Gail Thomson

Crimean-Congo hemorrhagic fever in Europe: current situation calls for preparedness.

During the last decade Crimean-Congo hemorrhagic fever (CCHF) emerged and/or re-emerged in several Balkan countries, Turkey, southwestern regions of the Russian Federation, and the Ukraine, with considerable high fatality rates. Reasons for re-emergence of CCHF include climate and anthropogenic factors such as changes in land use, agricultural practices or hunting activities, movement of livestock that may influence host-tick-virus dynamics. In order to be able to design prevention and control measures targeted at the disease, mapping of endemic areas and risk assessment for CCHF in Europe should be completed. Furthermore, areas at risk for further CCHF expansion should be identified and human, vector and animal surveillance be strengthened.

Ribavirin for Crimean-Congo hemorrhagic fever: systematic review and meta-analysis

BackgroundCrimean-Congo hemorrhagic fever epidemics often occur in areas where health services are limited, and result in high case fatality rates. Besides intensive care, ribavirin is often recommended. A solid evidence base for the use of this drug will help justify assuring access to the drug in areas where epidemics are common.MethodsWe carried out a systematic review of observational and experimental studies of people with suspected or confirmed Crimean-Congo hemorrhagic fever that included comparisons between patients given ribavirin and those not. We extracted data on mortality, hospital stay, and adverse events. Risk of bias was assessed using a standard checklist, and data were presented in meta-analytical graphs, stratified by study design, and GRADE tables presented. The risk of bias was summarised using the GRADE method.Results21 unique studies, including one randomised controlled trial of ribavirin, were included. Quality of the evidence was very low, with a Down and Black median score of 4 (maximum possible 33). Ribavirin treatment was not shown to be superior to no ribavirin treatment for mortality rate in a single RCT (RR: 1.13, 95%CI: 0.29 to 4.32, 136 participants, GRADE=low quality evidence); but ribavirin was associated with reduced mortality by 44% when compared to no ribavirin treatment in the pooled observational studies (RR: 0.56, 95%CI: 0.35 to 0.90, 955 participants; GRADE=very low quality evidence). Adverse events were more common with the ribavirin patients, but no severe adverse events were reported. No difference in length of hospital stay was reported.ConclusionsNo clear message of benefit is available from the current data on ribavirin as observational data are heavily confounded, and the one trial carried out has limited power. However, ribavirin could potentially have benefits in this condition and these results clearly indicate a pragmatic, randomised controlled trial in the context of good quality supportive care, is urgently needed and ethically justified.

Influenza aerosols in UK hospitals during the H1N1 (2009) pandemic--the risk of aerosol generation during medical procedures.

Background Nosocomial infection of health-care workers (HCWs) during outbreaks of respiratory infections (e.g. Influenza A H1N1 (2009)) is a significant concern for public health policy makers. World Health Organization (WHO)-defined ‘aerosol generating procedures’ (AGPs) are thought to increase the risk of aerosol transmission to HCWs, but there are presently insufficient data to quantify risk accurately or establish a hierarchy of risk-prone procedures. Methodology/Principal Findings This study measured the amount of H1N1 (2009) RNA in aerosols in the vicinity of H1N1 positive patients undergoing AGPs to help quantify the potential risk of transmission to HCWs. There were 99 sampling occasions (windows) producing a total of 198 May stages for analysis in the size ranges 0.86–7.3 µm. Considering stages 2 (4–7.3 µm) and 3 (0.86–4 µm) as comprising one sample, viral RNA was detected in 14 (14.1%) air samples from 10 (25.6%) patients. Twenty three air samples were collected while potential AGPs were being performed of which 6 (26.1%) contained viral RNA; in contrast, 76 May samples were collected when no WHO 2009 defined AGP was being performed of which 8 (10.5%) contained viral RNA (unadjusted OR = 2.84 (95% CI 1.11–7.24) adjusted OR = 4.31 (0.83–22.5)). Conclusions/Significance With our small sample size we found that AGPs do not significantly increase the probability of sampling an H1N1 (2009) positive aerosol (OR (95% CI) = 4.31 (0.83–22.5). Although the probability of detecting positive H1N1 (2009) positive aerosols when performing various AGPs on intensive care patients above the baseline rate (i.e. in the absence of AGPs) did not reach significance, there was a trend towards hierarchy of AGPs, placing bronchoscopy and respiratory and airway suctioning above baseline (background) values. Further, larger studies are required but these preliminary findings may be of benefit to infection control teams.

Infection control management of patients with suspected highly infectious diseases in emergency departments: data from a survey in 41 facilities in 14 European countries

BackgroundIn Emergency and Medical Admission Departments (EDs and MADs), prompt recognition and appropriate infection control management of patients with Highly Infectious Diseases (HIDs, e.g. Viral Hemorrhagic Fevers and SARS) are fundamental for avoiding nosocomial outbreaks.MethodsThe EuroNHID (European Network for Highly Infectious Diseases) project collected data from 41 EDs and MADs in 14 European countries, located in the same facility as a national/regional referral centre for HIDs, using specifically developed checklists, during on-site visits from February to November 2009.ResultsIsolation rooms were available in 34 facilities (82,9%): these rooms had anteroom in 19, dedicated entrance in 15, negative pressure in 17, and HEPA filtration of exhausting air in 12. Only 6 centres (14,6%) had isolation rooms with all characteristics. Personnel trained for the recognition of HIDs was available in 24 facilities; management protocols for HIDs were available in 35.ConclusionsPreparedness level for the safe and appropriate management of HIDs is partially adequate in the surveyed EDs and MADs.

EuroNHID checklists for the assessment of high‐level isolation units and referral centres for highly infectious diseases: results from the pilot phase of a European survey

Healthcare settings have been identified as preferential for the transmission of many agents causing highly infectious diseases (HIDs). Infection control procedures strongly reduce the risk of transmission of HIDs in hospital settings, when adequately applied. The main objective of the European Network for Highly Infectious Diseases (EuroNHID), a network co-funded by the European Commission, is to assess the current capabilities for dealing with HIDs in Europe, specifically in the context of infection control and healthcare worker (HCW) safety, through conducting an on-the-field survey of high-level isolation units (HLIUs)/referral centres for the management of HIDs in participating countries. During the first year of the projects activities, specifically designed, evidence-based checklists were developed. This review introduces the EuroNHID checklists as a standard tool for the assessment of hospital capabilities concerning infection control and HCW safety in the management of patients with HIDs, and presents preliminary results from five HLIUs.

Infection control practices in facilities for highly infectious diseases across Europe

Summary Background The management of patients with highly infectious diseases (HIDs) is a challenge for healthcare provision requiring a high level of care without compromising the safety of other patients and healthcare workers. Aim To study the infection control practice in isolation facilities participating in the European Network for Highly Infectious Diseases (EuroNHID) project. Methods A survey was conducted during 2009 of 48 isolation facilities caring for patients with HIDs in 16 European countries. Checklists and standard evaluation forms were used to collect and interpret data on hand hygiene, routine hygiene and disinfection, and waste management. Findings Forty percent of HIDs had no non-hand-operated sinks or alcohol-based antiseptic distributors, while 27% did not have procedures for routine hygiene, final disinfection, or safe discarding of non-disposable objects or equipment. There was considerable variation in the management of waste and in the training of housekeeping personnel. EuroNHID has developed recommendations for hand hygiene, disinfection, routine hygiene, and waste management. Conclusions Most aspects of hand hygiene, routine hygiene and disinfection, and waste management were considered at least partially adequate in the majority of European isolation facilities dedicated for the care of patients with HIDs. But considerable variability was observed, with management of waste and training of housekeeping personnel being generally less satisfactory.

Review of Crimean Congo Hemorrhagic Fever Infection in Kosova in 2008 and 2009: Prolonged Viremias and Virus Detected in Urine by PCR

Crimean-Congo hemorrhagic fever (CCHF) is a virus transmitted predominantly by ticks. However, contact with infected body fluids or tissues can result in animal-to-human or human-to-human transmission. Numbers of CCHF cases appear to be increasing, especially in Europe. We reviewed cases admitted to a tertiary referral unit in Kosova with suspected CCHF in 2008 and 2009, and looked at a smaller number of specimens which were sent to the Health Protection Agency, Porton Down, U.K., in further detail. The clinical features of cases admitted with suspected CCHF infection were assessed in more detail, and these are the focus of this article. Between 2008 and 2009, the numbers of patients admitted for suspected CCHF infection increased. Of the samples received in Porton Down, CCHF virus was detected in urine samples, and these patients were found to have prolonged viremia. The detection of CCHF in urine, as well as the prolonged viremias seen, are important for clinicians to know, as they may have public health implications with regard to the risk of infection, as well as provide insights into the biology and pathophysiology of infection. Further studies are required regarding the pathogenesis of this virus.

Diagnostic issues and capabilities in 48 isolation facilities in 16 European countries: data from EuroNHID surveys

BackgroundHighly infectious diseases (HIDs) are defined as being transmissible from person to person, causing life-threatening illnesses and presenting a serious public health hazard. The sampling, handling and transport of specimens from patients with HIDs present specific bio-safety concerns.FindingsThe European Network for HID project aimed to record, in a cross-sectional study, the infection control capabilities of referral centers for HIDs across Europe and assesses the level of achievement to previously published guidelines. In this paper, we report the current diagnostic capabilities and bio-safety measures applied to diagnostic procedures in these referral centers. Overall, 48 isolation facilities in 16 European countries were evaluated. Although 81% of these referral centers are located near a biosafety level 3 laboratory, 11% and 31% of them still performed their microbiological and routine diagnostic analyses, respectively, without bio-safety measures.ConclusionsThe discrepancies among the referral centers surveyed between the level of practices and the European Network of Infectious Diseases (EUNID) recommendations have multiple reasons of which the interest of the individuals in charge and the investment they put in preparedness to emerging outbreaks. Despite the fact that the less prepared centers can improve by just updating their practice and policies any support to help them to achieve an acceptable level of biosecurity is welcome.

Global Clinical Networking and Pandemic Influenza

From June 2009 to February 2010, the Health Protection Agency hosted a clinical network including regular teleconferences, with the aim of sharing clinical experiences of the international participants about pandemic influenza. The minutes of the teleconferences over a two month period were analysed to identify clinical themes. A systematic literature search was then undertaken to identify peer-reviewed publications that either supported or refuted these themes. Observations relating to patient demographics, clinical features and clinical management were supported by published literature. Younger adults and children were more likely to be infected, but young adults were more likely to require intensive care. Obesity, pregnancy and asthma were confirmed as risk factors for severe influenza illness. Extra-pulmonary organ dysfunction was common, often requiring specific interventions. The benefit of certain ventilatory and non-ventilatory interventions remains unclear, although they were frequently used. This global clinical networking model facilitated the real-time exchange of valuable clinical information and provided the basis for clinical practice notes.

Influenza aerosols in UK hospitals during the influenza H1N1 (2009–10) pandemic: air sampling in the vicinity of patients undergoing WHO-defined aerosol generating procedures

Abstract Background Nosocomial infection of health-care workers during outbreaks of respiratory infections (eg, influenza A H1N1 [2009]) is a great concern for public health policy makers. WHO-defined aerosol generating procedures (AGPs; eg, bronchoscopy, non-invasive ventilation) are thought to increase risk of aerosol transmission to health-care workers, but data to quantify risk accurately are insufficient. This study aims to provide some evidence base behind the requirement for respirators with FFP2 protection level to be worn in the vicinity of patients infected with influenza. Methods We measured the amount of pandemic H1N1 (2009) RNA in aerosols in the vicinity of H1N1-positive patients undergoing AGPs to help to quantify the potential risk of transmission to health-care workers. Sampling was done in the 2009–10 influenza seasons in five hospitals in England. Peak sampling times corresponded with peak levels of influenza activity (Nov, 2009–Jan, 2010; and Nov, 2010–Jan, 2011). Patient inclusion criteria were new changes in chest radiograph in the presence of one or more of: central temperature 38°C or higher (38·5°C in children) or 36°C or lower, white blood cell count less than 4000 or more than 12–000 cells per μL, positive microbiology or virology from respiratory secretions, and mucopurulent secretions from the respiratory tract. Aerosol sampling was done with the May 3 stage impinger (which allows fractionation of air samples into three aerodynamic size ranges: 0·86–4·0, 4·0–7·3, and >7·3 μm) at head height about 1 m away from the patient. Air samples were taken while WHO-defined AGPs were occurring, and baseline samples were taken when no AGP was being done. Samples were returned frozen to the laboratory, concentrated by centrifugation, and assayed by quantitative rt-PCR. A sample was deemed positive for aerosolised influenza particles if influenza RNA was detected in particles in the aerodynamic size range 0·86–7·3 μm. We used a univariable logistic regression model, adjusted for repeated measurements on the same individual, to examine the relation between propensity to obtain a positive H1N1 aerosol sample and undertaking of AGPs. Exact binomial confidence intervals were calculated for unadjusted sample proportions. Findings We obtained 198 air samples from 39 patients with influenza H1N1 (2009) during 99 sampling windows. Most participants were male (25 of 39 [64%]) and older than 50 years (28 of 39 [72%]). Only four (10%) participants were younger than 5 years. Mean time of sampling was 5·5 days (SD 8·56) since diagnosis. Viral RNA was detected in 21 of 198 (10·6%, 95% CI 6·7–15·8) air samples from ten of 39 (26%) patients. 46 air samples were obtained while WHO-defined AGPs were being done, of which nine (19·6%, 95% CI 9·4–33·9) contained viral RNA. Of 152 samples taken when no AGP was being done, 12 (7·9%, 4·2–13·4) contained viral RNA. Although AGPs did not significantly increase the probability of sampling an H1N1 (2009) positive aerosol, the point estimate and associated 95% CI from the regression model indicated that risk is likely to be heightened (odds ratio 4·31, 95% CI 0·83–22·5). Interpretation Our findings show that H1N1 RNA aerosols were often associated with infected patients within intensive-care units and were more frequently detected when a WHO-defined AGP was being done. Our results should be interpreted with caution because of the small sample size and limitations of the study design, which could not control for all potential sources of bias. Nevertheless on the basis of our results, we believe that infection control guidance for the use of FFP2 respirators in the vicinity of H1N1-positive patients should stand, until further data can be obtained. Funding Health Protection Agency.