Helen C. Maltezou

Crimean-congo hemorrhagic fever

Purpose of review Crimean-Congo hemorrhagic fever is a tick-borne viral zoonosis with the potential of human-to-human transmission, affecting wide areas in Asia, Southeastern Europe, and Africa. Hemorrhagic manifestations constitute a prominent symptom of late stage disease with case fatality rates from 10% to 50%. The purpose of this article is to review recent literature on Crimean-Congo hemorrhagic fever with emphasis on its epidemiology and management. Recent findings Climate and environmental changes may affect Crimean-Congo hemorrhagic fever epidemiology and trigger community outbreaks. Risk factors for acquisition of infection have been well studied. In the hospital, high-risk activities include interventions for gastrointestinal bleeding and needle stick injuries. Reverse transcription-polymerase chain reaction may rapidly diagnose Crimean-Congo hemorrhagic fever with high sensitivity and specificity. Ribavirin is the only promising therapeutic agent currently available but case–control studies have not been conducted. Recently, the Mx proteins have been found to act against Crimean-Congo hemorrhagic fever virus and deserve further research. Summary Clinicians should be aware of the potential of importation of Crimean-Congo hemorrhagic fever cases from endemic areas and nosocomial transmission. Studies on the efficacy of ribavirin are needed.

Metallo-β-lactamases in gram-negative bacteria: introducing the era of pan-resistance?

Metallo-beta-lactamases (MBLs) are being reported with increasing frequency and from several countries worldwide and are becoming the prevalent and most clinically significant determinants of carbapenem resistance. Furthermore, MBL-producing strains that exhibit a pan-resistant phenotype are increasingly detected. Initially MBLs were detected in Pseudomonas aeruginosa, however nowadays they are frequently found in Acinetobacter baumannii, Klebsiella pneumoniae and other Enterobacteriaceae. MBLs spread easily on plasmids and cause nosocomial infections and outbreaks with excess mortality. Such infections mainly concern patients admitted to Intensive Care Units with several co-morbidities and a history of prolonged administration of antibiotics. MBL-producing strains exhibit resistance to almost all currently available antibiotics. In vitro studies reveal that tigecycline and colistin are the only antibacterial agents with consistent activity against MBL-producing strains. Randomised controlled trials are required in order to evaluate the available therapeutic regimens, including treatment combinations. Tigecycline and colistin should be used under appropriate prescribing practices. Surveillance to monitor the emergence of resistance to these agents as well as implementation of infection control measures should be strengthened. MBL inhibitors are urgently needed, however, none is in late pre-clinical development.

Nosocomial influenza: new concepts and practice.

Purpose of review Nosocomial influenza constitutes a serious risk among patients with underlying diseases and those of extreme age, and is associated with excess health-care costs. This article will review recent literature on this area. Recent findings Despite longstanding recommendations and the fact that influenza vaccination of health-care workers improves patient and employee safety, vaccine coverage among health-care workers remains low worldwide. The Centers for Disease Prevention and Control recommends the use of signed declination forms for those health-care workers who refuse vaccination. Rapid antigen detection tests may accurately diagnose influenza at the point of care, and their use has been associated with reduced antibiotic use, diagnostic tests, and costs. Multiplex molecular methods may simultaneously detect several respiratory viruses and might prove advantageous for surveillance within hospitals. The beginning of the 2007–2008 influenza season was marked by the detection of a significant proportion of influenza A/H1N1 viruses resistant to oseltamivir in Europe. Given the prohibiting rates of resistance to adamantanes worldwide, our means for containing outbreaks within health-care facilities may narrow. Summary Provision of influenza vaccine at no cost and at the work site, education to promote vaccination, and switch to a mandatory influenza vaccination policy should be implemented in order to achieve high and sustained vaccine coverage among health-care workers. Surveillance to monitor antiviral resistance in influenza viruses should be enhanced. Development of new antivirals is needed.

Influenza vaccination acceptance among health-care workers: a nationwide survey.

We conducted a nationwide survey to investigate reasons for influenza vaccine uptake or refusal among health-care workers (HCWs) in Greece. Vaccination rates increased with increasing age, and among HCWs working in Northern Greece, in direct contact with patients, and with influenza vaccination in the past. Self-protection was the main reason for vaccination (89.1%), whereas 55.2% of HCWs reported vaccination to protect patients. Main reasons for refusing vaccination were perception of not being at risk for influenza (43.2%) and fear of vaccine adverse effects (33.4%).

Evaluation of a rapid antigen detection test in the diagnosis of streptococcal pharyngitis in children and its impact on antibiotic prescription

OBJECTIVES To study the performance of the Becton-Dickinson Link 2 Strep A Rapid Test, a rapid antigen detection test (RADT) for diagnosing streptococcal pharyngitis in children presenting to private offices and to the Pediatric Outpatient Clinic of a university hospital, in relation to clinical criteria (fever, tender anterior cervical lymph nodes, tonsillar exudate and absence of cough), and its impact on antibiotic prescription. METHODS Children were enrolled in Group A (enrolment by private-practice paediatricians; diagnosis by clinical picture only), Group B (enrolment by private-practice paediatricians; diagnosis by RADT and culture) or Group C (enrolment by hospital-affiliated paediatricians in the Pediatric Outpatient Clinic; diagnosis by RADT and culture). RESULTS During a 2 year period, 820 children were enrolled [369 (45%) in Group A, 270 (33%) in Group B and 181 (22%) in Group C]. Streptococcal pharyngitis was diagnosed by RADT and culture in 146 (32.4%) of the 451 tested children. The sensitivity, specificity and positive and negative predictive values of the RADT were 83.1%, 93.3%, 82.4% and 93.6%, respectively. A stepwise increase in the sensitivity of the RADT was noted among children with one, two, three or four clinical criteria (60.9% to 95.8%). Paediatricians without access to laboratory tests were more likely to prescribe antibiotics compared with paediatricians with access to tests (72.2% versus 28.2%, P < 0.001). Private-practice paediatricians prescribed antibiotics more frequently compared with hospital-affiliated paediatricians (55.7% versus 19.9%, P < 0.001). CONCLUSIONS Our findings support screening of all children with pharyngitis for Centor criteria and subsequently performing an RADT to guide decision for antibiotic administration. Such a strategy has an important impact on limiting throat culture testing and is associated with reduced antibiotic prescription.

Crimean-Congo hemorrhagic fever in Greece: a public health perspective.

In June 2008 the first non-imported fatal case of Crimean-Congo hemorrhagic fever (CCHF) was recorded in northern Greece. We present herein the public health interventions and the case definitions we developed for the epidemiological investigation. The possibility of CCHF establishing endemicity in this area is discussed.

Strategies to increase influenza vaccine uptake among health care workers in Greece.

The aim of the current study was to investigate the contribution of various strategies to increase influenza vaccine uptake among health care workers (HCWs) working in hospitals in Greece during the 2005–2006 season. A total of 132 Greek public hospitals participated in the study. The mean HCWs vaccination rate against influenza during 2005–2006 was 16.36% compared with 1.72% during the previous season. Logistic regression analysis showed that the implementation of the following strategies was significantly associated with influenza vaccination rates above the mean vaccination rate: a mobile vaccination team (OR 2.942, 95% CI 1.154–5.382, p-value 0.016) and lectures on influenza and influenza vaccine (OR 2.386, 95% CI 0.999–5.704, p-value 0.036). In conclusion, in Greece influenza vaccination rates among HCWs remain low; however, the implementation of specific strategies was associated with increased vaccine uptakes.

Pre-travel counselling in Greece for travellers visiting friends and relatives.

Pre-travel services are underused by travellers visiting friends and relatives (VFRs). The objective of this study was to define the proportion and the profile of VFRs who seek pre-travel counselling in Greece. The study was conducted prospectively, from July, 2005 to December, 2007, in seven Health Departments of the Prefectures in Athens and Attica, where 35.6% of the Greek population resides; migrants account for 17% and 8% of the population in these areas, respectively. 2548 travellers seeking pre-travel advice were studied; 23 (0.9%) were identified as VFRs. Children younger than 15 years accounted for 30.4% of VFRs, compared to 2.3% among non-VFRs. VFRs were younger than non-VFRs (mean ages: 29.9 versus 40.4 years, respectively). A comparison of VFRs with non-VFRs revealed that VFRs travelled for longer periods of time, stayed at local peoples home more frequently (87% versus 15.5%), and travelled on an organized trip less frequently (4.3% versus 54.6%). Considering the fact that 36,056 VFRs travelled from Greece to Africa and Asia during 2005-2007, and that only 1 out of 700 VFRs to these destinations pre-travel advice in Greece, communication strategies to access efficiently this group of travellers should be explored urgently.

Contact tracing and serosurvey among healthcare workers exposed to Crimean-Congo haemorrhagic fever in Greece

We investigated the probability of nosocomial transmission of Crimean-Congo haemorrhagic fever (CCHF) virus among healthcare workers (HCWs) who cared for the first CCHF case in Greece. Specific IgM and/or IgG antibodies against CCHF virus were not detected in the 21 HCWs studied. Although person-to-person transmission did not take place, education of HCWs about the modes of CCHF virus transmission and appropriate infection control measures is needed in order to avoid future nosocomial cases.

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.