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Dahlén T, Zhao J, Busch MP, Edgren G. Using routine health-care data to search for unknown transfusion-transmitted disease: a nationwide, agnostic retrospective cohort study. Lancet Digit Health 2024; 6:e105-e113. [PMID: 38278613 DOI: 10.1016/s2589-7500(23)00228-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 10/20/2023] [Accepted: 11/08/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND Identification and prevention of transfusion-transmitted disease is essential for blood transfusion safety. However, current surveillance systems are largely driven by reports of sentinel events, which is an approach that might be inadequate for identifying transmission of pathogens not known to be transmissible or pathogens with long incubation periods. Using a combination of health-data registers and blood-bank databases, we aimed to perform an agnostic search for potential transfusion-transmitted diseases and to identify unknown threats to the blood supply. METHODS In this nationwide, agnostic retrospective cohort study, we developed a systematic algorithm for performing a phenome-wide search for transfusion-transmitted disease without consideration of any a-priori suspicion of blood-borne transmissibility. We applied this algorithm to a nationwide Swedish transfusion database (SCANDAT-3S) to test for possible transmission of 1155 disease entities based on all relevant diagnostic coding systems in use during the period. We ascertained health outcomes of blood donors and transfusion recipients from the Swedish National Inpatient Register, Swedish Cause of Death Register, and Swedish Cancer Register. Analyses were two-pronged, studying both disease diagnosis concordance between donors and recipients and a possible shared increased disease risk among all recipients of a given donor. For both approaches, we used Cox proportional hazards regression models with time-dependent covariates. Adjustment for multiple comparisons was done using a false discovery rate method. FINDINGS The analyses included data on 1·72 million patients who had received 18·97 million transfusions (red blood cell, plasma, platelet, or whole blood units) between Jan 1, 1968, and Dec 31, 2017, from 1·04 million blood donors. The median follow-up was 4·5 (IQR 0·9-11·4) years for recipients and 18·5 (8·3-26·2) years for donors. We found evidence of transfusion-transmission for 15 diseases, of which 13 were validated using a second conceptually different approach. We identified transmission of viral hepatitis and its complications (eg, oesophageal varices) but also transmission of other conditions (eg, pneumonia of unknown origin). The diseases that could not be validated in this second approach, HIV and abnormal findings in specimens from male genital organs, were not statistically significant after adjustment for multiple testing. The effect sizes were small (close to 1) for other conditions. INTERPRETATION We find no strong evidence of unexpected, widespread transfusion-transmitted disease. This novel approach serves as a proof-of-concept for agnostic, data-driven surveillance for transfusion-transmitted disease using routinely collected blood-bank and health-care data. FUNDING Department of Health and Human Services, US National Heart, Lung, and Blood Institute, US National Institutes of Health, Swedish Research Council and Region Stockholm.
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Affiliation(s)
- Torsten Dahlén
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden; Department of Haematology, Karolinska University Hospital, Stockholm, Sweden
| | - Jingcheng Zhao
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
| | - Michael P Busch
- Vitalant Research Institute, San Francisco, CA, USA; Department of Laboratory Medicine, UCSF, San Francisco, CA, USA
| | - Gustaf Edgren
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Södersjukhuset, Stockholm, Sweden.
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Nelson CA, Winberg J, Bostic TD, Davis KM, Fleck-Derderian S. Systematic Review: Clinical Features, Antimicrobial Treatment, and Outcomes of Human Tularemia, 1993-2023. Clin Infect Dis 2024; 78:S15-S28. [PMID: 38294108 DOI: 10.1093/cid/ciad736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Francisella tularensis, the causative agent of tularemia, is endemic throughout the Northern Hemisphere and requires as few as 10 organisms to cause disease, making this potential bioterrorism agent one of the most infectious bacterial pathogens known. Aminoglycosides, tetracyclines, and, more recently, fluoroquinolones are used for treatment of tularemia; however, data on the relative effectiveness of these and other antimicrobial classes are limited. METHODS Nine databases, including Medline, Global Health, and Embase, were systematically searched for articles containing terms related to tularemia. Articles with case-level data on tularemia diagnosis, antimicrobial treatment, and patient outcome were included. Patient demographics, clinical findings, antimicrobial administration, and outcome (eg, intubation, fatality) were abstracted using a standardized form. RESULTS Of the 8878 publications identified and screened, 410 articles describing 870 cases from 1993 to 2023 met inclusion criteria. Cases were reported from 35 countries; more than half were from the United States, Turkey, or Spain. The most common clinical forms were ulceroglandular, oropharyngeal, glandular, and pneumonic disease. Among patients treated with aminoglycosides (n = 452 [52%]), fluoroquinolones (n = 339 [39%]), or tetracyclines (n = 419 [48%]), the fatality rate was 0.7%, 0.9%, and 1.2%, respectively. Patients with pneumonic disease who received ciprofloxacin had no fatalities and the lowest rates of thoracentesis/pleural effusion drainage and intubation compared to those who received aminoglycosides and tetracyclines. CONCLUSIONS Aminoglycosides, fluoroquinolones, and tetracyclines are effective antimicrobials for treatment of tularemia, regardless of clinical manifestation. For pneumonic disease specifically, ciprofloxacin may have slight advantages compared to other antimicrobials.
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Affiliation(s)
- Christina A Nelson
- Bacterial Diseases Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Jessica Winberg
- Alaka`ina Foundation, Contracting Agency for Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Taylor D Bostic
- Bacterial Diseases Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
- Oak Ridge Institute of Science and Education, Centers for Disease Control and Prevention Fellowship Program, Oak Ridge, Tennessee, USA
| | - K Meryl Davis
- Gilstrap Obstetrics and Gynecology Fellow, CDC Foundation, Atlanta, Georgia, USA
| | - Shannon Fleck-Derderian
- Bacterial Diseases Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
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Köppen K, Rydzewski K, Doellinger J, Myrtennäs K, Forsman M, Appelt S, Scholz H, Heuner K. Phenotypic and genotypic discrimination of Francisella tularensis ssp. holarctica clades. Int J Med Microbiol 2023; 313:151583. [PMID: 37331050 DOI: 10.1016/j.ijmm.2023.151583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 06/20/2023] Open
Abstract
Francisella tularensis is the causative agent of tularemia, a zoonotic disease with a wide host range. F. tularensis ssp. holarctica (Fth) is of clinical relevance for European countries, including Germany. Whole genome sequencing methods, including canonical Single Nucleotide Polymorphism (canSNP) typing and whole genome SNP typing, have revealed that European Fth strains belong to a few monophyletic populations. The majority of German Fth isolates belong to two basal phylogenetic clades B.6 (biovar I) and B.12 (biovar II). Strains of B.6 and B.12 seem to differ in their pathogenicity, and it has been shown that strains of biovar II are resistant against erythromycin. In this study, we present data corroborating our previous data demonstrating that basal clade B.12 can be divided into clades B.71 and B.72. By applying phylogenetic whole genome analysis as well as proteome analysis, we could verify that strains of these two clades are distinct from one another. This was confirmed by measuring the intensity of backscatter light on bacteria grown in liquid media. Strains belonging to clades B.6, B.71 or B.72 showed clade-specific backscatter growth curves. Furthermore, we present the whole genome sequence of strain A-1341, as a reference genome of clade B.71, and whole proteomes comparison of Fth strains belonging to clades B.6, B.71 and B.72. Further research is necessary to investigate phenotypes and putative differences in pathogenicity of the investigated different clades of Fth to better understand the relationship between observed phenotypes, pathogenicity and distribution of Fth strains.
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Affiliation(s)
- Kristin Köppen
- Working group: Cellular Interactions of Bacterial Pathogens, Centre for Biological Threats and Special Pathogens, Highly Pathogenic Microorganisms (ZBS 2), Robert Koch Institute, Berlin, Germany
| | - Kerstin Rydzewski
- Working group: Cellular Interactions of Bacterial Pathogens, Centre for Biological Threats and Special Pathogens, Highly Pathogenic Microorganisms (ZBS 2), Robert Koch Institute, Berlin, Germany
| | - Joerg Doellinger
- Centre for Biological Threats and Special Pathogens, Proteomics and Spectroscopy (ZBS 6), Robert Koch Institute, Berlin, Germany
| | - Kerstin Myrtennäs
- Division of CBRN Defence and Security, Swedish Defence Research Agency (FOI), Umeå, Sweden
| | - Mats Forsman
- Division of CBRN Defence and Security, Swedish Defence Research Agency (FOI), Umeå, Sweden
| | - Sandra Appelt
- Centre for Biological Threats and Special Pathogens, Highly Pathogenic Microorganisms (ZBS 2), Robert Koch Institute, Berlin, Germany
| | - Holger Scholz
- Centre for Biological Threats and Special Pathogens, Highly Pathogenic Microorganisms (ZBS 2), Robert Koch Institute, Berlin, Germany
| | - Klaus Heuner
- Working group: Cellular Interactions of Bacterial Pathogens, Centre for Biological Threats and Special Pathogens, Highly Pathogenic Microorganisms (ZBS 2), Robert Koch Institute, Berlin, Germany; Centre for Biological Threats and Special Pathogens, Highly Pathogenic Microorganisms (ZBS 2), Robert Koch Institute, Berlin, Germany.
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Narayanan S, Couger B, Bates H, Gupta SK, Malayer J, Ramachandran A. Characterization of three Francisella tularensis genomes from Oklahoma, USA. Access Microbiol 2023; 5:acmi000451. [PMID: 37424551 PMCID: PMC10323801 DOI: 10.1099/acmi.0.000451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 03/08/2023] [Indexed: 07/11/2023] Open
Abstract
Francisella tularensis , the causative agent for tularaemia, is a Tier 1 select agent, and a pan-species pathogen of global significance due to its zoonotic potential. Consistent genome characterization of the pathogen is essential to identify novel genes, virulence factors, antimicrobial resistance genes, for studying phylogenetics and other features of interest. This study was conducted to understand the genetic variations among genomes of F. tularensis isolated from two felines and one human source. Pan-genome analysis revealed that 97.7 % of genes were part of the core genome. All three F. tularensis isolates were assigned to sequence type A based on single nucleotide polymorphisms (SNPs) in sdhA. Most of the virulence genes were part of the core genome. An antibiotic resistance gene coding for class A beta-lactamase was detected in all three isolates. Phylogenetic analysis showed that these isolates clustered with other isolates reported from Central and South-Central USA. Assessment of large sets of the F. tularensis genome sequences is essential in understanding pathogen dynamics, geographical distribution and potential zoonotic implications.
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Affiliation(s)
- Sai Narayanan
- Oklahoma Animal Disease Diagnostic Laboratory, College of Veterinary Medicine, Oklahoma State University, 1950 W Farm Rd, Stillwater, OK 74078, USA
| | - Brian Couger
- Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Haley Bates
- Yale School of Nursing, 400 W Campus Dr., Orange, CT 06477, USA
| | - Sushim Kumar Gupta
- Oklahoma Animal Disease Diagnostic Laboratory, College of Veterinary Medicine, Oklahoma State University, 1950 W Farm Rd, Stillwater, OK 74078, USA
| | - Jerry Malayer
- College of Veterinary Medicine, Oklahoma State University, 208 S McFarland St., Stillwater, OK 74078, USA
| | - Akhilesh Ramachandran
- Oklahoma Animal Disease Diagnostic Laboratory, College of Veterinary Medicine, Oklahoma State University, 1950 W Farm Rd, Stillwater, OK 74078, USA
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Appelt S, Faber M, Köppen K, Jacob D, Grunow R, Heuner K. Francisella tularensis Subspecies holarctica and Tularemia in Germany. Microorganisms 2020; 8:microorganisms8091448. [PMID: 32971773 PMCID: PMC7564102 DOI: 10.3390/microorganisms8091448] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 12/26/2022] Open
Abstract
Tularemia is a zoonotic disease caused by Francisella tularensis a small, pleomorphic, facultative intracellular bacterium. In Europe, infections in animals and humans are caused mainly by Francisella tularensis subspecies holarctica. Humans can be exposed to the pathogen directly and indirectly through contact with sick animals, carcasses, mosquitoes and ticks, environmental sources such as contaminated water or soil, and food. So far, F. tularensis subsp. holarctica is the only Francisella species known to cause tularemia in Germany. On the basis of surveillance data, outbreak investigations, and literature, we review herein the epidemiological situation-noteworthy clinical cases next to genetic diversity of F. tularensis subsp. holarctica strains isolated from patients. In the last 15 years, the yearly number of notified cases of tularemia has increased steadily in Germany, suggesting that the disease is re-emerging. By sequencing F. tularensis subsp. holarctica genomes, knowledge has been added to recent findings, completing the picture of genotypic diversity and geographical segregation of Francisella clades in Germany. Here, we also shortly summarize the current knowledge about a new Francisella species (Francisella sp. strain W12-1067) that has been recently identified in Germany. This species is the second Francisella species discovered in Germany.
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Affiliation(s)
- Sandra Appelt
- Centre for Biological Threats and Special Pathogens (ZBS 2), Robert Koch Institute, 13353 Berlin, Germany; (S.A.); (D.J.); (R.G.)
| | - Mirko Faber
- Gastrointestinal Infections, Zoonoses and Tropical Infections (Division 35), Department for Infectious Disease Epidemiology, Robert Koch Institute, 13353 Berlin, Germany;
| | - Kristin Köppen
- Cellular Interactions of Bacterial Pathogens, ZBS 2, Robert Koch Institute, 13353 Berlin, Germany;
| | - Daniela Jacob
- Centre for Biological Threats and Special Pathogens (ZBS 2), Robert Koch Institute, 13353 Berlin, Germany; (S.A.); (D.J.); (R.G.)
| | - Roland Grunow
- Centre for Biological Threats and Special Pathogens (ZBS 2), Robert Koch Institute, 13353 Berlin, Germany; (S.A.); (D.J.); (R.G.)
| | - Klaus Heuner
- Cellular Interactions of Bacterial Pathogens, ZBS 2, Robert Koch Institute, 13353 Berlin, Germany;
- Correspondence: ; Tel.: +49-301-8754-2226
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Nelson CA, Brown J, Riley L, Dennis A, Oyer R, Brown C. Lack of Tularemia Among Health Care Providers With Close Contact With Infected Patients-A Case Series. Open Forum Infect Dis 2019; 7:ofz499. [PMID: 32016130 DOI: 10.1093/ofid/ofz499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/18/2019] [Indexed: 11/12/2022] Open
Abstract
Francisella tularensis has a low infectious dose and can infect laboratory staff handling clinical specimens. The risk to health care providers exposed during patient care is poorly defined. We describe 9 examples of health care providers who did not develop tularemia after significant exposures to infected patients.
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Affiliation(s)
- Christina A Nelson
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Jennifer Brown
- University of California Davis Medical Center, Sacramento, California, USA
| | - Linda Riley
- Cooley Dickinson Hospital, Northampton, Massachusetts, USA
| | - Anne Dennis
- Good Samaritan Medical Center, Lafayette, Colorado, USA
| | - Ryan Oyer
- Kaiser Permanente, Denver, Colorado, USA
| | - Catherine Brown
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Jamaica Plain, Massachusetts, USA
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