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Abstracts in [TEXT NOT REPRODUCIBLE IN ASCII], Francais, [TEXT NOT REPRODUCIBLE IN ASCII] and Espanol at the end of each article. Introduction Throughout the African 'meningitis belt', epidemics of meningococcal [...], Objective To develop a tool for evaluating the risk that an outbreak of meningitis will occur in a particular district of the Niger after outbreaks have been reported in other, specified districts of the country. Methods A Bayesian network was represented by a graph composed of 38 nodes (one for each district in the Niger) connected by arrows. In the graph, each node directly influenced each of the 'child' nodes that lay at the ends of the arrows arising from that node, according to conditional probabilities. The probabilities between 'influencing' and 'influenced' districts were estimated by analysis of databases that held weekly records of meningitis outbreaks in the Niger between 1986 and 2005. For each week of interest, each district was given a Boolean-variable score of 1 (if meningitis incidence in the district reached an epidemic threshold in that week) or 0. Findings The Bayesian network approach provided important and original information, allowing the identification of the districts that influence meningitis risk in other districts (and the districts that are influenced by any particular district) and the evaluation of the level of influence between each pair of districts. Conclusion Bayesian networks offer a promising approach to understanding the dynamics of epidemics, estimating the risk of outbreaks in particular areas and allowing control interventions to be targeted at high-risk areas. Une approche de reseau bayesien de l'etude des bases de donnees epidemiologiques historiques: la modelisation des noussees de meningite au Niger/ Un enfoque de red bayesiana para el estudio de bases historicas de datos epidemiologicos: modelo de brotes de meningitis en Niger Objectif Developper un outil permettant d'evaluer le risque d'apparition d'une poussee de meningite dans un district particulier du Niger apres le signalement d'autres poussees dans d'autres districts specifies du pays. Methocles Un reseau bayesien a ete represente par un graphique compose de 38 nceuds (un pour chaque district du Niger) relies par des fleches. Dans le graphique, chaque nceud a directement influence chacun des noeuds <> aux extremites des fleches resultant de ces nceuds, selon les probabilites conditionnelles. Les probabilites entre les districts <> et <> ont ete estimees par I'analyse des bases de donnees qui contenaient les enregistrements hebdomadaires des poussees de meningite au Niger entre 1986 et 2005. Pour chaque semaine d'interet, on a attribue a chaque district un score booleen variable de 1 (si I'incidence de meningite dans le district atteignait un seuil epidemique au cours de cette semaine) ou de 0. Resultats L'approche de reseau bayesien a fourni des informations originates et importantes, permettant d'identifier les districts q'ui influencent le risque de meningite dans d'autres districts (et les districts qui sont influences par un district particulier) et d'evaluer le niveau d'influence entre chaque couple de districts. Conclusion Les reseaux bayesiens offrent une approche prometteuse pour comprendre la dynamique des epidemies, evaluant le risque de poussees dans des zones particulieres et permettant de cibler les interventions de lutte contre la maladie dans les zones a risque eleve. Objetivo Desarrollar una herramienta para evaluar el riesgo de la aparicion de un brote de meningitis en un distrito determinado dei Niger despues de que se haya informado acerca de otros brotes en otros distritos especificos dei pais. Metodos Se represento una red bayesiana con un grafico compuesto por 38 nodos (uno por cada distrito en el Niger) conectados mediante flechas. En el grafico, cada nodo influia directamente en cada uno de los nodos de 'nioos' que se encuentran en los extremos de las flechas que surgen de dicho nodo, de acuerdo con las probabilidades condicionales. Se calcularon las probabilidades entre distritos 'influyentes' e 'influidos' mediante el analisis de bases de datos que recogian registros semanales de los brotes de meningitis en Niger entre 1986 y 2005. Por cada sema na de interes, se adjudicaba a cada uno de los distritos un valor de variable booleana de 1 (si la incidencia de meningitis en el distrito alcanzaba un umbral epidemico en esa semana) o de 0. Resultados El enfoque de red bayesiana proporciona informacion importante y original, lo que permite identificar cuales son los distritos que influyen en el riesgo de meningitis de otros distritos (y cuales estan bajo la influencia de cualquier distrito determinado) y evaluar el nivel de influencia entre cada par de distritos. Conclusion Las redes bayesianas ofrecen un enfoque prometedor para entender las dinamicas de las epidemias, permiten calcular el riesgo de brotes en areas determinadas y concentrar las intervenciones de control objetivo en las areas de alto riesgo.

Background: Hand hygiene prevents cross infection in hospitals, but compliance with recommended instructions is commonly poor. We attempted to promote hand hygiene by implementing a hospital-wide programme, with special emphasis on bedside, alcohol-based hand disinfection. We measured nosocomial infections in parallel.Methods: We monitored the overall compliance with hand hygiene during routine patient care in a teaching hospital in Geneva, Switzerland, before and during implementation of a hand-hygiene campaign. Seven hospital-wide observational surveys were done twice yearly from December, 1994, to December, 1997. Secondary outcome measures were nosocomial infection rates, attack rates of methicillin-resistant Staphylococcus aureus (MRSA), and consumption of handrub disinfectant.Findings: We observed more than 20,000 opportunities for hand hygiene. Compliance improved progressively from 48% in 1994, to 66% in 1997 (p<0.001). Although recourse to handwashing with soap and water remained stable, frequency of hand disinfection substantially increased during the study period (p<0.001). This result was unchanged after adjustment for known risk factors of poor adherence. Hand hygiene improved significantly among nurses and nursing assistants, but remained poor among doctors. During the same period, overall nosocomial infection decreased (prevalence of 16.9% in 1994 to 9.9% in 1998; p=0.04), MRSA transmission rates decreased (2.16 to 0.93 episodes per 10,000 patient-days; p<0.001), and the consumption of alcohol-based handrub solution increased from 3.5 to 15.4 L per 1000 patient-days between 1993 and 1998 (p<0.001).Interpretation: The campaign produced a sustained improvement in compliance with hand hygiene, coinciding with a reduction of nosocomial infections and MRSA transmission. The promotion of bedside, antiseptic handrubs largely contributed to the increase in compliance. [ABSTRACT FROM AUTHOR]

Background: Noma is a gangrenous disease that leads to severe disfigurement of the face with high morbidity and mortality, but its etiology remains unknown. Young children in developing countries are almost exclusively affected. The purpose of the study was to record and compare bacterial diversity in oral samples from children with or without acute noma or acute necrotizing gingivitis from a defined geographical region in Niger by culture-independent molecular methods. Methods and Principal Findings: Gingival samples from 23 healthy children, nine children with acute necrotizing gingivitis, and 23 children with acute noma (both healthy and diseased oral sites) were amplified using "universal" PCR primers for the 16 S rRNA gene and pooled according to category (noma, healthy, or acute necrotizing gingivitis), gender, and site status (diseased or control site). Seven libraries were generated. A total of 1237 partial 16 S rRNA sequences representing 339 bacterial species or phylotypes at a 98-99% identity level were obtained. Analysis of bacterial composition and frequency showed that diseased (noma or acute necrotizing gingivitis) and healthy site bacterial communities are composed of similar bacteria, but differ in the prevalence of a limited group of phylotypes. Large increases in counts of Prevotella intermedia and members of the Peptostreptococcus genus are associated with disease. In contrast, no clear-cut differences were found between noma and non-noma libraries. Conclusions: Similarities between acute necrotizing gingivitis and noma samples support the hypothesis that the disease could evolve from acute necrotizing gingivitis in certain children for reasons still to be elucidated. This study revealed oral microbiological patterns associated with noma and acute necrotizing gingivitis, but no evidence was found for a specific infection-triggering agent. [ABSTRACT FROM AUTHOR]

OBJECTIVE: There is growing evidence that low nurse staffing jeopardizes quality of patient care. The objective of the study was to determine whether low staffing level increases the infection risk in critical care. DESIGN: Observational, single-center, prospective cohort study. SETTING: Medical intensive care unit of the University of Geneva Hospitals, Switzerland. PATIENTS: All patients admitted over a 4-yr period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Study variables included all infections acquired in critical care, daily nurse-to-patient ratio, demographic characteristics, admission diagnosis and severity score, comorbidities, daily individual exposure to invasive devices, and selected drugs. Of a cohort of 1,883 patients totaling 10,637 patient-days, 415 (22%) developed at least one healthcare-associated infection while in critical care. Overall infection rate was 64.5 episodes per 1000 patient-days. Infected patients experienced higher mortality with a longer duration of stay both in critical care and in the hospital than noninfected patients (all p < .001). Median 24-hr nurse-to-patient ratio was 1.9. Controlling for exposure to central venous catheter, mechanical ventilation, urinary catheter, and antibiotics, we found that higher staffing level was associated with a >30% infection risk reduction (incidence rate ratio, 0.69; 95% confidence interval, 0.50-0.95). We estimated that 26.7% of all infections could be avoided if the nurse-to-patient ratio was maintained >2.2. CONCLUSIONS: Staffing is a key determinant of healthcare-associated infection in critically ill patients. Assuming causality, a substantial proportion of all infections could be avoided if nurse staffing were to be maintained at a higher level. [ABSTRACT FROM AUTHOR]

Abstract Background The epidemiology of meningococcal meningitis in the African meningitis belt is characterised by seasonality, localised epidemics and epidemic waves. To facilitate research and surveillance, we aimed to develop a definition for localised epidemics to be used in real-time surveillance based on weekly case reports at the health centre level. Methods We used national routine surveillance data on suspected meningitis from January 2004 to December 2008 in six health districts in western and central Burkina Faso. We evaluated eight thresholds composed of weekly incidence rates at health centre level for their performance in predicting annual incidences of 0.4%and 0.8% in health centre areas. The eventually chosen definition was used to describe the spatiotemporal epidemiology and size of localised meningitis epidemics during the included district years. Results Among eight weekly thresholds evaluated, a weekly incidence rate of 75 cases per 100,000 inhabitants during at least two consecutive weeks with at least 5 cases per week had 100% sensitivity and 98% specificity for predicting an annual incidence of at least 0.8% in health centres. Using this definition, localised epidemics were identified in all but one years during 2004-2008, concerned less than 10% of the districts' population and often were geographically dispersed. Where sufficient laboratory data were available, localised epidemics were exclusively due to meningococci. Conclusions This definition of localised epidemics a the health centre level will be useful for risk factor and modelling studies to understand the meningitis belt phenomenon and help documenting vaccine impact against epidemic meningitis where no widespread laboratory surveillance exists for quantifying disease reduction after vaccination.

OBJECTIVES: Hand hygiene promotion interventions rarely result in sustained improvement, and an assessment of their impact on individual infection risk has been lacking. We sought to measure the impact of hand hygiene promotion on health care worker compliance and health care-associated infection risk among neonates. METHODS: We conducted an intervention study with a 9-month follow-up among all of the health care workers at the neonatal unit of the Children's Hospital, University of Geneva Hospitals, between March 2001 and February 2004. A multifaceted hand hygiene education program was introduced with compliance assessed during successive observational surveys. Health care-associated infections were prospectively monitored, and genotypic relatedness of bloodstream pathogens was assessed by pulsed-field gel electrophoresis. A comparison of observed hand hygiene compliance and infection rates before, during, and after the intervention was conducted. RESULTS: A total of 5325 opportunities for hand hygiene were observed. Overall compliance improved gradually from 42% to 55% across study phases. This trend remained significant after adjustment for possible confounders and paralleled the measured increase in hand-rub consumption (from 66.6 to 89.2 L per 1000 patient-days). A 9-month follow-up survey showed sustained improvement in compliance (54%), notably with direct patient contact (49% at baseline vs 64% at follow-up). Improved compliance was independently associated with infection risk reduction among very low birth weight neonates. Bacteremia caused by clonally related pathogens markedly decreased after the intervention. CONCLUSIONS: Hand hygiene promotion, guided by health care workers' perceptions, identification of the dynamics of bacterial contamination of health care workers' hands, and performance feedback, is effective in sustaining compliance improvement and is independently associated with infection risk reduction among high-risk neonates. [ABSTRACT FROM AUTHOR]

Background: Non-pharmaceutical interventions (NPIs) are a crucial suite of measures to prevent and control infectious disease outbreaks. Despite being particularly important for crisis-affected populations and those living in informal settlements, who typically reside in overcrowded and resource limited settings with inadequate access to healthcare, guidance on NPI implementation rarely takes the specific needs of such populations into account. We therefore conducted a systematic scoping review of the published evidence to describe the landscape of research and identify evidence gaps concerning the acceptability, feasibility, and effectiveness of NPIs among crisis-affected populations and informal settlements., Methods: We systematically reviewed peer-reviewed articles published between 1970 and 2020 to collate available evidence on the feasibility, acceptability, and effectiveness of NPIs in crisis-affected populations and informal settlements. We performed quality assessments of each study using a standardised questionnaire. We analysed the data to produce descriptive summaries according to a number of categories: date of publication; geographical region of intervention; typology of crisis, shelter, modes of transmission, NPI, research design; study design; and study quality., Results: Our review included 158 studies published in 85 peer-reviewed articles. Most research used low quality study designs. The acceptability, feasibility, and effectiveness of NPIs was highly context dependent. In general, simple and cost-effective interventions such as community-level environmental cleaning and provision of water, sanitation and hygiene services, and distribution of items for personal protection such as insecticide-treated nets, were both highly feasible and acceptable. Logistical, financial, and human resource constraints affected both the implementation and sustainability of measures. Community engagement emerged as a strong factor contributing to the effectiveness of NPIs. Conversely, measures that involve potential restriction on personal liberty such as case isolation and patient care and burial restrictions were found to be less acceptable, despite apparent effectiveness., Conclusions: Overall, the evidence base was variable, with substantial knowledge gaps which varied between settings and pathogens. Based on the current landscape, robust evidence-based guidance is not possible, and a research agenda is urgently required that focusses on these specific vulnerable populations. Although implementation of NPIs presents unique practical challenges in these settings, it is critical that such an agenda is put in place, and that the lessons learned from historical and present experiences are documented to build a firm evidence base., (© 2022. The Author(s).)

Contact tracing in an Ebola virus disease (EVD) outbreak is the process of identifying individuals who may have been exposed to infected persons with the virus, followed by monitoring for 21 days (the maximum incubation period) from the date of the most recent exposure. The goal is to achieve early detection and isolation of any new cases in order to prevent further transmission. We performed a retrospective data analysis of 261 probable and confirmed EVD cases in the national EVD database and 2525 contacts in the Contact Line Lists in Kenema district, Sierra Leone between 27 April and 4 September 2014 to assess the performance of contact tracing during the initial stage of the outbreak. The completion rate of the 21-day monitoring period was 89% among the 2525 contacts. However, only 44% of the EVD cases had contacts registered in the Contact Line List and 6% of probable or confirmed cases had previously been identified as contacts. Touching the body fluids of the case and having direct physical contact with the body of the case conferred a 9- and 20-fold increased risk of EVD status, respectively. Our findings indicate that incompleteness of contact tracing led to considerable unmonitored transmission in the early months of the epidemic. To improve the performance of early outbreak contact tracing in resource poor settings, our results suggest the need for prioritized contact tracing after careful risk assessment and better alignment of Contact Line Listing with case ascertainment and investigation.This article is part of the themed issue 'The 2013-2016 West African Ebola epidemic: data, decision-making and disease control'., (© 2017 The Author(s).)

Background: A group A meningococcal (MenA) conjugate vaccine has progressively been introduced in the African meningitis belt since 2010. A country-wide risk assessment tool, the District Prioritization Tool (DPT), was developed to help national stakeholders combine existing data and local expertise to define priority geographical areas where mass vaccination campaigns should be conducted., Methods: DPT uses an Excel-supported offline tool that was made available to the countries proposed for immunization campaigns. It used quantitative-qualitative methods, relying predominantly on evidence-based risk scores complemented by expert opinion., Results: DPT was used by most of the countries that introduced the group A conjugate vaccine. Surveillance data enabled the computation of severity scores for meningitis at the district level (magnitude, intensity, and frequency). District data were scaled regionally to facilitate phasing decisions. DPT also assessed the country's potential to conduct efficient preventive immunization campaigns while paying close attention to the scope of the geographic extension of the campaigns. The tool generated meningitis district profiles that estimated the number of vaccine doses needed. In each assessment, local meningitis experts contributed their knowledge of local risk factors for meningitis epidemics to refine the final prioritization decisions., Conclusions: DPT proved to be a useful and flexible tool that codified information and streamlined discussion among stakeholders while facilitating vaccine distribution decisions after 2011. DPT methodology may be tailored to prioritize vaccine interventions for other diseases., (© 2015 World Health Organization; licensee Oxford Journals.)

In 2012, Neisseria meningitidis serogroup W caused a widespread meningitis epidemic in Burkina Faso. We describe the dynamic of the epidemic at the subdistrict level. Disease detection at this scale allows for a timelier response, which is critical in the new epidemiologic landscape created in Africa by the N. meningitidis A conjugate vaccine.

Global vaccine stockpiles, in which vaccines are reserved for use when needed for emergencies or supply shortages, have effectively provided countries with the capacity for rapid response to emergency situations, such as outbreaks of yellow fever and meningococcal meningitis. The high cost and insufficient supply of many vaccines, including oral cholera vaccine and pandemic influenza vaccine, have prompted discussion on expansion of the use of vaccine stockpiles to address a wider range of emerging and re-emerging diseases. However, the decision to establish and maintain a vaccine stockpile is complex and must take account of disease and vaccine characteristics, stockpile management, funding, and ethical concerns, such as equity. Past experience with global vaccine stockpiles provide valuable information about the processes for their establishment and maintenance. In this Review we explored existing literature and stockpile data to discuss the lessons learned and to inform the development of future vaccine stockpiles., (Copyright © 2015 World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. Published by Elsevier Ltd. All rights reserved.)

Background: The epidemiology of bacterial meningitis in the African 'meningitis belt' changes periodically. In order to design an effective vaccination strategy, we have examined the epidemiological and microbiological patterns of bacterial meningitis, and especially that of meningococcal meningitis, in Niger during the period 2008-2011. During this period a mass vaccination campaign with the newly developed meningococcal A conjugate vaccine (MenAfriVac®) was undertaken., Method: Cerebrospinal fluid samples were collected from health facilities throughout Niger and analysed by culture, seroagglutination and/or speciation polymerase chain reaction, followed by genogrouping PCR for Neisseria meningitidis infections. A sample of strains were analysed by multi-locus sequence typing., Results: N. meningitidis serogroup A cases were prevalent in 2008 and 2009 [98.6% and 97.5% of all N. meningitidis cases respectively]. The prevalence of serogroup A declined in 2010 [26.4%], with the emergence of serogroup W Sequence Type (ST) 11 [72.2% of cases], and the serogroup A meningococcus finally disappeared in 2011. The geographical distribution of cases N. meningitidis serogroups A and W within Niger is described., Conclusion: The substantial decline of serogroup A cases that has been observed from 2010 onwards in Niger seems to be due to several factors including a major polysaccharide A/C vaccination campaign in 2009, the introduction of MenAfriVac® in 10 districts at risk in December 2010, the natural dynamics of meningococcal infection and the persistence of serogroup A sequence-type 7 for about 10 years. The emergence of serogroup W strains suggests that there may be a need for serogroup W containing vaccines in Niger in the coming years.

Background: Noma is a poorly studied disease that leads to severe facial tissue destruction in children in developing countries, but the cause remains unknown. We aimed to identify the epidemiological and microbiological risk factors associated with noma disease., Methods: We did a prospective, matched, case-control study in Niger between Aug 1, 2001, and Oct 31, 2006, in children younger than 12 years to assess risk factors for acute noma. All acute noma cases were included and four controls for each case were matched by age and home village. Epidemiological and clinical data were obtained at study inclusion. We undertook matched-paired analyses with conditional logistic regression models., Findings: We included 82 cases and 327 controls. Independent risk factors associated with noma were: severe stunting (odds ratio [OR] 4·87, 95% CI 2·35-10·09) or wasting (2·45, 1·25-4·83); a high number of previous pregnancies in the mother (1·16, 1·04-1·31); the presence of respiratory disease, diarrhoea, or fever in the past 3 months (2·70, 1·35-5·40); and the absence of chickens at home (1·90, 0·93-3·88). After inclusion of microbiological data, a reduced proportion of Fusobacterium (4·63, 1·61-13·35), Capnocytophaga (3·69, 1·48-9·17), Neisseria (3·24, 1·10-9·55), and Spirochaeta in the mouth (7·77, 2·12-28·42), and an increased proportion of Prevotella (2·53, 1·07-5·98), were associated with noma. We identified no specific single bacterial or viral pathogen in cases., Interpretation: Noma is associated with indicators of severe poverty and altered oral microbiota. The predominance of specific bacterial commensals is indicative of a modification of the oral microbiota associated with reduced bacterial diversity., Funding: Gertrude Hirzel Foundation., (Copyright © 2013 Baratti-Mayer et al. Open Access article distributed under the terms of CC BY-NC-ND. Published by .. All rights reserved.)

Background: Fixed laboratory capacity in Africa may be inadequate; mobile microbiological laboratories may address this issue but their utility has seldom been evaluated., Methods: During 2012, the Benin Ministry of Health requested mobile microbiological laboratory (LaboMobil®) support following the failure of polysaccharide meningococcal A+C vaccine to prevent an epidemic in five Northern districts. Within four days, the intervention was initiated. A fixed site in Northern Togo, Pasteur Institutes in Côte d'Ivoire and France, and a research laboratory in Burkina Faso provided additional laboratory support., Results: Local laboratories initially reported most cases to have Gram-positive diplococci suggestive of pneumococcal meningitis. The LaboMobil® evaluated 200 cerebrospinal fluid (CSF) samples and 59 stored isolates collected from 149 individuals. Of the 74 individuals with etiologic confirmation, 60 (81%) had NmW135 and 11 (15%) NmX identified; no pneumococci were identified. Testing in France on 30 NmW135 and 3 NmX confirmed the etiology in all cases. All five districts had crossed the epidemic threshold (10 cases per 100,000 per week), all had NmW135 identified and four had NmX identified. NmX were identified as X:ST-181:ccST-181:5-1:10-1:F1-31 and NmW135 as W:ST-11: ccST-11:5:2:F1-1., Conclusions: In an area with limited local laboratory capacity, a mobile microbiology laboratory intervention occurred in four days through the cooperation of four African and one European country. Results were different from those reported by local laboratories. Despite the introduction of serogroup A meningococcal and 13-valent pneumococcal conjugate vaccines, endemic and epidemic meningitis will continue in the region, emphasizing the usefulness of the LaboMobil® in the short and medium term.

For over 100 years, large epidemics of meningococcal meningitis have occurred every few years in areas of the African Sahel and sub-Sahel known as the African meningitis belt. Until recently, the main approach to the control of these epidemics has been reactive vaccination with a polysaccharide vaccine after an outbreak has reached a defined threshold and provision of easy access to effective treatment but this approach has not prevented the occurrence of new epidemics. Meningococcal conjugate vaccines, which can prevent meningococcal carriage and thus interrupt transmission, may be more effective than polysaccharide vaccines at preventing epidemics. Because the majority of African epidemics have been caused by serogroup A meningococci, a serogroup A polysaccharide/tetanus toxoid protein conjugate vaccine (PsA-TT) has recently been developed. Results from an initial evaluation of the impact of this vaccine on meningococcal disease and meningococcal carriage in Burkina Faso have been encouraging. To review how the research agenda for meningococcal disease in Africa has been changed by the advent of PsA-TT and to define a new set of research priorities for study of meningococcal infection in Africa, a meeting of 41 scientists was held in Dakar, Senegal on April 24th and 25th 2012. The research recommendations developed during the course of this meeting are presented in this paper. The need for enhanced surveillance for meningitis in defined populations with good diagnostic facilities in African countries at risk of epidemics was identified as the highest priority. This is needed to determine the duration of protection against serogroup A meningococcal disease provided by PsA-TT and to determine the risk of disease and carriage caused by meningococci of other serogroups. Other research areas given high priority included identification and validation of serological correlates of protection against meningococcal disease and carriage, development of improved methods for detecting carriage and epidemiological studies aimed at determining the reasons underlying the peculiar epidemiology of meningococcal disease in the African meningitis belt. Minutes and working papers from the meeting are provided in supplementary tables and some of the presentations made at the meeting are available on the MenAfriCar consortium website (www.menafricar.org) and on the web site of the Centers for Disease Control (www.cdc.gov)., (Copyright © 2013. Published by Elsevier Ltd.. All rights reserved.)

Background: Bacterial meningitis is a major public health problem in the African 'Meningitis Belt', where recurrent unpredictable epidemics occur. Despite the introduction in 2010 of the conjugate A vaccine, the reactive strategy remains important for responding to epidemics caused by other bacteria and in areas not yet vaccinated. Review of weekly numbers of suspected cases in Niger, Mali and Burkina Faso identified spatial disparities in the annual patterns of meningitis, which suggested a more local way of defining epidemics and initiating a timely vaccination campaign., Method: We defined an epidemic district-year as an excess of cases compared to the incidence previously experienced in the given district. Groups of similar districts in terms of seasonal patterns were identified by cluster analysis. We investigated a cluster-specific criterion of early epidemic onset to anticipate epidemic district-years., Results: These were encouraging, as epidemic district-years were fairly efficiently captured, with an average time gained of 2.5 weeks over the current strategy., Conclusion: This early-onset criterion could help ensure timely implementation of vaccination campaigns without the need to modify the implemented surveillance system. The next step is to extend this study to other countries of the Meningitis Belt, and to explain the differences in seasonal patterns in the different clusters.

Intensive care units (ICUs) play an important role in the epidemiology of methicillin-resistant Staphyloccocus aureus (MRSA). Although successful interventions are multi-modal, the relative efficacy of single measures remains unknown. We developed a discrete time, individual-based, stochastic mathematical model calibrated on cross-transmission observed through prospective surveillance to explore the transmission dynamics of MRSA in a medical ICU. Most input parameters were derived from locally acquired data. After fitting the model to the 46 observed cross-transmission events and performing sensitivity analysis, several screening and isolation policies were evaluated by simulating the number of cross-transmissions and isolation-days. The number of all cross-transmission events increased from 54 to 72 if only patients with a past history of MRSA colonization are screened and isolated at admission, to 75 if isolation is put in place only after the results of the admission screening become available, to 82 in the absence of admission screening and with a similar reactive isolation policy, and to 95 when no isolation policy is in place. The method used (culture or polymerase chain reaction) for admission screening had no impact on the number of cross-transmissions. Systematic regular screening during ICU stay provides no added-value, but aggressive admission screening and isolation effectively reduce the number of cross-transmissions. Critically, colonized healthcare workers may play an important role in MRSA transmission and their screening should be reinforced.

A new Group A meningococcal (Men A) conjugate vaccine, MenAfriVac™, was prequalified by the World Health Organization (WHO) in June 2010. Because Burkina Faso has repeatedly suffered meningitis epidemics due to Group A Neisseria meningitidis special efforts were made to conduct a country-wide campaign with the new vaccine in late 2010 and before the onset of the next epidemic meningococcal disease season beginning in January 2011. In the ensuing five months (July-November 2010) the following challenges were successfully managed: (1) doing a large safety study and registering the new vaccine in Burkina Faso; (2) developing a comprehensive communication plan; (3) strengthening the surveillance system with particular attention to improving the capacity for real-time polymerase chain reaction (PCR) testing of spinal fluid specimens; (4) improving cold chain capacity and waste disposal; (5) developing and funding a sound campaign strategy; and (6) ensuring effective collaboration across all partners. Each of these issues required specific strategies that were managed through a WHO-led consortium that included all major partners (Ministry of Health/Burkina Faso, Serum Institute of India Ltd., UNICEF, Global Alliance for Vaccines and Immunization, Meningitis Vaccine Project, CDC/Atlanta, and the Norwegian Institute of Public Health/Oslo). Biweekly teleconferences that were led by WHO ensured that problems were identified in a timely fashion. The new meningococcal A conjugate vaccine was introduced on December 6, 2010, in a national ceremony led by His Excellency Blaise Compaore, the President of Burkina Faso. The ensuing 10-day national campaign was hugely successful, and over 11.4 million Burkinabes between the ages of 1 and 29 years (100% of target population) were vaccinated. African national immunization programs are capable of achieving very high coverage for a vaccine desired by the public, introduced in a well-organized campaign, and supported at the highest political level. The Burkina Faso success augurs well for further rollout of the Men A conjugate vaccine in meningitis belt countries., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Research suggests that patients could improve healthcare workers' compliance with hand hygiene recommendations by reminding them to cleanse their hands., Objective: To assess patients' perceptions of a patient-participation program to improve healthcare workers' compliance with hand hygiene., Design: Cross-sectional survey of patient knowledge and perceptions of healthcare-associated infections, hand hygiene, and patient participation, defined as the active involvement of patients in various aspects of their health care., Setting: Large Swiss teaching hospital., Results: Of 194 patients who participated, most responded that they would not feel comfortable asking a nurse (148 respondents [76%]) or a physician (150 [77%]) to perform hand hygiene, and 57 (29%) believed that this would help prevent healthcare-associated infections. In contrast, an explicit invitation from a healthcare worker to ask about hand hygiene doubled the intention to ask a nurse (from 34% to 83% of respondents; P < .001) and to ask a physician (from 30% to 78%; P < .001). In multivariate analysis, being nonreligious, having an expansive personality, being concerned about healthcare-associated infections, and believing that patient participation would prevent healthcare-associated infections were associated with the intention to ask a nurse or a physician to perform hand hygiene (P < .05). Being of Jewish, Eastern Orthodox, or Buddhist faith was associated also with increased intention to ask a nurse (P < .05), compared with being of Christian faith., Conclusions: This study identifies several sociodemographic characteristics associated with the intention to ask nurses and physicians about hand hygiene and underscores the importance of a direct invitation from healthcare workers to increase patient participation and foster patient empowerment. These findings could guide the development of future hand hygiene-promotion strategies.

A novel influenza A (H1N1) virus has spread rapidly across the globe. Judging its pandemic potential is difficult with limited data, but nevertheless essential to inform appropriate health responses. By analyzing the outbreak in Mexico, early data on international spread, and viral genetic diversity, we make an early assessment of transmissibility and severity. Our estimates suggest that 23,000 (range 6000 to 32,000) individuals had been infected in Mexico by late April, giving an estimated case fatality ratio (CFR) of 0.4% (range: 0.3 to 1.8%) based on confirmed and suspected deaths reported to that time. In a community outbreak in the small community of La Gloria, Veracruz, no deaths were attributed to infection, giving an upper 95% bound on CFR of 0.6%. Thus, although substantial uncertainty remains, clinical severity appears less than that seen in the 1918 influenza pandemic but comparable with that seen in the 1957 pandemic. Clinical attack rates in children in La Gloria were twice that in adults (<15 years of age: 61%; >/=15 years: 29%). Three different epidemiological analyses gave basic reproduction number (R0) estimates in the range of 1.4 to 1.6, whereas a genetic analysis gave a central estimate of 1.2. This range of values is consistent with 14 to 73 generations of human-to-human transmission having occurred in Mexico to late April. Transmissibility is therefore substantially higher than that of seasonal flu, and comparable with lower estimates of R0 obtained from previous influenza pandemics.

Adults more than 40 years old are not necessarily immune to measles. A measles outbreak that involved healthcare workers occurred after contact with a 44-year-old patient. Results of a hospital-wide program of mass screening revealed that 117 (4.5%) of 2,600 individuals tested seronegative for measles; 31 (26.1%) of these 117 individuals were more than 40 years old.

Introduction: Hand hygiene is one of the cornerstones of the prevention of health care-associated infection, but health care worker (HCW) compliance with good practices remains low. Alcohol-based handrub is the new standard for hand hygiene action worldwide and usually requires a system change for its successful introduction in routine care. Product acceptability by HCWs is a crucial step in this process., Methods: We conducted a prospective intervention study to compare the impact on HCW compliance of a liquid (study phase I) versus a gel (phase II) handrub formulation of the same product during daily patient care. All staff (102 HCWs) of the medical intensive care unit participated. Compliance with hand hygiene was monitored by a single observer. Skin tolerance and product acceptability were assessed using subjective and objective scoring systems, self-report questionnaires, and biometric measurements. Logistic regression was used to estimate the association between predictors and compliance with the handrub formulation as the main explanatory variable and to adjust for potential risk factors., Results: Overall compliance (phases I and II) with hand hygiene practices among nurses, physicians, nursing assistants, and other HCWs was 39.1%, 27.1%, 31.1%, and 13.9%, respectively (p = 0.027). Easy access to handrub improved compliance (35.3% versus 50.6%, p = 0.035). Nurse status, working on morning shifts, use of the gel formulation, and availability of the alcohol-based handrub in the HCW's pocket were independently associated with higher compliance. Immediate accessibility was the strongest predictor. Based on self-assessment, observer assessment, and the measurement of epidermal water content, the gel performed significantly better than the liquid formulation., Conclusion: Facilitated access to an alcohol-based gel formulation leads to improved compliance with hand hygiene and better skin condition in HCWs.

Introduction: The clinical and economic burden of ventilator-associated pneumonia (VAP) is uncontested. We conducted the present study to determine whether low nurse-to-patient ratio increases the risk for VAP and whether this effect is similar for early-onset and late-onset VAP., Methods: This prospective, observational, single-centre cohort study was conducted in the medical intensive care unit (ICU) of the University of Geneva Hospitals. All patients who were at risk for ICU-acquired infection admitted from January 1999 to December 2002 were followed from admission to discharge. Collected variables included patient characteristics, admission diagnosis, Acute Physiology and Chronic Health Evaluation II score, co-morbidities, exposure to invasive devices, daily number of patients and nurses on duty, nurse training level and all-site ICU-acquired infections. VAP was diagnosed using standard definitions., Results: Among 2,470 patients followed during their ICU stay, 262 VAP episodes were diagnosed in 209/936 patients (22.3%) who underwent mechanical ventilation. Median duration of mechanical ventilation was 3 days (interquartile range 2 to 6 days) among patients without VAP and 11 days (6 to 19 days) among patients with VAP. Late-onset VAP accounted for 61% of all episodes. The VAP rate was 37.6 episodes per 1,000 days at risk (95% confidence interval 33.2 to 42.4). The median daily nurse-to-patient ratio over the study period was 1.9 (interquartile range 1.8 to 2.2). By multivariate Cox regression analysis, we found that a high nurse-to-patient ratio was associated with a decreased risk for late-onset VAP (hazard ratio 0.42, 95% confidence interval 0.18 to 0.99), but there was no association with early-onset VAP., Conclusion: Lower nurse-to-patient ratio is associated with increased risk for late-onset VAP.

Postoperative endophthalmitis is a rare but potentially devastating condition. We investigated an outbreak of 8 cases of endophthalmitis in patients who underwent phakectomy performed by a single surgeon from January through September 2004. The outbreak was traced to damaged surgical blades, and it highlights the importance of the quality of the surgical wound.

Objective: An important problem that arises in hospitals is the monitoring and detection of nosocomial or hospital acquired infections (NIs). This paper describes a retrospective analysis of a prevalence survey of NIs done in the Geneva University Hospital. Our goal is to identify patients with one or more NIs on the basis of clinical and other data collected during the survey., Methods and Material: Standard surveillance strategies are time-consuming and cannot be applied hospital-wide; alternative methods are required. In NI detection viewed as a classification task, the main difficulty resides in the significant imbalance between positive or infected (11%) and negative (89%) cases. To remedy class imbalance, we explore two distinct avenues: (1) a new re-sampling approach in which both over-sampling of rare positives and under-sampling of the noninfected majority rely on synthetic cases (prototypes) generated via class-specific sub-clustering, and (2) a support vector algorithm in which asymmetrical margins are tuned to improve recognition of rare positive cases., Results and Conclusion: Experiments have shown both approaches to be effective for the NI detection problem. Our novel re-sampling strategies perform remarkably better than classical random re-sampling. However, they are outperformed by asymmetrical soft margin support vector machines which attained a sensitivity rate of 92%, significantly better than the highest sensitivity (87%) obtained via prototype-based re-sampling.

Background: Risk factors influencing the incidence of human immunodeficiency virus (HIV) infection were investigated in a case-control study nested within a community-randomized trial of treatment of syndromic sexually transmitted infections (STIs) in rural Tanzania., Methods: Case patients were persons who became HIV positive, and control subjects were randomly selected from among persons who remained HIV negative. For each sex, we obtained adjusted odds ratios (ORs) and population-attributable fractions (PAFs) for biomedical and behavioral factors., Results: We analyzed 92 case patients and 903 control subjects. In both sexes, the incidence of HIV infection was significantly higher in subjects with an HIV-positive spouse than in those with HIV-negative spouse (men: OR, 25.1; women: OR, 34.0). The incidence of HIV infection was significantly higher in those who became positive for herpes simplex virus type 2 (HSV-2) (men: OR, 5.60; women: OR, 4.76) and those who were HSV-2-positive at baseline (men: OR, 3.66; women: OR, 2.88) than in subjects who were HSV-2 negative. In women, living elsewhere (OR, 3.22) and never having given birth (OR, 4.27) were significant risk factors. After adjustment, the incidence of HIV infection was not significantly associated with a history of injections or STIs in either sex., Conclusion: HSV-2 infection was the most important risk factor for HIV infection, which highlights the need for HSV-2 interventions in HIV infection control, and there were particularly strong associations with recent HSV-2 seroconversion. The PAF associated with having an HIV-positive spouse was low, but this is likely to increase during the epidemic.

Background: Focal outbreaks of sexually transmitted infections (STIs) such as syphilis and gonorrhoea have been reported in the large cities of Western Europe over the past few years. The aim of our study was to determine whether a similar trend is observed in Geneva and the situation with regard to HIV infection., Methods: We review the incidence of syphilis, gonorrhoea, Chlamydia trachomatis and HIV in Geneva from 1999 to 2004., Results: Figures indicate a steady and sustained increase in the incidence of syphilis, gonorrhoea and Chlamydia trachomatis in Geneva since 1999 that is maintained into 2004. As for HIV, the number of positive testings in Switzerland has stabilised and primary infection figures do not indicate an increase in newly acquired infections in Geneva., Conclusion: The situation in Geneva is similar to that observed elsewhere in Western Europe and indicates the need of public health interventions., (Copyright (c) 2006 S. Karger AG, Basel.)