Clostridium difficile infection in the community: Are proton pump inhibitors to blame?

Once a nosocomial disease,Clostridium difficile infection(CDI)now appears frequently in the community in the absence of exposure to antibiotics.Prior studies have shown that patients with community-acquired CDI are younger,more likely to be female,and have fewer comorbidities compared to patients with hospital-associated CDI.Because most studies of CDI are hospitalbased,comparatively little is known about communityacquired CDI.The recent study by Chitnis has received widespread attention because it used active surveillance to capture all cases of community-acquired CDI within a large population and assessed key risk factors.The authors found that low-level healthcare exposure and proton pump inhibitor use were common among those with non-antibiotics associated,community-acquired CDI.In this commentary,we discuss the changing epidemiology of community-acquired CDI and the evidence basis for the controversial association between proton pump inhibitors and community-acquired CDI.     

重庆市一起学校肺结核聚集性疫情调查分析

目的: 对重庆市一起学校肺结核疫情进行调查和分析,为强化学校结核病防控工作提供思路和建议。方法: 采用描述性流行病学方法,对重庆市2020年12月至2021年5月一起学校肺结核疫情进行流行病学调查和分析。采用症状筛查、结核菌素皮肤试验(tuberculin skin test,TST)和胸部X线摄片(简称“胸片”)开展肺结核筛查,并对接触者开展流行病学调查。结果: 在确诊1例病原学阳性肺结核病例(指示病例)后,经过4次接触者筛查及1次随访检查,检出8例活动性肺结核患者和42例结核分枝杆菌潜伏感染者。校内8例学生患者均集中在指示病例所在班级,该班肺结核罹患率为12.7%(8/63),病原学阳性者占2/8,结核分枝杆菌潜伏感染者34例,潜伏感染率为61.8%(34/55),均全部完成预防性治疗。指示病例所在班级学生发病风险和感染风险均高于其他班级(RR=27.6,95%CI:13.5~56.4)。校内8例学生肺结核患者中,男生6例,女生2例,年龄分布以15岁组最多(6例)。因首次接触者筛查胸片质量差,未能及时发现学生患者,导致后续因症就诊发现3例患者。2例学生潜伏感染者因未规范服药,在预防性治疗期间转为肺结核患者。 结论: 本次肺结核疫情聚集性明显,筛查质量低、未能规范完成预防性治疗是疫情蔓延的重要原因。在处置学校肺结核疫情时,应提高筛查质量,根据流行病学调查情况充分考虑窗口期问题,保证预防性治疗的规范性和完成率。     

Molecular and point-of-care diagnostics for Ebola and new threats: National POCT policy and guidelines will stop epidemics

Introduction: US hospitals that admitted Ebola virus disease (EVD) patients mitigated risk by using point-or-care testing (POCT) for critical support in isolation units. Success proved unequivocally the need for POCT. Additionally, molecular diagnostics have been used to help stop new outbreaks, and even handheld diagnostic solutions are emerging.

Areas covered: This update of ‘Molecular detection and point-of-care testing in Ebola virus disease and other threats’ [Expert Reviews 2015;15(10):1249–1255], assesses the impact of EVD epidemics, documents insights from recent reviews, summarizes evolving POC molecular technologies, presents General Accountability Office (GAO) recommendations, identifies the role of POC Coordinators, and casts a vision for national POCT policies and guidelines. Factual updating comprised summarizing EVD outbreaks including 2017–2018, analyzing reviews and evidence-based publications since the 2014–2016 epidemic, and tabulating published technical and molecular diagnostics. New graphics illustrate POC error mitigation/risk reduction, a framework for national POCT policy and guidelines, modular adaptations for country-specific solutions, and a logic diagram for future progress embedding artificial intelligence.

Expert commentary: The USA is still not prepared for highly infectious diseases. Key is lack of community rapid response and resilience, which must be enhanced not via mechanisms distant, but instead by molecular diagnostics directly at critical points of need.     

Evaluation of dengue fever reports during an epidemic,Colombia

OBJECTIVE

To assess the validity of dengue fever reports and how they relate to the definition of case and severity.

METHODS

Diagnostic test assessment was conducted using cross-sectional sampling from a universe of 13,873 patients treated during the fifth epidemiological period in health institutions from 11 Colombian departments in 2013. The test under analyses was the reporting to the National Public Health Surveillance System, and the reference standard was the review of histories identified by active institutional search. We reviewed all histories of patients diagnosed with dengue fever, as well as a random sample of patients with febrile syndromes. The specificity and sensitivity of reports were estimated for this purpose, considering the inverse of the probability of being selected for weighting. The concordance between reporting and the findings of the active institutional search was calculated using Kappa statistics.

RESULTS

We included 4,359 febrile patients, and 31.7% were classified as compatible with dengue fever (17 with severe dengue fever; 461 with dengue fever and warning signs; 904 with dengue fever and no warning signs). The global sensitivity of reports was 13.2% (95%CI 10.9;15.4) and specificity was 98.4% (95%CI 97.9;98.9). Sensitivity varied according to severity: 12.1% (95%CI 9.3;14.8) for patients presenting dengue fever with no warning signs; 14.5% (95%CI 10.6;18.4) for those presenting dengue fever with warning signs, and 40.0% (95%CI 9.6;70.4) for those with severe dengue fever. Concordance between reporting and the findings of the active institutional search resulted in a Kappa of 10.1%.

CONCLUSIONS

Low concordance was observed between reporting and the review of clinical histories, which was associated with the low reporting of dengue fever compatible cases, especially milder cases.     

内蒙古自治区不同生态系鼠疫自然疫源地动物鼠疫流行现状及流行风险简析

内蒙古面临着多种类型疫源地鼠疫流行和复燃的风险。蒙古旱獭疫源地虽然暂未在国内发现动物间鼠疫流行,但过去检出过阳性血清,同时蒙古旱獭种群数量持续增加且分布范围不断扩大,毗邻的蒙古国和俄罗斯联邦的蒙古旱獭疫源地动物间鼠疫持续流行;达乌尔黄鼠疫源地动物间鼠疫时隐时现;长爪沙鼠疫源地动物间鼠疫流行猛烈,并频频波及人间。由于蒙古旱獭和达乌尔黄鼠鼠疫耶尔森菌菌株毒力明显高于长爪沙鼠鼠疫耶尔森菌菌株,且在历史上曾给当地带来深重灾难,因此内蒙古自治区鼠疫防控重点应在常规鼠疫监测的基础上,进一步加强蒙古旱獭和达乌尔黄鼠疫源地流行动态的监测,警惕该两个疫源地复燃并波及人间。     

Exclusion of pregnant people from emergency vaccine clinical trials: A systematic review of clinical trial protocols and reporting from 2009 to 2019

BackgroundExisting ethics guidance and regulatory requirements emphasize the need for pregnancy-specific safety and efficacy data during the development of vaccines in health emergencies. Our objective was to conduct a systematic review of vaccine clinical trials during active epidemic periods.MethodsWe searched for Phase II and Phase III vaccine clinical trials initiated during the H1N1 influenza, Middle East Respiratory Syndrome Coronavirus (MERS-CoV), Zika, and Ebola virus disease (EVD) outbreaks from 2009 to 2019. Data were extracted from clinical trial protocols identified in the following registries: ClinicalTrials.gov, Pan African Clinical Trial Registry (PACTR), and all primary registries indicated by the World Health Organization’s International Clinical Trials Registry Platform (ICTRP). Published studies from registered clinical trials were located through PubMed. Data was extracted on eligibility criteria and pregnancy outcomes. Data from this study is available in the Center for Open Science Data Repository: https://osf.io/nfk2p/?view_only=47deb3b206724af9b46c9c0c0083a267.ResultsWe identified 96 vaccine clinical trial protocols and included 84 in analysis. 5 records were excluded in screening for irrelevant abstracts, 7 were excluded in full-text assessment (1 for a therapeutic drug trial, 3 for enrolling elderly adults only, 3 for enrolling children/adolescents only). There were no eligible trials for MERS-CoV or Zika virus vaccines. Overall, 8 protocols explicitly included pregnant people; of these, 3 were completed trials with published results. Incidental pregnancies and outcomes of pregnant participants were reported in 2 studies, 10 studies reported serious adverse events related to pregnancy without mentioning total incidental pregnancies. A total of 411 recorded pregnancy outcomes were reported, with 293 from the 3 pregnancy-eligible studies with results. 71 serious adverse events pertaining to pregnancy were reported from all clinical trials with results.ConclusionPregnant people are underrepresented in vaccine clinical trials conducted during outbreaks, resulting in underreporting of pregnancy-related outcomes and a lack of protection for pregnant people and neonates from infectious diseases.