes cases, 18% and 24% of hypertension cases, and 18% and 16% of hypercholesterolemia cases. The kappa coefficient between BCHI and self-reported diabetes, hypertension, and hypercholesterolemia was 0.79, 0.59, and 0.49, respectively. Gender, age, and subjective health significantly affected the agreement in chronic condition classification between BHIS and BCHI.

Conclusions

Data on reimbursed drugs is a potential alternative method in the surveillance of chronic diabetes. This procedure could be used in estimating disease prevalence but further validation is needed to evaluate its applicability and bias in other chronic conditions.

Key messages

• BCHI is a possible alternative data source for the surveillance of diabetes in the population.

• BCHI overestimated hypertension and underestimated hypercholesterolemia prevalence.

Federated learning for describing COVID-19 patients and hospital outcomes: An unCoVer analysis

Background

Since the onset of the pandemic, the unCoVer network has been identifying real-world data from EMR of hospitalised patients with COVID-19 across countries. These heterogeneous data are integrated into a multi-user data repository operated through Opal/DataSHIELD, an interoperable open-source server application, providing privacy-preserving access to individual-level information for federated data analyses.

Methods

unCoVer’s federated data platform provided access to EMR collected between 02/2020 - 04/2022 from 6 hospitals in Bosnia and Herzegovina (1), Romania (2), Spain (2), and Turkey (1) for a total of 14,236 patients. Demographics, and co-morbidities at admission, length of hospital stay and intensive care (ICU) needs, are presented according to the patients’ status at discharge.

Results

A total of 11,248 (79.0%) of all patients reviewed recovered from COVID-19 after an average 11.5 (SD 10.8) days hospitalised, with only 4.09% of patients needing ICU. A smaller proportion of patients were transferred (5.93%), and 2143 (15.1%) were considered in-hospital deaths after an average 11.6 (SD 10.5) days in the hospital where most (81.2%) needed ICU. Recovered patients had a mean age of 57.7 (SD 16.3) years old, and gender neutral (51.2% men), in contrast to deceased patients that were 74.2 (SD 12.4) years old (59.7% men). Current smoking was infrequent for both recovered or deceased patients (3.27%, and 2.83%, respectively). Cardiometabolic conditions were less commonly reported among later recovered patients in comparison with deceased patients: obesity (10.7% vs 12.1%), diabetes (15.9% vs 27.4%), hypertension (23.2% vs 42.7%), and CVD (9.33% vs 44.9%). Chronic pulmonary disease was also more frequent among deceased patients (10.3% vs 18.1%).

Conclusions

Characteristics of hospitalised COVID-19 patients differ according to outcomes at discharge with more in-hospital death reported among older, chronic patients across 6 hospitals in 4 countries.

Key messages

• Federated analyses provide unique opportunities for robust results by privacy-preserving accessing individual-level data from heterogeneous data sources.

• The unCoVer network aims to demonstrate the usability of the infrastructure to address research questions related to the COVID-19 while extending the concept to other clinical areas.

Emergence of a febrile illness of unknown causes among the population and visitors of Upper Egypt

This is a fictional case study for training that encourages participants to interact and apply theory into practice. A febrile illness of unknown cause that occurred in Upper Egypt in 2002 was chosen for the events. The location of Aswan was selected to define the climate, topography, and location with the characteristics that support the events. Data obtained from applied research work in Egypt was included. The case study deals with the incidence of severe cases of fever of unknown origin accompanied by neurological and intestinal symptoms, as well as a high percentage of deaths. Most of the symptoms appear in people with direct contact with farm animals especially equines and birds, or those who were near waterways, either tourism workers or tourists. Most of the infected cases or deaths have accumulated in Aswan and some in the neighbouring governorates. This case study focusses on the steps taken during an outbreak investigation, and deals with investigative challenges as well as concepts of biosafety and biosecurity.

Containment of a fatal and highly infectious disease outbreak

This case study was designed based on several experience with several viral haemorrhagic fevers (VHFs) outbreaks responded to in Uganda between 2000 and 2016. Fictitious scenarios have been included to facilitate learning of the users. The major goal of the case study is to facilitate learners to appreciate incident detection and the incident management processes for control and containment of a fatal and highly infectious viral disease outbreak. This case study is targeted towards health scientists of medicine, nursing, biomedical laboratory and public health background. We specifically orient learners on clinical presentation of viral infections and laboratory tests considered for incident detection, conducting a risk assessment for an infectious disease, Infection Prevention and Control in the outbreak setting, skills of incident management, analysis and interpretation of epidemiological data to aid epidemic response and control decisions.

Investigation of an outbreak caused by an unknown infectious pathogen in rural Zola

This case study was written as part of a fellowship in biosafety and biosecurity organised by the German Biosecurity Programme, namely the Global Partnership Initiated Biosecurity Academia for Controlling Health Threats (GIBACHT). Among other objectives, the fellowship focuses on equipping participants with the skills of developing their own country-specific case studies with focus on biosafety- and biosecurity-related scenarios. Upon completion of the underlying case study, participants should be able to identify some existing gaps with regards to early detection and investigation of outbreaks, describe the key steps in outbreak investigation, explain the role of communication and coordination among the various stakeholders in outbreak investigations and analyse epidemiological data obtained during outbreak investigations. They should also be able to suggest appropriate control and prevention measures for specific disease outbreaks with focus on foodborne outbreaks and to distinguish between biosafety and biosecurity concepts.

Cholera outbreak in Funpur, Winland

Vibrio Cholerae is a category B agent which has moderate to high potential to be used in bioterrorist events. This fictitious case study is based on man-made outbreak investigation and response carried out by disease surveillance and response unit of country Winland. The numbers of acute watery diarrhoea cases (AWDs) were concentrated in city Funpur of country Winland which share international border with Robiland, another country with poor health infrastructure. Regular movement of nomadic population between two countries has additional risk of international spread. This case study is designed for the training of public health students and workers on steps of outbreak investigation, packaging of biological samples, understanding IHR reporting algorithm, understanding difference between biosafety and biosecurity, different categories of bioterrorism organisms and PPE & its zones. This case study can be used as supporting training tool for application of learned concepts to a real situation and can be carried out in 2-3 hours.

Outbreak investigation of an unknown gastrointestinal illness in District Victoria, Country Mala, 2016

This case study is based on an outbreak investigation conducted by multisectoral team from animal and public health offices in Kaktong (a remote village in Zhemgang District Bhutan) during July-September 2010. This outbreak caused by ingestion of infected cow meat which had died after a brief illness (bleeding of unclotted blood from nostrils). The owner of the affected cow had opened the carcass and dressed the meat, which he shared or sold within the village for human consumption. It simulates an epidemiological investigation including active and passive case finding, descriptive and analytical epidemiology, laboratory confirmation, risk communication with implementation of control measures. This case study is designed for the training of front-line public health professional, basic, intermediate and advanced level field epidemiology trainees. The case study will build the capacity of the trainees regarding investigating illnesses caused by animal-human interface.

Inequalities in non-communicable diseases across the European Union: current state and trends from 2000 to 2019

Background

Non-communicable diseases (NCDs) remain the leading cause of disease burden in the European Union (EU). However, this burden varies across Member States, driven by the socioeconomic and demographic structure of the populations, as well as health care and social support systems in each country. This geographical gradient in the burden of NCDs represents health inequalities that may have expanded as a result of population ageing, migration, and economic crisis, and historic backgrounds.

Methods

Using data from the GBD 2019 study, we quantify the inequality gap between EU countries, characterize the geographical gradient of total and individual NCDs, and analyze the trends over the last 20 years.

Results

A considerable gap exists in the rates of NCD-related DALYs between the country with the lowest burden (Slovenia in 2019) and the highest (Bulgaria in 2019), with a constant (p-trend > 0.05) ratio of 1.6 (95%CI, 1.57; 1.64) since the year 2000. The largest inequality was observed for the burden of stroke between the lowest (France in 2019) and the highest (Bulgaria in 2019) with a ratio of 7.47 (6.78; 8.24) Increasing steadily (p-trend < 0.001) since 2000. Using the relative index of inequality to characterize the gradient of inequalities across the EU, a decreasing trend (p < 0.001) can be observed for NCD-related DALYs rates from 1.56 (1.44; 1.7) in 2000 to in 1.42 (1.33; 1.52) 2019.

Conclusions

Despite overall improvements in health, spatial disparities related to NCDs in the EU persist. Our estimates provide a baseline to inform future equitable health policies.

Interleukin-1Beta and risk of premature death and MACE in patients with myocardial infarction

Background

Inhibition of the interleukin-1β (IL-1β) innate immunity pathway is associated with anti-inflammatory effects and a reduced risk of recurrent cardiovascular events in stable patients with previous myocardial infarction (MI) and elevated high sensitivity C-reactive protein (hs-CRP). However, the prognosis value of IL-1β level in acute myocardial infarction patients has never been evaluated. We aim to assess the association between IL-1β level with all-cause mortality in patients with acute ST segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention and the interplay between IL-1β and hs-CRP concentrations on the risk of premature death.

Methods

IL-1β concentration was measured among 1398 STEMI patients enrolled in a prospective cohort study. Crude and hazard ratios for all-cause and cardiovascular mortality were analyzed at 90-days and one-year using a multivariate-cox proportional regression analysis. Major cardiovascular events (MACE) were also analyzed.

Results

In a STEMI population, IL-1β concentration measured at admission was independently associated with all-cause mortality at 90 days (adjusted hazard ratio [adjHR], 1.43 per 1SD increase; 95% CI, 1.12 to 1.83; p<0.005). The relation was nonlinear, and we identified a threshold of IL-1β >10 pg/mL that was markedly associated with higher mortality rates at 90 days (adjHR: 2.80; 95% CI: 1.63–4.80, p=0.0002) and one-year (adjHR: 1.75; 95% CI: 1.09–2.78, p=0.019), regardless of the hs-CRP concentration. The relationship was even stronger when considering cardiovascular mortality and MACE at 90 days (adjHR: 2.31; 95% CI: 1.30–4.10, p=0.004 and 2.17; 95% CI: 1.24–3.80, p=0.006) and at one year (adjHR: 2.26; 95% CI: 1.31–3.87, p=0.03 and 2.25; 95% CI: 1.33–3.79, p=0.004).

Conclusion

IL-1β measured at admission in acute MI patients is associated with the risk of mortality and recurrent major cardiovascular events, regardless of the CRP level. A threshold of 10 pg/mL identifies patients at higher risk of events.

Survival

Funding Acknowledgement

Type of funding source: None

Impact of left atrial appendage closure on left atrial hemodynamics: a prospective single center study

Background

Percutaneous left atrial (LA) appendage closure is increasingly used to prevent strokes in patients with atrial fibrillation (AF). While LA appendage plays a key role in LA physiology, data regarding the impact of LA appendage occlusion on LA hemodynamics are lacking. The alteration of LA compliance by LA appendage occlusion may represent a clinical issue in AF patients which are at high risk of heart failure.

Purpose

To describe the impact of LA appendage occlusion on LA hemodynamics.

Material and methods

From july 2015 to january 2020, all patients undergoing LA occlusion procedure at Pitié-Salpêtrière Hospital (Paris, France) in whom LA pressure curves were recorded, before and immediately after device implantation, were included. The LA mean pressure was measured at baseline and after LA appendage occlusion during the same procedure. Abnormal LA mean pressure was defined as >15mmHg. We also recorded cardiovascular death and hospitalization for congestive heart failure at longest follow-up.

Results

We enrolled 85 patients (78±8 years, 46 men), the CHA2DS2-VASc score was 5±1 and the HAS-BLED score was 4±1. The mean LA volume index was 51±15mL/m2, the left ventricular ejection fraction was 60±7%. The LA mean pressure increased significatively after LA appendage closure from 12.6±3.9mmHg to 15.5±5.2mmHg (p<0.0001, Figure). The prevalence of abnormal LA pressure was 20% (17/85) at baseline and 45% (38/85) after LA appendage closure (p=0.005). Post procedural LA pressure elevation was not related to procedure duration nor to fluid expansion volume.

During a median follow-up of 364 [124–726] days, 3 (3.5%) patients died from a cardiovascular cause. Hospitalization for heart failure occurred in 6 (16%) of the 38 patients with abnormal postprocedural LA pressure, whereas no congestive episode was observed in the rest of the study population (p=0.006).

Conclusion

Catheter-based LA appendage occlusion induces an acute alteration of LA hemodynamics. Post procedural abnormal LA pressure may be linked to heart failure episodes in some patients. Further studies are warranted to investigate heart failure as a potential late complication of LA appendage closure.

Variations of mean LA pressure

Funding Acknowledgement

Type of funding source: None

Exposure of domestic swine to influenza A viruses in Ghana suggests unidirectional, reverse zoonotic transmission at the human-animal interface

Influenza A viruses (IAVs) have both zoonotic and anthroponotic potential and are of public and veterinary importance. Swine are intermediate hosts and 'mixing vessels' for generating reassortants, progenies of which may harbour pandemic propensity. Swine handlers are at the highest risk of becoming infected with IAVs from swine but there is little information on the ecology of IAVs at the human-animal interface in Africa. We analysed and characterized nasal and throat swabs from swine and farmers respectively, for IAVs using RT-qPCR, from swine farms in the Ashanti region, Ghana. Sera were also analysed for IAVs antibodies and serotyped using ELISA and HI assays. IAV was detected in 1.4% (n = 17/1,200) and 2.0% (n = 2/99) of swine and farmers samples, respectively. Viral subtypes H3N2 and H1N1pdm09 were found in human samples. All virus-positive swine samples were subtyped as H1N1pdm09 phylogenetically clustering closely with H1N1pdm09 that circulated among humans during the study period. Phenotypic markers that confer sensitivity to Oseltamivir were found. Serological prevalence of IAVs in swine and farmers by ELISA was 3.2% (n = 38/1,200) and 18.2% (n = 18/99), respectively. Human H1N1pdm09 and H3N2 antibodies were found in both swine and farmers sera. Indigenous swine influenza A viruses and/or antibodies were not detected in swine or farmers samples. Majority (98%, n = 147/150) of farmers reported of not wearing surgical mask and few (4%, n = 6) reported to wear gloves when working. Most (n = 74, 87.7%) farmers reported of working on the farm when experiencing influenza-like illness. Poor husbandry and biosafety practices of farmers could facilitate virus transmission across the human-swine interface. Farmers should be educated on the importance of good farm practices to mitigate influenza transmission at the human-animal interface.

Understanding attitude, practices and knowledge of zoonotic infectious disease risks among poultry farmers in Ghana

Zoonotic infectious diseases (ZIDs) are increasing globally, and livestock farmers in low‐ and middle‐income countries are at particularly high risk. An evaluation of farmer's behaviour on farms can be used to identify the risk factors and to develop tailored control strategies. This study documents the knowledge of zoonotic poultry diseases (ZPD) among 152 poultry farm workers (respondents) from 76 farms in the Ashanti region of Ghana and assessed their on‐farm attitude and practices that increase their risk to exposure of ZPD. The median age of respondents was 29 years, 91.4% (n = 139) had a formal education, and 80.9% (n = 123) had worked on the farm for more than 1 year. The majority of farms (n = 69, 90.8%) had multiple flocks and 27.6% (n = 21) kept other animals, of which 57.1% (n = 12) were pigs. The majority of respondents had good knowledge about poultry diseases but not about ZPD. A higher level of education and longer work experience improved respondents’ knowledge of poultry and ZPD. Although respondents identified the wearing of personal protective equipment (PPE) as a major ZPD preventive measure, the majority did not put that knowledge into practice. Most farms (71.1%, n = 54) had no footbath and 55.3% (n = 42) deposited farm‐waste on the farm. While 97.4% (n = 148) of respondents washed their hands after working, only 48.7% (n = 74) wore protective footwear, 2.7% (n = 4) wore overalls, 2% (n = 3) wore nose masks and none (n = 0) wore gloves. The husbandry practices and attitude of farmers expose them to pathogens on the farm and increase their risk of becoming infected with ZPD in the sub‐region. The results from this study could be used to promote human health among farm workers in Ghana.

Pre-exercise hypohydration prevalence in soccer players: A quantitative systematic review

Pre-exercise hypohydration can impair soccer performance and has been extensively studied in different soccer populations. Therefore, the aim of this systematic review was to report hypohydration prevalence, measured by blood or urine samples, in different soccer populations based on sex (males and females), performance level (professional and recreational players) and context (training sessions and games). The Pubmed, Web of Science and SPORTDiscus databases were systematically searched until November 2018. Data were pooled to compare hypohydration prevalence between the different subgroups. Following the systematic search selection process, 24 studies were included. The results indicated that overall pre-exercise hypohydration prevalence was 63.3%, 37.4% and 58.8% for urine specific gravity (USG), urine osmolality (U Osm) and urine colour, respectively. Furthermore, no study implemented blood samples to examine hypohydration prevalence in soccer players. The subgroup analyses using USG data indicated that pre-exercise hypohydration prevalence was significantly higher amongst males (66.0%; p = 0.001), professional soccer players (66.2%; p = 0.020) and before a training session (79.6%; p < 0.001). Pre-exercise hypohydration prevalence was 46.8% among female soccer players, 55.6% in recreational soccer players and 41,3% before a game. The subgroup analyses using U Osm data indicated that hypohydration prevalence was significantly higher before a training session (52.6%; p = 0.023). Based on these results, it can be concluded that hypohydration prevalence in soccer players is of major concern. Future research should explore how pre-exercise hydration status can be improved in a sustainable way.

Fluoroquinolone-Resistant Salmonella enterica, Campylobacter spp., and Arcobacter butzleri from Local and Imported Poultry Meat in Kumasi, Ghana

Salmonella and Campylobacter are important gastroenteric pathogens. Arcobacter butzleri is an emerging enteric pathogen. Data on the frequencies of these poultry-associated pathogens on meat products sold in sub-Saharan Africa are scarce. This study aimed to analyze the frequency of Salmonella, Campylobacter, and Arcobacter antibiotic resistance and underlying mechanisms of resistance to fluoroquinolones in locally produced and imported poultry sold in urban Ghana. Chicken meat was collected and cultured on standard media. Bacterial strains were identified by biochemical methods and by mass spectrometry. Antibiotic susceptibility was tested by disk diffusion. Ciprofloxacin-resistant strains were assessed for molecular mechanisms of resistance. Among 200 samples, comprising 34% (n = 68) from the Ghanaian poultry industry and 66% (n = 132) from imports, 9% (n = 17) contained Salmonella, 11% (n = 22) Campylobacter, and 26.5% (n = 53) A. butzleri. Higher overall contamination frequencies were found in local meat. Most common Salmonella serovars identified were Kentucky (n/N = 5/16; 31%) and Poona (n/N = 4/16; 25%). Campylobacter were C. coli (n/N = 10/19; 53%) and C. jejuni (n/N = 9/19; 47%). Resistance to fluoroquinolones was high with 63% (n = 10), 75% (n = 15), and 52% (n = 25) in Salmonella, Campylobacter, and Arcobacter, respectively. A link between Salmonella Kentucky [sequence type (ST) 198] and a ciprofloxacin minimum inhibitory concentration of 16 μg/mL was found. Salmonella Poona-ST308 revealed transferable qnrB2 fluoroquinolone resistance genes. Markedly high frequencies of resistant Salmonella, Campylobacter, and Arcobacter predominant in locally produced meat represent a probable transmission reservoir for human infections. These findings highlight the need for implementation of surveillance systems that focus on food hygiene, use of antibiotics in animal husbandry, and continuous monitoring of the quality of meat products from imports.

Relation between sugar-sweetened beverage consumption and micronutrient intake in a prospective study

Micronutrient dilution following sugar-sweetened beverage (SSB) consumption can lead to a qualitative impoverishment of a dietary pattern. The aim of this prospective study was to investigate the relation between SSB consumption and micronutrients. A total 562 adults were tested in 2002 and 2012 for the same anthropometric, lifestyle and nutritional intake activity parameters. Calcium, iron and magnesium intake decreased with increasing baseline SSB intake, and with increasing SSB consumption during the 10 years. A 100 ml increase in SSB consumption was associated with a 22 mg lower intake of calcium, 0.4 mg of iron and 9 mg of magnesium. There was no relation between vitamins and SSB consumption. In conclusion, there was limited evidence in our study, which suggests SSB have minimal dilutional effect on dietary micronutrient consumption. A major limitation of the present study is that of the original 1569 participants in 2002, 36% returned for participation in 2012.

No serological evidence for Zika virus infection and low specificity for anti-Zika virus ELISA in malaria positive individuals among pregnant women from Madagascar in 2010

It was previously reported that a malaria infection may interfere with the specificity of a commercial ELISA test against Zika virus (ZIKV). We analyzed 1,216 plasma samples from healthy, pregnant women collected in two sites in Madagascar in 2010 for ZIKV antibodies using a commercial ELISA and for Plasmodium infection by PCR. This screen revealed six putative ZIKV-positive samples by ELISA. These results could not be confirmed by indirect immunofluorescence assays or virus neutralization tests. Four of these six samples were also positive for P. falciparum. We noted that the frequency of malaria positivity was higher in ZIKV-ELISA positive samples (50% and 100% in the two study sites) than ZIKV-negative samples (17% and 10%, respectively), suggesting that malaria may have led to false ZIKV-ELISA positives.

Stability of physical activity, fitness components and diet quality indices

BACKGROUND

Regular physical activity (PA), a high level of fitness and a high diet quality are positively associated with health. However, information about stability of fitness components and diet quality indices is limited. This study aimed to evaluate stability of those parameters.

METHODS

This study includes 652 adults (men=57.56 (10.28) years; women=55.90 (8.34) years at follow-up) who participated in 2002-2004 and returned for follow-up at the Policy Research Centre Leuven in 2012-2014. Minutes sport per day and Physical activity level (PAL) were calculated from the Flemish Physical Activity Computerized Questionnaire. Cardiorespiratory fitness (CRF), morphological fitness (MORF; body mass index and waist circumference) and metabolic fitness (METF) (blood cholesterol and triglycerides) were used as fitness components. Diet quality indices (Healthy Eating Index-2010 (HEI), Diet Quality Index (DQI), Mediterranean Diet Score (MDS)) were calculated from a diet record. Tracking coefficients were calculated using Pearson/Spearman correlation coefficients (rPearson) and intra-class correlation coefficients (rICC).

RESULTS

In both men (rPearson&ICC=0.51) and women (rPearson=0.62 and rICC=0.60) PAL showed good stability, while minutes sport remained stable in women (rPearson&ICC=0.57) but less in men (rPearson&ICC=0.45). Most fitness components remained stable (r⩾0.50) except some METF components in women. In general the diet quality indices and their components were unstable (r<0.50).

CONCLUSIONS

PAL and the majority of the fitness components remained stable, while diet quality was unstable over 10 years. For unstable parameters such as diet quality measurements are needed at both time points in prospective research.

Antibiotic resistance and clonal diversity of invasive Staphylococcus aureus in the rural Ashanti Region, Ghana

Background

Staphylococcus aureus is among the most common pathogens isolated from blood cultures in Ghana; yet the epidemiology of blood infections in rural settings is poorly described. This study aims to investigate antimicrobial susceptibility and clonal diversity of S. aureus causing bloodstream infections in two hospitals in the Ashanti Region, Ghana.

Methods

Blood cultures were performed for all febrile patients (≥37.5 °C) on hospital admission. Antibiotic susceptibility testing for S. aureus isolates was carried out by the VITEK 2 system. Multiplex polymerase chain reaction (PCR) was used to detect S. aureus-specific nuc gene, Panton-Valentine leukocidin (PVL), and methicillin-resistant S. aureus (MRSA)-specific mecA and mecC genes. The population structure of S. aureus was assessed by spa typing.

Results

In total, 9,834 blood samples were cultured, out of which 0.6% (n = 56) were positive for S. aureus. Multidrug resistance (MDR) was detected in 35.7% (n = 20) of the S. aureus strains, of which one was a MRSA. The highest rate of antibiotic resistance was seen for commonly available antibiotics, including penicillin (n = 55; 98.2%), tetracycline (n = 32; 57.1%) and trimethoprim/sulfamethoxazole (n = 26; 46.4%). Of all S. aureus strains, 75.0% (n = 42) carried the PVL-encoding genes. We found 25 different spa types with t355 (n = 11; 19.6%), t314 (n = 8; 14.3%), t084 (n = 8; 14.3%) and t311 (n = 5; 8.9%) being predominant.

Conclusion

The study exhibited an alarmingly large level of antibiotic resistance to locally available antibiotics. The frequency of genetically diverse and PVL-positive methicillin-sensitive S. aureus (MSSA) was high and could represent a reservoir for the emergence of virulent PVL-positive MRSA clones.

Foodborne hepatitis A outbreak associated with bakery products in northern Germany, 2012

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Assessment of public health issues of migrants at the Greek-Turkish border, April 2011

A joint mission to assess the public health situation of migrants in Greek detention centres was undertaken in April 2011 by the European Centre for Disease Prevention and Control (ECDC) and the World Health Organization (WHO) Regional Office for Europe. The assessment visit follows the increased migration to the Evros prefecture, Eastern Macedonia and Thrace region, at the Greek-Turkish border where large numbers of migrants are entering Greece via the Evros River, a natural border. Migrants are housed in local detention centres. The main problem in detention centres are the substandard hygiene conditions, especially overcrowding and lack of personal hygiene facilities, lack of basic supplies and lack of access to fresh air and physical exercise. As the migration route via the Evros region is increasingly used since 2009, and due to the unstable political situation in North Africa and the Middle East, an increased influx of migrants was to be expected with the falling water levels of the Evros River in summer, resulting in further deterioration of the already critical situation in the Thrace region’s detention centres.

Assessment of public health issues of migrants at the Greek-Turkish border, April 2011

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West Nile virus and its emergence in the United States of America

Zoonotic West Nile virus (WNV) circulates in natural transmission cycles involving certain mosquitoes and birds, horses, humans, and a range of other vertebrates are incidental hosts. Clinical infections in humans can range in severity from uncomplicated WNV fever to fatal meningoencephalitis. Since its introduction to the Western Hemisphere in 1999, WNV had spread across North America, Central and South America and the Caribbean, although the vast majority of severe human cases have occurred in the United States of America (USA) and Canada. By 2002-2003, the WNV outbreaks have involved thousands of patients causing severe neurologic disease (meningoencephalitis and poliomyelitis-like syndrome) and hundreds of associated fatalities in USA. The purpose of this review is to present recent information on the epidemiology and pathogenicity of WNV since its emergence in North America.

MECHANISM OF THE AUGMENTING ACTION OF MINERAL OIL ON ANTIBODY PRODUCTION : TISSUE REACTIONS AND ANTIBODY RESPONSE TO DYSENTERY VACCINE IN SALINE, AND IN SALINE-LANOLIN-MINERAL OIL EMULSION

A comparative study was made in rabbits of antibody production and tissue changes following the injection into the foot pads, of saline in Falba and mineral oil emulsion, of killed cells of Shigella paradysenteriae Flexner in saline, and of killed cells of Shigella paradysenteriae in saline in Falba-mineral oil emulsion. It was found that antibody production was greatly prolonged by the emulsification in oil. While with antigen in saline the serum titers began to fall 9 days after injection and disappeared somewhere between the 3rd and 6th months, with antigen in paraffin oil they began to drop only after 14 days, and were still high after 10 months, when the experiment was ended. The toxic effects of the antigen were greatly reduced by the emulsification in oil. A subcutaneous dose of 1.5 mg. of antigen in saline caused mesenchymal reactions in lung, liver, and spleen as well as toxic degeneration and sometimes necrosis of the liver whereas eight times as much of the antigen in oil produced no systemic lesions. Oil drops remained detectable in the foot pad until the end of the experiment. Bacteria remained visible in the oil for 1 week or more, but with saline they disappeared within 1 day. The latter observation shows that retention of antigen at the site of injection is at least one of the mechanisms of prolongation of antibody formation by paraffin oil. The tissue reaction in the foot pad to antigen in oil was largely one of suppuration with the production of persisting mononuclear granulomata whereas after antigen in saline it was chiefly one of catarrhal inflammation, subsiding within a month. The changes in the regional lymph nodes were essentially those of lymphatic hyperplasia with the production of numerous lymphocytes and large active secondary nodules, the macrophages remaining subsidiary. The lymphocytic reaction in the lymph nodes closely paralleled the antibody response but the monocytic reaction at the site of injection was not correlated with this response; in fact, in the antigen in oil experiments the monocytic reaction reached its height after the peak of antibody production. The tissue changes observed in the various experiments were consistent with the finding previously reported from this laboratory, that the lymphocyte is concerned in antibody formation.

THE ROLE OF THE LYMPHOCYTE IN ANTIBODY FORMATION

Following the injection of typhoid antigen or sheep erythrocytes into the pad of the rabbit's hind foot, lymph from the efferent lymphatic of the popliteal lymph node was collected and analyzed for antibody content. On separating the lymphocytes from the lymph plasma, it was found that the antibody titer of the cell extract was substantially and consistently higher than that of the surrounding fluid. This difference was greatest at the time of greatest rate of increase of antibody titer in the whole lymph, rather than when the antibody titer of the lymph plasma was highest. These results can only be interpreted to mean that the lymphocytes either produce antibodies or take them up from the lymph plasma. Incubation in vitro of lymphocytes containing one species of antibody with lymph plasma containing another showed that antibodies pass from the cells to the supernatant lymph fluid to reach approximate equilibrium; acquisition of antibody from supernatant lymph fluid was not observed. Similar results were obtained when normal lymphocytes were allowed to incubate in vivo in their own lymph fluid to which antibodies had been added. It was again found that antibodies were not absorbed or adsorbed by lymphocytes. These results seem to indicate that lymphocytes are instrumental in the formation of antibodies.

Viral determinants in the NS3 helicase and 2K peptide that promote West Nile virus resistance to antiviral action of 2',5'-oligoadenylate synthetase 1b

The interferon-inducible 2',5'-oligoadenylate synthetase 1b (Oas1b) protein inhibits West Nile virus (WNV) infection by preventing viral RNA (vRNA) accumulation in infected cells. Serial passage of WNV in Oas1b-expressing mouse cells selected a virus variant with improved growth capacity. Two major amino acid substitutions were identified in this Oas1b-resistant WNV variant: NS3-S365G in the ATPase/helicase domain of NS3 and 2K-V9M in the C-terminal segment of NS4A. To assess their effect on antiviral activity of Oas1b, the NS3 and 2K mutations were engineered into an infectious WNV cDNA clone. The NS3 mutation alters requirement of ATP for ATPase activity and attenuates Oas1b-mediated suppression of vRNA accumulation. However, growth of NS3-mutant virus remains impaired in Oas1b-expressing cells. Only the 2K-V9M mutation efficiently rescued viral growth by promoting vRNA replication. Thus, WNV resistance to Oas1b antiviral action could be attributed to the 2K-V9M substitution with a potential role of NS3-S365G through rescue of vRNA accumulation.

Hepatitis C virus-induced secretion of inflammatory chemokines preferentially recruits NKG2A+CD8+ T cells

In patients with hepatitis C, a loss-of-function mutation of chemokine receptor CCR5 (CCR5Delta32) has been shown to be associated with spontaneous viral clearance and lower levels of hepatic inflammation. In the present study, we show that CCR5 is coexpressed with the inhibitory NKG2A receptor on CD8(+) T cells. Consequently, CCR5(+) T cells were highly susceptible to NKG2A-mediated inhibition of cytotoxic activity and NKG2A(+) lymphocytes were preferentially attracted by CCR5 ligands induced by hepatitis C virus E2 antigen. Thus, CCR5 is likely to exert immunoregulatory effects in hepatitis C virus infection by preferentially recruiting CD8(+) T cells bearing the inhibitory NKG2A receptor to the liver.