Primary Series and Booster Coronavirus Disease 2019 Vaccine Effectiveness in a Cohort of Healthcare Workers in Albania During a BA.1 and BA.2 Variant Period, January-May 2022

Background

Healthcare workers (HCWs) have experienced high rates of coronavirus disease 2019 (COVID-19) morbidity and mortality. We estimated COVID-19 2-dose primary series and monovalent booster vaccine effectiveness (VE) against symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron (BA.1 and BA.2) infection among HCWs in 3 Albanian hospitals during January-May 2022.

Methods

Study participants completed weekly symptom questionnaires, underwent polymerase chain reaction (PCR) testing when symptomatic, and provided quarterly blood samples for serology. We estimated VE using Cox regression models (1 - hazard ratio), with vaccination status as the time-varying exposure and unvaccinated HCWs as the reference group, adjusting for potential confounders: age, sex, prior SARS-CoV-2 infection (detected by PCR, rapid antigen test, or serology), and household size.

Results

At the start of the analysis period, 76% of 1462 HCWs had received a primary series, 10% had received a booster dose, and 9% were unvaccinated; 1307 (89%) HCWs had evidence of prior infection. Overall, 86% of primary series and 98% of booster doses received were BNT162b2. The median time interval from the second dose and the booster dose to the start of the analysis period was 289 (interquartile range [IQR], 210-292) days and 30 (IQR, 22-46) days, respectively. VE against symptomatic PCR-confirmed infection was 34% (95% confidence interval [CI], -36% to 68%) for the primary series and 88% (95% CI, 39%-98%) for the booster.

Conclusions

Among Albanian HCWs, most of whom had been previously infected, COVID-19 booster dose offered improved VE during a period of Omicron BA.1 and BA.2 circulation. Our findings support promoting booster dose uptake among Albanian HCWs, which, as of January 2023, was only 20%. Clinical Trials Registration. NCT04811391.

Primary series COVID-19 vaccine effectiveness among healthcare workers in Albania, February-December 2021

Background

Healthcare workers have experienced high rates of morbidity and mortality from coronavirus disease 2019 (COVID-19).

Methods

A prospective cohort study was conducted in three Albanian hospitals between 19 February and 14 December 2021. All participants underwent polymerase chain reaction (PCR) and serological testing at enrolment, regular serology throughout, and PCR testing when symptomatic.Vaccine effectiveness (VE) against COVID-19 and against all severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infections (symptomatic or asymptomatic) was estimated. VE was estimated using a Cox regression model, with vaccination status as a time-varying variable.

Findings

In total, 1504 HCWs were enrolled in this study; 70% had evidence of prior SARS-CoV-2 infection. VE was 65.1% [95% confidence interval (CI) 37.7-80.5] against COVID-19, 58.2% (95% CI 15.7-79.3) among participants without prior SARS-CoV-2 infection, and 73.6% (95% CI 24.3-90.8) among participants with prior SARS-CoV-2 infection. For BNT162b2 alone, VE was 69.5% (95% CI 44.5-83.2). During the period when the Delta variant was predominant, VE was 67.1% (95% CI 38.3-82.5). VE against SARS-CoV-2 infection for the full study period was 36.9% (95% CI 15.8-52.7).

Interpretation

This study found moderate primary series VE against COVID-19 among healthcare workers in Albania. These results support the continued promotion of COVID-19 vaccination in Albania, and highlight the benefits of vaccination in populations with high levels of prior infection.

Factors associated with receipt of COVID-19 vaccination and SARS-CoV-2 seropositivity among healthcare workers in Albania (February 2021-June 2022): secondary analysis of a prospective cohort study

Background

Healthcare workers (HCWs) have been disproportionally affected by COVID-19. We investigated factors associated with two- and three-dose COVID-19 vaccine uptake and SARS-CoV-2 seropositivity among 1504 HCWs enrolled (19 February-7 May 2021) in a prospective COVID-19 vaccine effectiveness cohort in Albania through a secondary analysis.

Methods

We collected sociodemographic, occupational, health, prior SARS-CoV-2 infection, and COVID-19 vaccination data from all HCWs at enrollment. Vaccination status was assessed weekly through June 2022. A serum sample was collected from all participants at enrollment and tested for anti-spike SARS-CoV-2 antibodies. We analyzed HCWs characteristics and outcomes using multivariable logistic regression.

Findings

By 11 June 2022, 1337 (88.9%) HCWs had received two COVID-19 vaccine doses, of whom 255 (19.1%) received a booster. Factors significantly associated with receiving three doses (adjusted odds ratio (aOR), 95% CIs) were being ≥35 years (35-44 years: 1.76 (1.05-2.97); 45-54 years: 3.11 (1.92-5.05); ≥55 years: 3.38 (2.04-5.59)) and vaccinated against influenza (1.78; 1.20-2.64). Booster dose receipt was lower among females (0.58; 0.41-0.81), previously infected (0.67; 0.48-0.93), nurses and midwives (0.31; 0.22-0.45), and support staff (0.19; 0.11-0.32). Overall 1076 (72%) were SARS-CoV-2 seropositive at enrollment. Nurses and midwifes (1.45; 1.05-2.02), support staff (1.57; 1.03-2.41), and HCWs performing aerosol-generating procedures (AGPs) (1.40; 1.01-1.94) had higher odds of being seropositive, while smokers had reduced odds (0.55; 0.40-0.75).

Interpretation

In a large cohort of Albanian HCWs, COVID-19 vaccine booster dose uptake was very low, particularly among younger, female, and non-physician HCWs, despite evidence demonstrating the added benefit of boosters in preventing infection and severe disease. Reasons behind these disparities should be explored to develop targeted strategies in order to promote uptake in this critical population. SARS-CoV-2 seroprevalence was higher among non-physicians and HCWs performing APGs. A better understanding of the factors contributing to these differences is needed to inform interventions that could reduce infections in the future.

Funding

This study was funded by the Task Force for Global Health (US Centers for Disease Control (CDC) cooperative agreement # NU51IP000873) and the World Health Organization, Regional Office for Europe.

COVID-19 vaccine effectiveness among healthcare workers in Albania (COVE-AL): protocol for a prospective cohort study and cohort baseline data

INTRODUCTION

Critical questions remain about COVID-19 vaccine effectiveness (VE) in real-world settings, particularly in middle-income countries. We describe a study protocol to evaluate COVID-19 VE in preventing laboratory-confirmed SARS-CoV-2 infection in health workers (HWs) in Albania, an upper-middle-income country.

METHODS AND ANALYSIS

In this 12-month prospective cohort study, we enrolled HWs at three hospitals in Albania. HWs are vaccinated through the routine COVID-19 vaccine campaign. Participants completed a baseline survey about demographics, clinical comorbidities, and infection risk behaviours. Baseline serology samples were also collected and tested against the SARS-CoV-2 spike protein, and respiratory swabs were collected and tested for SARS-CoV-2 by RT-PCR. Participants complete weekly symptom questionnaires and symptomatic participants have a respiratory swab collected, which is tested for SARS-CoV-2. At 3, 6, 9 months and 12 months of the study, serology will be collected and tested for antibodies against the SARS-CoV-2 nucleocapsid protein and spike protein. VE will be estimated using a piecewise proportional hazards model (VE=1-HR).

BASELINE DATA

From February to May 2021, 1504 HWs were enrolled. The median age was 44 (range: 22-71) and 78% were female. At enrolment, 72% of participants were seropositive for SARS-CoV-2. 56% of participants were vaccinated with one dose, of whom 98% received their first shot within 4 days of enrolment. All HWs received the Pfizer BNT162b2 mRNA COVID-19 vaccine.

ETHICS AND DISSEMINATION

The study protocol and procedures were reviewed and approved by the WHO Ethical Review Board, reference number CERC.0097A, and the Albanian Institute of Public Health Ethical Review Board, reference number 156. All participants have provided written informed consent to participate in this study. The primary results of this study will be published in a peer-reviewed journal at the time of completion.

TRIAL REGISTRATION NUMBER

NCT04811391.

May Measurement Month 2019: an analysis of blood pressure screening results from Albania

This article discusses the results of the May Measurement Month (MMM) 2019 campaign, which contributed to a third round of MMM hypertension screening campaigns carried out in Albania, a transitional country in the Western Balkans. The hypertension screening campaign in Albania was carried out during the period 1-31 May 2019 in 30 sites in many districts of the country. Overall, 19 154 participants aged ≥18 years were included (approximately 68% of these were women), with an overall mean age of 47.0 ± 15.3 years. Blood pressure (BP) was measured with OMRON sphygmomanometers (Omron Healthcare, Kyoto, Japan). Hypertension was defined as systolic BP ≥140 mmHg, or diastolic BP ≥90 mmHg, or on treatment for hypertension. Self-reported data consisted of height and weight, pre-existing conditions, including smoking status and alcohol consumption. Overall, the proportion of participants with hypertension was 38.6%. Less than two-thirds (64.7%) of hypertensive individuals were aware of their condition. Also, less than half (48.3%) of participants on antihypertensive medication had controlled BP (<140/90 mmHg). The most sizable correlations of high BP were with known hypertension status, use of antihypertensive medication, and obesity. The MMM campaign contributes to routine hypertension screening in Albania. Hence, health professionals and policymakers in Albania should act on the findings of MMM screening campaigns and continue its support as a valuable tool for early detection of hypertension in the general population.

New cervical screening program in Albania. Access and barriers in all levels of health system

Background

In 2019 Albania started a national screening program which uses as primary screening examination the high risk Human Papilloma Virus (hrHPV) testing. It targets women 40-50 years old providing systematic screening tests, as part of the routine examinations at primary health care centers. The evaluation study aimed to identify the performance of the program in its first year, barriers and satisfaction of women.

Methodology

A representative sample of 200 women, positive in screening test, was retrieved from the database of program information system. They were interviewed during the period October-November 2019, using a standardized questionnaire.

Results

Although the risk of being hrHPV-positive was higher in cities (OR = 1.52; 95%CI=1.29-1.81), the program was used more by women living in rural areas compared to those living in urban areas (OR = 1.81; 95%CI =1.74-1.89). 60.2% of women found the vaginal sampling procedure very simple and 72.4% not at all painful. 95.8% of women received the test results within two months. At the time of the survey, 90.4% of HPV-positive women had gone for follow up visit (71.7%) or were planning to go as soon as possible (18.7%). 35.2% of women who have performed colposcopy, have chosen private healthcare, with 7.8% going abroad. Higher education increased the odds to use a private facility or go abroad for the follow up visit. 87.2% of women reported substantial worries about the positive result. 89.8% of the sample rated the overall service as 'good' or 'very good'.

Conclusions

While results from the first evaluation show good acceptance from users, the program should address the proportion of women who chose private clinics for follow up examination.

Key messages

Results from the first evaluation of the cervical screening program in Albania show good acceptance from users. Program should address the proportion of women who chose private clinics for follow up examination.

Isolation of the first New Delhi metallo-ß-lactamase-1 (NDM-1)-producing and colistin-resistant Klebsiella pneumoniae sequence type ST15 from a digestive carrier in Albania, May 2018

OBJECTIVES

Carbapenemases represent a public health threat, as they can spread through horizontal gene transfer and cause outbreaks. New Delhi metallo-ß-lactamase-1 (NDM-1) is a metallo-ß-lactamase that has spread rapidly in the last decade, causing worldwide alarm. This study aimed to describe the first isolate of NDM-1-producing and extensively drug resistant Klebsiella pneumoniae in Albania, its clinical context and genetic characterization.

METHODS

Strain was isolated from both oral and rectal intensive care unit admission screening swabs of a 70-year-old male patient with no history of international travel in the previous 6 months. Sequencing was performed by Illumina NextSeq500 platform, with a paired-end run of 2 by 150bp, after Nextera XT paired-end library preparation. Sequencing reads were assembled using SPAdes Genome (version 3.6.1) with accurate de novo settings. The assembled contigs were uploaded into the online tools: BIGSdb-Kp, ResFinder and PlasmidFinder.

RESULTS

Isolate was resistant to all tested antibiotics but tigecycline and trimethoprim-sulfamethoxazole. Sequencing revealed the presence of acquired resistance genes conferring resistance to β-lactams (bla_NDM-1, bla_CMY-6, bla_CTX-M-15and bla_SHV-28), aminoglycosides (rmtC, aac(6')-Ib3), fluoroquinolones (oqxA, oqxB, aac(6')-Ib-cr), fosfomycin (fosA) and sulfonamides (sul1). The bla_NDM-1 gene was located on an IncA/C2 plasmid. Plasmid mediated mcr-1 to mcr-8 genes were absent in both isolates. Resistance to colistin was due to an amino acid substitution (Thr157Pro) in PmrB protein.

CONCLUSIONS

NDM-1-producing Enterobacteriaceae are spreading in the Balkans. Identification of NDM-1-producing and extensively drug resistant K. pneumoniae ST15 in Albania is a cause for serious concern. There should be a continuous national and Balkan multinational surveillance of bla_NDM-1-carrying isolates.

Extracorporeal membrane oxygenation support for life-threatening acute severe status asthmaticus

INTRODUCTION

Status asthmaticus is a life-threatening condition characterized by progressive respiratory failure due to asthma that is unresponsive to standard therapeutic measures. We used extracorporeal membrane oxygenation (ECMO) to treat patients with near-fatal status asthamticus who did not respond to aggressive medical therapies and mechanical ventilation under controlled permissive hypercapnia.

MATERIALS AND METHODS

Between January 2011 and October 2015, we treated 16 adult patients with status asthmaticus (8 women, 8 men, mean age: 50.5±10.6years) with veno-venous ECMO (13 patients) or veno-arterial (3 patients). Patients failed to respond to conventional therapies despite receiving the most aggressive therapies, including maximal medical treatments, mechanical ventilation under controlled permissive hypercapnia and general anesthetics.

RESULTS

Mean time spent on ECMO was 300±11.8 hours (range 36-384 hours). PaO₂, PaCO₂ and pH showed significant improvement promptly after ECMO initiation p=0.014, 0.001 and <0.001, respectively, and such values remained significantly improved after ECMO, p=0.004 and 0.001 and <0.001, respectively. The mean time of ventilation after decannulation until extubation was 175±145.66 hours and the median time to intensive care unit discharge after decannulation was 234±110.30 hours. All 16 patients survived without neurological sequelae.

CONCLUSIONS

ECMO could provide adjunctive pulmonary support for intubated asthmatic patients who remain severely acidotic and hypercarbic despite aggressive conventional therapy. ECMO should be considered as an early treatment in patients with status asthmaticus whose gas exchange cannot be satisfactorily maintained by conventional therapy for providing adequate gas change and preventing lung injury from the ventilation.

Results of a tuberculin skin testing survey in Albania

Introduction: Tuberculosis affected about 8.5 million patients in 2011. Numerous efforts are needed to reduce the pool of individuals with latent TB infection (LTBI). The aim of the study was to describe a tuberculin skin testing (TST) survey carried out in Albania to estimate the LTBI burden; furthermore, knowledge of TB was evaluated through an ad hoc questionnaire. Methodology: A TST survey was performed in three geographical districts of Albania: Tirana-Kamez, Vlora, and Dibra. Cluster sampling was carried out of young Albanian students. In addition, the same students were given a questionnaire to assess their knowledge, attitudes, and any misconceptions about TB. The mean (standard deviation) age of the individuals, according to their educational level, was the following: grade five, 11.03 (0.18) years; grade six, 12.02 (0.17) years; and grade seven, 13.02 (0.16) years. Results: The TST induration size was read in 4,648 students. About 5.0% showed a reaction >5 mm, with a significant variability in the districts selected (12.1% in the district of Dibra). An induration diameter >15 mm was found mainly in those areas with high TB incidence (i.e., Tirana-Kamez and Dibra). About 13% of the students had no knowledge of TB. Conclusion: LTBI prevalent cases are estimated to be low in Albania, although there are areas where the TB management should be improved to reduce the probability of Mycobacterium tuberculosis transmission. The level of knowledge about TB disease is inadequate and new public health strategies should be implemented, focusing on educational TV programs.

Glucose-6-phosphate dehydrogenase plays a crucial role in protection from redox-stress-induced apoptosis

Glucose-6-phosphate dehydrogenase-deleted embryonic stem (ES) cells (G6pd Delta) proliferate in vitro without special requirements, but when challenged with oxidants fail to sustain glutathione disulphide reconversion to reduced glutathione (GSH), entering a condition of oxidative stress. Here, we investigate the signalling events downstream of GSH oxidation in G6pd Delta and wild-type (wt) ES cells. We found that G6pd Delta ES cells are very sensitive to oxidants, activating an apoptotic pathway at oxidant concentrations otherwise sublethal for wt ES cells. We show that the apoptotic pathway activated by low oxidant concentrations is accompanied by mitochondria dysfunction, and it is therefore blocked by the overexpression of Bcl-X(L). Bcl-X(L) does not inhibit the decrease in cellular GSH and reactive oxygen species formation following oxidant treatment. We also found that oxidant treatment in ES cells is followed by the activation of the MEK/extracellular signal-regulated kinase (ERK) pathway. Interestingly, ERK activation has opposite outcomes in G6pd Delta ES cells compared to wt, which has a proapoptotic function in the first and a prosurvival function in the latter. We show that this phenomenon can be regulated by the cellular GSH level.

Apoptosis-resistant phenotype in HL-60-derived cells HCW-2 is related to changes in expression of stress-induced proteins that impact on redox status and mitochondrial metabolism

The onset of resistance to drug-induced apoptosis of tumour cells is a major problem in cancer therapy. We studied a drug-selected clone of promyelocytic HL-60 cells, called HCW-2, which display a complex resistance to a wide variety of apoptosis-inducing agents and we found that these cells show a dramatic increase in the expression of heat shock proteins (Hsps) 70 and 27, while the parental cell line does not. It is known that stress proteins such as Hsps can confer resistance to a variety of damaging agents other than heat shock, such as TNF-alpha, monocyte-induced cytotoxicity, and also play a role in resistance to chemotherapy. This elevated expression of Hsps is paralleled by an increased activity of mitochondrial metabolism and pentose phosphate pathway, this latter leading to high levels of glucose-6-phosphate dehydrogenase and, consequently, of glutathione. Thus, the apoptotic-deficient phenotype is likely because of the presence of high levels of stress response proteins and GSH, which may confer resistance to apoptotic agents, including chemotherapy drugs. Moreover, the fact that in HCW-2 cells Hsp70 are mainly localised in mitochondria may account for the increased performances of mitochondrial metabolism. These observations could have some implications for the therapy of cancer, and for the design of combined strategies that act on antioxidant defences of the neoplastic cell.

Incontinenza urinaria nella donna: Inquadramento clinico e nostra esperienza nella terapia chirurgica: Urinary incontinence in women: Clinical classification and personal experience in surgical treatment

After having outlined the clinical classification and physiopathology of urinary incontinence (IU), the authors present their cases which include 225 operations using Burch's colposuspension technique. Patients with 1st grade or no cystocele, slight relaxation of the pelvic floor and no sign of bladder instability were selected for this procedure. The technique is described. Lastly the authors confirm the effectiveness of the method, given the good results and total absence of risks and complications.

[Prophylaxis of superficial tumors of the bladder with interferon alfa-2B]

The AA. report the results obtained on patients suffering from surface bladder cancer [Ta-T1 (G1-G2)] treated with alpha 2b interferon with the aim to elongate the relapse period. The results turned out to be very satisfactory as concerns the tolerability of the drug as well as the actual improvement in relapse onset. Moreover, the AA. could notice the grading steadiness or decrease, as to neglistic relapses.