WHO Global Situational Alert System: a mixed methods multistage approach to identify country-level COVID-19 alerts

BACKGROUND

Globally, since 1 January 2020 and as of 24 January 2023, there have been over 664 million cases of COVID-19 and over 6.7 million deaths reported to WHO. WHO developed an evidence-based alert system, assessing public health risk on a weekly basis in 237 countries, territories and areas from May 2021 to June 2022. This aimed to facilitate the early identification of situations where healthcare capacity may become overstretched.

METHODS

The process involved a three-stage mixed methods approach. In the first stage, future deaths were predicted from the time series of reported cases and deaths to produce an initial alert level. In the second stage, this alert level was adjusted by incorporating a range of contextual indicators and accounting for the quality of information available using a Bayes classifier. In the third stage, countries with an alert level of 'High' or above were added to an operational watchlist and assistance was deployed as needed.

RESULTS

Since June 2021, the system has supported the release of more than US$27 million from WHO emergency funding, over 450 000 rapid antigen diagnostic testing kits and over 6000 oxygen concentrators. Retrospective evaluation indicated that the first two stages were needed to maximise sensitivity, where 44% (IQR 29%-67%) of weekly watchlist alerts would not have been identified using only reported cases and deaths. The alerts were timely and valid in most cases; however, this could only be assessed on a non-representative sample of countries with hospitalisation data available.

CONCLUSIONS

The system provided a standardised approach to monitor the pandemic at the country level by incorporating all available data on epidemiological analytics and contextual assessments. While this system was developed for COVID-19, a similar system could be used for future outbreaks and emergencies, with necessary adjustments to parameters and indicators.

Machine learning analysis including social determinants of health for predication of mortality following transcatheter aortic valve implantation: a single center experience

Funding Acknowledgements

Type of funding sources: None.

Introduction

Social determinants of health (SDOH) are increasingly being recognized as critical, independent prognosticators in cardiovascular disease. Despite this, little is known about the role of SDOH in predicting outcomes following transcatheter aortic valve implantation (TAVI).

Purpose

To assess the value of adding census-derived SDOH in developing machine learning (ML) models for prediction of all-cause mortality in patients following TAVI.

Methods

A total of 398 patients, who underwent TAVI in 2019, were studied. Clinical, demographic, echocardiographic (echo) and census-derived SDOH data were collected. All-cause mortality at 1 year was the endpoint. A general linear ML model was fit with 100 iterations and a 70:30 training-test split. We compared the predictive performance of the model with and without adding SDOH. The SDOH included in the ML model were race (white vs. non-white), % zip code population as female, and zip code average yearly income less than $45,000.

Results

Baseline SDOH, demographic, clinical, and echo data are shown in Table 1. Following univariate and multivariate predictor analysis, the following input data were used for the ML model without the SDOH: post TAVI all-cause hospitalizations, history of outpatient hemodialysis, atrial fibrillation, heart failure with reduced ejection fraction, myocardial infarction, coronary artery disease and beta-blockers. The ML model with SDOH used the same input as well as the SDOH variables. The model with vs. without SDOH had a median AUC of 0.75 vs. 0.73 (p = 0.9957).

Conclusions

Despite not reaching statistical significance, our ML model provides a holistic picture of mortality predictors. Larger studies are needed to more assess the predictive value of SDOH post TAVI. Abstract Figure. Baseline patient characteristics  Abstract Figure. ML Model: Area Under Curve

Increased transmissibility and global spread of SARS-CoV-2 variants of concern as at June 2021

We present a global analysis of the spread of recently emerged SARS-CoV-2 variants and estimate changes in effective reproduction numbers at country-specific level using sequence data from GISAID. Nearly all investigated countries demonstrated rapid replacement of previously circulating lineages by the World Health Organization-designated variants of concern, with estimated transmissibility increases of 29% (95% CI: 24-33), 25% (95% CI: 20-30), 38% (95% CI: 29-48) and 97% (95% CI: 76-117), respectively, for B.1.1.7, B.1.351, P.1 and B.1.617.2.

Cladosporium sphaerospermum causing brain abscess, a saprophyte turning pathogen: Case and review of published reports

Emergence of saprophytic fungi thriving in dead plant material and soil as opportunistic human pathogens is of great concern. Cladosporium species are environmental saprophytes reported to cause various superficial and invasive fungal infections worldwide. C. sphaerospermum, a predominantly indoor fungus has been reported from cases of meningitis, subcutaneous and pulmonary fungal infections in the past. Herein we report the first case of cerebral abscess due to C. sphaerospermum in an immunocompetent host who was successfully managed by combined medical and surgical therapy.

Abstract P6-04-04: Maternal embryonic leucine zipper kinase (MELK) is a novel radiosensitizing and therapeutic target and is independently prognostic in triple-negative breast cancer

Background: While effective targeted therapies exist for estrogen receptor (ER)-positive and HER2/neu-positive breast cancer, no such effective therapies exist for ER-negative, PR-negative, and HER2-negative (“triple negative”) cancers. Given the lack of targeted agents for triple negative (TN) disease and their relative radiation insensitivity, it is clear that additional targets for treatment are critically needed.

Our previous work identified one such novel molecular target as maternal embryonic leucine zipper kinase (MELK), and we sought to investigate the impact of MELK expression on radiation response and patient outcomes.

Methods: Using gene expression arrays, we interrogated the expression of MELK in 2,061 breast tumor samples as well as a panel of 51 breast cancer cell lines. We measured protein expression in TN cancers with western blotting and used clonogenic survival assays to quantitate radiosensitivity of BCC lines at baseline and after MELK inhibition. Multiple datasets were used to evaluate the prognostic import of MELK. Kaplan-Meier analysis using local control and survival data was performed. Chi squared scores were calculated to determine significance and hazard ratios (HR) and 95% confidence intervals (CI) were calculated. A Cox proportional hazards model was constructed to identify potential factors of survival.

Results: We demonstrate that MELK expression is significantly elevated in human TN breast cancers, including chemoradiation resistant tumors (305 tumors compared to 1756 non-TN breast tumors; p-value 7.5 e-21). MELK protein and RNA expression is induced by ionizing radiation (5.6-7.5 fold at 72 hours, p-value <0.01). We characterized the radiation sensitivity of BCC lines and demonstrated that MELK expression is significantly correlated with radioresistance (as measured by clonogenic survival) in 21 breast cancer cell lines (R: 0.62, p-value 0.003). Inhibition of MELK using both siRNA and small molecule inhibitors induces radiation sensitivity in vitro with and enhancement ratio (ER) of 1.5-1.6. We demonstrate that high MELK expression is strongly correlated with p53 mutation positive status (p-value <0.001). Finally, local control and survival analyses of patients with BC showed that those patients whose tumors have high expression of MELK have significantly higher rates of LR after radiation and an overall poorer prognosis than patients with low expression of MELK (HR for LR 1.89-2.23, p-value 0.001; HR for overall survival 1.46-3.3; p-value <0.001 in 3 independent datasets). In multivariate analysis of all patients, only MELK expression and grade were significantly associated with worse local recurrence free (LRF) survival with a HR of 1.35 (95% CI 1.05-1.72, p-value < 0.01).

Conclusion: Here, we identify MELK as a potential biomarker of radioresistance and target for radiosensitization in triple negative breast cancers. MELK overexpression was associated with local failure across multiple data sets. MVA identified MELK as the strongest factor associated with poor local control. Our results support the rationale for developing clinical strategies to inhibit MELK as a novel target in triple-negative breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-04-04.

Genetic polymorphisms in the P2X7 gene and its association with susceptibility to tuberculosis

BACKGROUND

Several studies have reported the influence of genetic variations on susceptibility to tuberculosis (TB). Polymorphism in P2X7 gene coding for P2X7 receptor present on macrophages has been linked to TB in different populations.

OBJECTIVE

To assess the role of P2X7 gene -762T/C and -1513A/C polymorphisms in TB susceptibility.

DESIGN

In a case-control study, polymerase chain reaction (PCR) amplification of genomic DNA extracted from peripheral blood samples of cases and controls was followed by restriction fragment length polymorphism or allele-specific PCR.

RESULTS

The 1513C allele was found to be associated with TB susceptibility (P = 0.02, OR for variant C allele 1.33, 95%CI 1.03-1.73). A significant protective association against TB was found for -762T/C polymorphism (P < 0.01, OR for variant C allele 0.72, 95%CI 0.57-0.91). On classifying samples on the basis of sex, only males showed a significant association between P2X7 -1513A/C and P2X7 -762T/C and TB in the present study.

CONCLUSION

A significant association of 762T/C and 1513A/C polymorphisms with TB in the P2X7 gene was found in our study population. A sex bias, with only males showing a significant association with the disease, is the first report of this kind. Genetic studies for the characterisation of the susceptibility genes can help to gain a better understanding of TB pathogenesis.

Applications of soluble, encapsulated and cross-linked peroxidases from Sapindus mukorossi for the removal of phenolic compounds

Peroxidases have been known to polymerize phenolic compounds and precipitate them from solution. Sapindus peroxidases (SPases) were extracted from the leaves of Sapindus mukorossi and precipitated with four volumes of chilled methanol. Soluble, encapsulated and cross-linked forms of enzymes were used for the removal of phenolic compounds (initial concentration 1.0 mM) in a stirred batch reactor. Calcium alginate beads were prepared using sodium alginate and calcium chloride at 1.5% and 5.0% (w/v), respectively. Sodium alginate and glutaraldehyde at 1.0% (w/v) and 0.8% (v/v), respectively, were optimized for cross-linking of SPases. The maximal removal of 2-chlorophenol was found in the buffers ofpH range 4-7 and at 30-60 degrees C in the presence of 1.2 mM H2O2 by soluble enzymes, but encapsulated and cross-linked enzymes worked well at pH 5 and at 50 degrees C in the presence of 0.8 mM H2O2. The optimized doses of soluble, encapsulated and cross-linked SPases were 1.2, 4.2 and 1.2 mg/mL, respectively, for the removal of phenolic compounds. Encapsulated and cross-linked enzymes showed a lower efficiency than soluble enzyme but can be reused in multiple cycles for the removal of phenolic compounds.

Association of mannose-binding lectin gene polymorphism with tuberculosis susceptibility and sputum conversion time

Mannose-binding lectin (MBL) plays an important role in innate immunity. The effect of low MBL levels producing variants of MBL2 gene on tuberculosis (TB) has been controversial with some studies reporting it to confer protection against the disease, whereas others estimating a susceptibility relation. Other than conducting a case-control study to evaluate the role of MBL A/B polymorphism on TB, we conducted a longitudinal study to check whether this MBL variant can influence the host response to Mycobacterium tuberculosis infection. A total of 357 TB patients (286 pulmonary TB, 71 extrapulmonary (EP) TB) and 392 healthy controls belonging to same ethnicity were included in the study. We found the mutant allele 'B' allele confers a protective role against TB in our study population. This effect was absent in EP patients. On stratification on the basis of sex, the protective role of the 'B' allele was found to be limited to females only and males reported no significant difference. No effect of MBL A/B polymorphism on sputum conversion time was reported. We conclude that MBL 'B' allele is associated with protection against TB, but no influence was found on sputum conversion rate.

Neuromyelitis optica immunoglobulins as a marker of disease activity and response to therapy in patients with neuromyelitis optica

Objective

To determine whether neuromyelitis optica (NMO) immunoglobulin (IgG) antibody status in NMO/Devic’s disease patients followed prospectively is persistent or can change relative to the clinical status and/or response to therapy.

Design

A cross-sectional group of patients with NMO, relapsing extensive longitudinal transverse myelitis (RLETM) or optico-spinal multiple sclerosis (OSMS) were evaluated for the presence of NMO IgG antibodies. Repeated evaluation was made in all NMO/RLETM patients and in a subgroup of OSMS patients.

Setting

Baird Multiple Sclerosis Center, Buffalo, New York, an academic multiple sclerosis center.

Results

Out of a consecutive cohort of 38 patients evaluated for the presence of NMO IgG, 12 had NMO and 26 had OSMS. Five of the 12 NMO/RLETM patients were NMO IgG positive at the time of their initial evaluation. Four of these patients were repeatedly tested for NMO IgG: two of these became negative and two remained positive. One patient who was initially negative became positive during an acute event and again became negative during the stable disease phase following treatment. A positive test result was associated with active disease, whereas a negative NMO IgG result was consistently found in stable, long-term treated patients. None of the OSMS patients were positive for NMO IgG even during acute attacks.

Conclusions

NMO IgG antibodies are associated with active NMO/RLETM. A well-controlled stable disease usually under effective immunosuppressive therapy can transform the NMO IgG to a negative status. Repeated NMO IgG testing should be considered as a useful biological marker for monitoring NMO/RLETM disease and or response to therapy.

Reproductive potential of male Portan rats exposed to various levels of lead with regard to zinc status

The present study was designed to elucidate the mechanisms accounting for disruption of the normal function of the testis exposed to various levels of Pb. Three different doses of Pb (10, 50, 200mg Pb/kg body weight per d) were given orally to male Portan rats (groups 2, 3, 4). Zn (1mg Zn/kg body weight per d) was also given with Pb (50mg Pb/kg body weight per d) in group 5. Treatments continued for 3 months. Plasma luteinizing hormone and follicle-stimulating hormone concentrations were found to be decreased in Pb-exposed rats. This was in turn reflected in the appreciable decline in fertility status. In cell kinetic studies, significant declines in various cell populations (preleptotene, pachytene, young (step 7) spermatids and mature (step 19) spermatids) were seen. However, in group 5 after Zn supplementation, hormone levels, cell numbers and fertility status were found to be close to normal. It is concluded that Pb might act at maturation level to cause conspicuous degenerative changes in the testis; Zn supplementation protected against these effects.

Characterization of Ionically Bound Peroxidases from Apple(Mallus pumilus) Fruits

Ionically bound peroxidases (POD) were salt extracted from the pulp of four Indian apple varieties, i.e., Golden delicious HP, Golden delicious JK, Red delicious, and Royal delicious. They were precipitated with chilled ethanol. Thermal treatments of partially purified enzymes were given from 40-70 degrees C for 30 minutes. Golden delicious HP peroxidase showed thermostability at 60 degrees C, while three other peroxidases were observed at 50 degrees C. Phenolic compounds (i.e., caffeic acid, ferulic acids, p-coumaric acid, protocatechuic acid) and metal ions (i.e., Cu2+ and Fe2+) activated all apple peroxidases. However, Mn2+ inhibited the peroxidases from Golden delicious HP, Golden delicious JK, and Red delicious, and a substantial increase was observed in Royal delicious peroxidase. Mg2+ inhibited the peroxidases from Golden delicious HP and Red delicious, but marginal activation was reported in peroxidases from Golden delicious JK and Royal delicious. Zn2+ established stimulation in Golden delicious HP and Golden delicious JK peroxidases, but inhibition was observed in peroxidases in Red delicious and Royal delicious.. Methionine, proline, tryptophan, and valine stimulated all four apple peroxidases, but cysteine showed inhibition in Golden delicious JK.

Modulatory effects of Salmonella LAP-LPS on murine macrophages

PURPOSE

To study the modulatory effects of Salmonella lipid associated protein - lipopolysaccharides (LAP-LPS) on murine macrophages as the intracellular survival within the host macrophages is an important feature for a number of gram-negative pathogens like S. typhi.

METHODS

Macrophage functions were studied in two groups of mice immunized with either LPS or LAP-LPS.

RESULTS

Comparison of protective efficacy of mice preimmunized with LPS based preparations, against challenge infectious doses, showed higher protection in LAP-LPS complex immunized mice group as compared to the mice group immunized with LPS alone. Aggregation of S. typhi cells was lesser with intestinal mucus extracted from LAP-LPS immunized mice as compared to LPS immunized challenged group. A significant increase in the number of macrophages in LAP-LPS immunized mice was also observed in comparison to control and LPS immunized mice groups. Nitric oxide (NO) and superoxide dismutase (SOD) production were also more in macrophages derived from LAP-LPS immunized mice group. Phagocytic uptake studies showed that there was enhanced uptake of bacteria in the LAP-LPS immunized animals in comparison to LPS immunized and controls. Similar trend was observed in intracellular killing of bacteria by the macrophages.

CONCLUSIONS

The results indicated the involvement of protein moiety in LAP on modulation of effects of LPS on macrophages.

Influence of lead and zinc on rat male reproduction at 'biochemical and histopathological levels'

Sequential lead accumulation and biochemical and histopathological changes were observed in rat testis and epididymis after oral administration at varied doses of lead (10, 50 and 200 mg kg(-1) body wt.) for 3 months and also following the concomitant administration of lead with zinc (1 mg kg(-1) body wt. +50 mg Pb kg(-1) body wt.). Accumulation of lead in both testis and epididymis increased with dose. The concomitant administration of zinc reduced the lead levels. Similarly, dose-related changes were seen in the activities of the enzymes alkaline phosphatase and Na(+)-K(+)-ATPase, which decreased with increased dose of lead. A significant improvement in the activities of these enzymes was seen in the groups given both lead and zinc. Histologically, discernible changes were noticed only at higher doses (50 and 200 mg kg(-1) body wt.), which included disorganization and disruption of spermatogenesis with accumulation of immature cells in lumen of tubule. At higher doses of lead, complete arrest of spermatogenesis was seen and a significant decrease in germ cell layer population was evident. Even in epididymis, the histoarchitecture was disrupted only at higher doses of lead both in the caput and corpus regions. The changes included damage of basement membrane, disorganization of epithelium and vacuolization of cells. The tubules were found almost empty, indicating arrest of spermatogenesis. However, with concomitant administration of lead and zinc both testis and epididymis presented a near-normal picture, indicating the protective role of zinc. Hence, the data indicate that the protective effect of zinc on lead toxicity was mediated largely by significant competition between lead and zinc or due to reduction of the available binding sites.

The effect of zinc supplementation on the effects of lead on the rat testis

With increasing concerns about environmental pollution, the interaction of micronutrients with toxic metals is of great interest. The present study was designed to investigate testicular effects of lead following concomitant administration of zinc. Lead was administered orally as lead acetate (50 mg/kg b.w.) daily for 3 months to male Portan rats with or without zinc (1 mg/kg b.w. as zinc sulphate). The control group was given the same volume of distilled water. Endpoints included lead concentration in various body organs as well as in the reproductive system, including testicular subfractions; the testicular enzymes superoxide dismutase (SOD) and catalase; the marker enzyme delta-aminolevulinic acid dehydratase (delta-ALAD); and testicular histoarchitecture. The concentrations of lead in bone, kidney, prostate, testis, liver, epididymis, spleen, seminal vesicles, and blood were significantly higher in lead-treated rats. Lead deposition was reduced in animals that received supplemental zinc. There was a 30% reduction in lead deposition in the testis when zinc was coadministered. At the subcellular level, there was differential accumulation of lead; the nucleus preferentially took up the metal after lead treatment alone, while zinc coadministration shifted lead accumulation to the mitochondria. A significant decrease in delta-ALAD and in SOD activity was seen in the testis with lead treatment. Coadministration of zinc prevented these decreases, at least partially. Zinc coadministration did not prevent the inhibition of catalase observed with lead treatment. Histologically, the alterations in the testis with lead treatment alone were more pronounced compared to animals in which zinc was supplemented. Improvement in the inhibition of delta-ALAD and in the ubiquitous cellular enzyme SOD suggests less testicular tissue damage due to detoxification of free radicals. In conclusion, zinc supplementation ameliorates lead-induced testicular damage both at the cellular and subcellular level. The protective effect may be due to differential distribution of lead, either because of competition between lead and zinc or displacement of lead by zinc.

Not clients, not consumers and definitely not maternants

OBJECTIVE

To determine appropriate terminology for addressing women in pregnancy.

DESIGN

100 women (aged 15-50) were asked to fill in a questionnaire using one of the six choices provided for addressing women in pregnancy.

SETTING

Antenatal clinic of a teaching hospital.

RESULTS

Preferences vary according to context but simple terms like mother-to-be and pregnant women were more popular than client, consumer and maternant.

CONCLUSION

No single terminology for addressing women in pregnancy wins all round approval but simple softer terms like Mother-to-be please a vast majority.

Is transcutaneous electrical nerve stimulation of any value during cervical laser treatment?

OBJECTIVE

To assess the value of transcutaneous electrical nerve stimulation (TENS) during cervical laser therapy.

DESIGN

Randomized three arm controlled clinical trial comparing (i) TENS, (ii) local anaesthetic and (iii) TENS plus local anaesthetic (direct infiltration of 2% lignocaine and 0.03 iu/ml octopressin).

SETTING

Colposcopy Unit adapted to run randomized trials.

SUBJECTS

100 women with CIN and no previous experience of cervical surgery.

MAIN OUTCOME MEASURE

Visual linear analogue pain scores.

RESULTS

The median pain score associated with TENS was greater than the score associated with local anaesthesia (23% compared with 17%; P = 0.1). Combining TENS with local anaesthesia did not further reduce pain scores.

CONCLUSION

Although there was considerable consumer satisfaction with TENS it provided no additional pain relieving effect in addition to direct infiltration of lignocaine and it is inferior to lignocaine alone. We are unable to advocate the use of TENS for laser treatment of the cervix.