Increasing access to healthcare in the Eastern Mediterranean Region

Lessons learnt from the COVID-19 pandemic have provided an opportunity to intensify efforts towards the health-related Sustainable Development Goals (SDGs). Innovations in digital health and advances in science witnessed during the pandemic can be harnessed to improve equitable access to healthcare and build resilient health systems. We also have stark reminders that without addressing the needs of the most vulnerable groups and societies, a simple expansion of service delivery efforts may even exacerbate existing inequities in healthcare.

The WHO AWaRe (Access, Watch, Reserve) antibiotic book and prevention of antimicrobial resistance

Guidance on the appropriate use of antibiotics for common infections is lacking in many settings. The World Health Organization (WHO) has recently released The WHO AWaRe (Access, Watch, Reserve) antibiotic book which complements the WHO Model list of essential medicines and WHO Model list of essential medicines for children. The book gives specific guidance on the empiric use of antibiotics in the model lists with a strong emphasis on the AWaRe framework, which is centred around the risk of antimicrobial resistance development associated with the use of different antibiotics. Recommendations in the book cover 34 common infections in primary and hospital care both for children and adults. The book also includes a section on the use of the last-resort Reserve antibiotics, whose use should be restricted to very selected cases when an infection is confirmed or suspected to be caused by multidrug-resistant pathogens. The book highlights the use of first-line Access antibiotics or no antibiotic care if this is the safest approach for the patient. Here we present the background behind the development of the AWaRe book and the evidence behind its recommendations. We also outline how the book could be used in different settings to help reach the WHO target of increasing the proportion of global consumption of Access antibiotics to at least 60% of total consumption. The guidance in the book will also more broadly contribute to improving universal health coverage.

Kinetics of antibody response in critically ill patients with Middle East respiratory syndrome and association with mortality and viral clearance

The objective of this study is to examine the IgG antibody response in critically ill patients with the Middle East respiratory syndrome (MERS) and to examine the association of early antibody response with mortality and viral clearance. We collected blood samples from 40 consecutive real-time reverse transcription-polymerase chain reaction (rRT-PCR) confirmed critically ill MERS patients on ICU days 1, 3, 7, 14 and 28. MERS-CoV antibodies were detected by enzyme-linked immunosorbent assay (ELISA), using wells coated with MERS-CoV S1 antigen. Patients were admitted to ICU after a median (Q1, Q3) of 9 (4, 13) days from onset of symptoms with an admission Sequential Organ Failure Assessment (SOFA) score of 11 (6.5, 12). Among the study cohort, 38 patients (95%) received invasive ventilation, 35 (88%) vasopressors, 21 (53%) renal replacement therapy and 17 (43%) corticosteroids. Median (Q1,Q3) ELISA optical density (OD) ratio significantly increased with time (p < 0.001) from 0.11 (0.07, 1.43) on day 1; to 0.69 (0.11, 2.08) on day 3, 2.72 (1.84, 3.54) on day 7, 2.51 (0.35, 3.35) on day 14 and 3.77 (3.70, 3.84) on day 28. Early antibody response (day 1-3) was observed in 13/39 patients (33%) and was associated with lower mortality (hazard ratio: 0.31, 95% CI 0.10, 0.96, p = 0.04) but was not associated with faster clearance of MERS-CoV RNA. In conclusion, among critically ill patients with MERS, early antibody response was associated with lower mortality but not with faster clearance of MERS-CoV RNA. These findings have important implications for understanding pathogenesis and potential immunotherapy.

Social media and drug resistance in nursing training: Using a Twitterchat to develop an international community of practice for antimicrobial resistance

AIMS AND OBJECTIVES

To assess the impact of a Twitterchat focusing on antimicrobial resistance and it is feasibility for integration within a nursing prelicensure research methods class.

BACKGROUND

Antimicrobial resistance is one of the greatest threats to global health and food security. Consequently, developing a global approach with large outreach is critical. Twitter, as a popular social media platform, is useful for creating communities of practice and communities of interest.

DESIGN

A case study design using a Twitterchat is a hosted, convened and focussed discussion on a particular topic using a discrete hashtag.

METHOD

Using a standardised protocol, a Twitterchat was undertaken over a 24-hr period and digital metrics assessed at 72 hr. A summary of impact was undertaken using an online tool provided by Union Metrics (https://unionmetrics.com/).

CONCLUSIONS

At 72 hr, 2,632,762 accounts were reached and over 10 million impressions achieved. Twitterchats can be useful in creating awareness and fostering a community of interest and demonstrating the role of nurses in thought leadership. A formalised research study will draw on this case study to evaluate the impact on the Twitter participants and nursing students.

RELEVANCE TO CLINICAL PRACTICE

Social media are an accessible and useful tool to harness focus and attention on clinical issues with global relevance. Demonstrating the utility and leverage to nursing students is important in increasing their understanding of the importance of communication and diffusion of information.

Feasibility of Using Convalescent Plasma Immunotherapy for MERS-CoV Infection, Saudi Arabia

Efficacy testing will be challenging because of the small pool of donors with sufficiently high antibody titers.

We explored the feasibility of collecting convalescent plasma for passive immunotherapy of Middle East respiratory syndrome coronavirus (MERS-CoV) infection by using ELISA to screen serum samples from 443 potential plasma donors: 196 patients with suspected or laboratory-confirmed MERS-CoV infection, 230 healthcare workers, and 17 household contacts exposed to MERS-CoV. ELISA-reactive samples were further tested by indirect fluorescent antibody and microneutralization assays. Of the 443 tested samples, 12 (2.7%) had a reactive ELISA result, and 9 of the 12 had reactive indirect fluorescent antibody and microneutralization assay titers. Undertaking clinical trials of convalescent plasma for passive immunotherapy of MERS-CoV infection may be feasible, but such trials would be challenging because of the small pool of potential donors with sufficiently high antibody titers. Alternative strategies to identify convalescent plasma donors with adequate antibody titers should be explored, including the sampling of serum from patients with more severe disease and sampling at earlier points during illness.

Histopathology of Middle East respiratory syndrome coronovirus (MERS-CoV) infection - clinicopathological and ultrastructural study

Aims

The pathogenesis, viral localization and histopathological features of Middle East respiratory syndrome – coronavirus (MERS‐CoV) in humans are not described sufficiently. The aims of this study were to explore and define the spectrum of histological and ultrastructural pathological changes affecting various organs in a patient with MERS‐CoV infection and represent a base of MERS‐CoV histopathology.

Methods and results

We analysed the post‐mortem histopathological findings and investigated localisation of viral particles in the pulmonary and extrapulmonary tissue by transmission electron microscopic examination in a 33‐year‐old male patient of T cell lymphoma, who acquired MERS‐CoV infection. Tissue needle biopsies were obtained from brain, heart, lung, liver, kidney and skeletal muscle. All samples were collected within 45 min from death to reduce tissue decomposition and artefact. Histopathological examination showed necrotising pneumonia, pulmonary diffuse alveolar damage, acute kidney injury, portal and lobular hepatitis and myositis with muscle atrophic changes. The brain and heart were histologically unremarkable. Ultrastructurally, viral particles were localised in the pneumocytes, pulmonary macrophages, renal proximal tubular epithelial cells and macrophages infiltrating the skeletal muscles.

Conclusion

The results highlight the pulmonary and extrapulmonary pathological changes of MERS‐CoV infection and provide the first evidence of the viral presence in human renal tissue, which suggests tissue trophism for MERS‐CoV in kidney.

Current treatment options and the role of peptides as potential therapeutic components for Middle East Respiratory Syndrome (MERS): A review

Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is a highly pathogenic respiratory virus with mechanisms that may be driven by innate immune responses. Despite the effort of scientific studies related to this virus, Middle East Respiratory Syndrome (MERS) is still a public health concern. MERS-CoV infection has a high mortality rate, and to date, no therapeutic or vaccine has been discovered, that is effective in treating or preventing the disease. In this review, we summarize our understanding of the molecular and biological events of compounds acting as MERS-CoV inhibitors, the outcomes of existing therapeutic options and the various drugs undergoing clinical trials. Currently, several therapeutic options have been employed, such as convalescent plasma (CP), intravenous immunoglobulin (IVIG), monoclonal antibodies and repurposing of existing clinically approved drugs. However, these therapeutic options have drawbacks, thus the need for an alternative approach. The requirement for effective therapeutic treatment has brought the necessity for additional MERS treatments. We suggest that antimicrobial peptides (AMPs) may be used as alternative therapeutic agents against MERS-CoV infection. In addition, we propose the feasibility of developing effective agents by repurposing the existing and clinically approved anti-coronavirus and anti-viral peptide drugs.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Association of human leukocyte antigen class II alleles with severe Middle East respiratory syndrome-coronavirus infection

BACKGROUND:

Middle East Respiratory Syndrome (MERS) is a disease of the lower respiratory tract and is characterized by high mortality. It is caused by a beta coronavirus (CoV) referred to as MERS-CoV. Majority of MERS-CoV cases have been reported from Saudi Arabia.

AIM:

We investigated the human leukocyte antigen (HLA) Class II alleles in patients with severe MERS who were admitted in our Intensive Care Unit.

METHODS:

A total of 23 Saudi patients with severe MERS-CoV infection were typed for HLA class II, results were compared with those of 161 healthy controls.

RESULTS:

Two HLA class II alleles were associated with the disease; HLA-DRB1*11:01 and DQB1*02:02, but not with the disease outcome.

CONCLUSIONS:

Our results suggest that the HLA-DRB1*11:01 and DQB1*02:02 may be associated with susceptibility to MERS.

Feasibility, safety, clinical, and laboratory effects of convalescent plasma therapy for patients with Middle East respiratory syndrome coronavirus infection: a study protocol

As of September 30, 2015, a total of 1589 laboratory-confirmed cases of infection with the Middle East respiratory syndrome coronavirus (MERS-CoV) have been reported to the World Health Organization (WHO). At present there is no effective specific therapy against MERS-CoV. The use of convalescent plasma (CP) has been suggested as a potential therapy based on existing evidence from other viral infections. We aim to study the feasibility of CP therapy as well as its safety and clinical and laboratory effects in critically ill patients with MERS-CoV infection. We will also examine the pharmacokinetics of the MERS-CoV antibody response and viral load over the course of MERS-CoV infection. This study will inform a future randomized controlled trial that will examine the efficacy of CP therapy for MERS-CoV infection. In the CP collection phase, potential donors will be tested by the enzyme linked immunosorbent assay (ELISA) and the indirect fluorescent antibody (IFA) techniques for the presence of anti-MERS-CoV antibodies. Subjects with anti-MERS-CoV IFA titer of ≥1:160 and no clinical or laboratory evidence of MERS-CoV infection will be screened for eligibility for plasma donation according to standard donation criteria. In the CP therapy phase, 20 consecutive critically ill patients admitted to intensive care unit with laboratory-confirmed MERS-CoV infection will be enrolled and each will receive 2 units of CP. Post enrollment, patients will be followed for clinical and laboratory outcomes that include anti-MERS-CoV antibodies and viral load. This protocol was developed collaboratively by King Abdullah International Medical Research Center (KAIMRC), Gulf Cooperation Council (GCC) Infection Control Center Group and the World Health Organization—International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC-WHO) MERS-CoV Working Group. It was approved in June 2014 by the Ministry of the National Guard Health Affairs Institutional Review Board (IRB). A data safety monitoring board (DSMB) was formulated. The study is registered at http://www.clinicaltrials.gov (NCT02190799).

The distribution of Blastocystis subtypes in isolates from Qatar

Background

Blastocystis is a common single-celled intestinal parasite of humans and other animals comprising at least 17 genetically distinct small subunit ribosomal RNA lineages (subtypes (STs)), nine of which have been found in humans. The geographic distribution of Blastocystis subtypes is variable, but the subtypes present in Qatar are at present unknown.

Methods

Stool samples were collected from randomly selected, apparently healthy subjects arriving in Qatar for the first time. Blastocystis subtypes were determined by sequencing of the small subunit rRNA gene (SSU rDNA) PCR products. Phylogenetic analyses were done using Maximum Composite Likelihood method.

Results

71.1 % of samples were positive for Blastocystis infection based on PCR-detection methodology compared to only 6.9 % by microscopy. Prevalence of Blastocystis did not differ between the sexes nor between age classes. However, there was a regional difference in prevalence with subjects arriving from Africa showing the highest (87.6 %), those from Western Asia intermediate (68.6 %) and from Eastern Asia the lowest prevalence (67.6 %). Genetic analysis detected only three STs. ST3 was the most common (69.3 %) and ST2 was the rarest (3.5 %), while ST1 had a prevalence of 27.2 %. ST2 showed a regional variation, being absent from the 64 Western Asian Blastocystis-positive subjects. Both ST1 and ST3 showed significant differences in prevalence between the sexes.

Conclusions

This is the first report exploring the distribution of Blastocystis subtypes in our region. We recommend that stool screening via microscopy for the presence of Blastocystis should be abandoned since it is extremely insensitive. In future, the prevalence of Blastocystis infections should be based on PCR methodology and we predict that in the years ahead diagnostic PCR will become the tool of choice. More work is needed to identify the full range of Blastocystis subtypes that circulate in our region.

Severe neurologic syndrome associated with Middle East respiratory syndrome corona virus (MERS-CoV)

BACKGROUND

Since the identification of the first case of infection with the Middle East respiratory syndrome corona virus (MERS-CoV) in Saudi Arabia in June 2012, the number of laboratory-confirmed cases has exceeded 941 cases globally, of which 347 died. The disease presents as severe respiratory infection often with shock, acute kidney injury, and coagulopathy. Recently, we observed three cases who presented with neurologic symptoms. These are so far the first reported cases of neurologic injury associated with MERS-CoV infection.

METHODS

Data was retrospectively collected from three patients admitted with MERS-CoV infection to Intensive Care unit (ICU) at King Abdulaziz Medical City, Riyadh. They were managed separately in three different wards prior to their admission to ICU.

FINDING

The three patients presented with severe neurologic syndrome which included altered level of consciousness ranging from confusion to coma, ataxia, and focal motor deficit. Brain MRI revealed striking changes characterized by widespread, bilateral hyperintense lesions on T2-weighted imaging within the white matter and subcortical areas of the frontal, temporal, and parietal lobes, the basal ganglia, and corpus callosum. None of the lesions showed gadolinium enhancement.

INTERPRETATION

CNS involvement should be considered in patients with MERS-CoV and progressive neurological disease, and further elucidation of the pathophysiology of this virus is needed.

Unusual rotavirus genotypes among children with acute diarrhea in Saudi Arabia

Background

Human rotavirus A (human RV-A) is the most common cause of viral gastroenteritis in infants. The objective of the study was to characterize the G and P genotypes among clinical rotavirus isolates from children with acute diarrhea admitted to a tertiary care hospital in Riyadh, Saudi Arabia.

Methods

From 2011 to 2012, 541 pediatric patients with acute diarrhea were tested for rotavirus infection. RNA extractions from the fecal specimens were done by commercial kit. RT-PCR and sequencing techniques were used to detect the prevalent genotypes. Phylogenetic analysis by Maximum Likelihood method was used to study the clustering of the circulating genotypes.

Results

The data showed that 171/541 (31.6%) faecal samples were positive for human RVA and majority were children aged below 2 years. From the G and P [types] detected it was seen that (a) 171 minus 43 ie. 128 rotavirus positives were G typed successfully (b) 171 minus 20 ie. 151 rotavirus positives were P typed successfully; (c) overall G [P] nature was determined for 113 rotavirus positives out of 171. VP4 genotyping showed that majority of the positives 146/151 (96.7%) were P [8]; 4/151 (2.6%) were P [4]; 1/151 (0.66%) was P [6]. The dominant strains included G1P [8] 70/113 (61.9%); G9P [8] 19/113 (16.8%); G12P [8] 7/113 (6.2%) and G3P [8] 5/113 (4.4%) while the uncommon strains detected from Saudi Arabia during the study were G1P [4] 1/113 (0.88%) and G12P [6] 1/113 (0.88%). Phylogenetic tree, based on VP4/VP7 sequence analysis, revealed that G1P [8] was distinctly related to homologous strains included in human RV-A vaccine strains. Nevertheless, the uncommon genotypes G1P [4] and G12P [6] were clustered with isolates from other countries such as Bangladesh, China, Japan, Thailand and Philippines.

Conclusions

More studies will be required to further focus on newly emerging genotypes in our region together with the seasonality of rotavirus infection in the region, especially after January 2013 when the rotavirus vaccination has become part of routine childhood immunizations.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 43 countries for 2007-2012. Device-associated module

We report the results of an International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2007-December 2012 in 503 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study using the Centers for Disease Control and Prevention's (CDC) U.S. National Healthcare Safety Network (NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 605,310 patients hospitalized in the INICC's ICUs for an aggregate of 3,338,396 days. Although device utilization in the INICC's ICUs was similar to that reported from ICUs in the U.S. in the CDC's NHSN, rates of device-associated nosocomial infection were higher in the ICUs of the INICC hospitals: the pooled rate of central line-associated bloodstream infection in the INICC's ICUs, 4.9 per 1,000 central line days, is nearly 5-fold higher than the 0.9 per 1,000 central line days reported from comparable U.S. ICUs. The overall rate of ventilator-associated pneumonia was also higher (16.8 vs 1.1 per 1,000 ventilator days) as was the rate of catheter-associated urinary tract infection (5.5 vs 1.3 per 1,000 catheter days). Frequencies of resistance of Pseudomonas isolates to amikacin (42.8% vs 10%) and imipenem (42.4% vs 26.1%) and Klebsiella pneumoniae isolates to ceftazidime (71.2% vs 28.8%) and imipenem (19.6% vs 12.8%) were also higher in the INICC's ICUs compared with the ICUs of the CDC's NHSN.

Screening for Middle East respiratory syndrome coronavirus infection in hospital patients and their healthcare worker and family contacts: a prospective descriptive study

The Saudi Arabian Ministry of Health implemented a pro-active surveillance programme for Middle East respiratory syndrome (MERS) coronavirus (MERS-CoV). We report MERS-CoV data from 5065 Kingdom of Saudi Arabia individuals who were screened for MERS-CoV over a 12-month period. From 1 October 2012 to 30 September 2013, demographic and clinical data were prospectively collected from all laboratory forms received at the Saudi Arabian Virology reference laboratory. Data were analysed by referral type, age, gender, and MERS-CoV real-time PCR test results. Five thousand and 65 individuals were screened for MER-CoV: hospitalized patients with suspected MERS-CoV infection (n = 2908, 57.4%), healthcare worker (HCW) contacts (n = 1695; 33.5%), and family contacts of laboratory-confirmed MERS cases (n = 462; 9.1%). Eleven per cent of persons tested were children (<17 years of age). There were 108 cases (99 adults and nine children) of MERS-CoV infection detected during the 12-month period (108/5065, 2% case detection rate). Of 108 cases, 45 were females (six children and 39 adults) and 63 were males (three children and 60 adults). Of the 99 adults with MERS-CoV infection, 70 were hospitalized patients, 19 were HCW contacts, and ten were family contacts. There were no significant increases in MERS-CoV detection rates over the 12-month period: 2.6% (19/731) in July 2013, 1.7% (19/1100) in August 2013, and 1.69% (21/1238) in September 2013. Male patients had a significantly higher MERS-CoV infection rate (63/2318, 2.7%) than females (45/2747, 1.6%) (p 0.013). MERS-CoV rates remain at low levels, with no significant increase over time. Pro-active surveillance for MERS-CoV in newly diagnosed patients and their contacts will continue.

Prevalence of antimicrobial resistance among gram-negative isolates in an adult intensive care unit at a tertiary care center in Saudi Arabia

BACKGROUND AND OBJECTIVES

Patients in the ICU have encountered an increasing emergence and spread of antibiotic-resistant pathogens. We examined patterns of antimicrobial susceptibility in gram-negative isolates to commonly used drugs in an adult ICU at a tertiary care hospital in Riyadh, Saudi Arabia.

METHODS

A retrospective study was carried out of gram-negative isolates from the adult ICU of King Fahad National Guard Hospital (KFNGH) between 2004 and 2009. Organisms were identified and tested by an automated identification and susceptibility system, and the antibiotic susceptibility testing was confirmed by the disk diffusion method.

RESULTS

The most frequently isolated organism was Acinetobacter baumannii, followed by Pseudomonas aeruginosa, Escherichia coli, Klebsiella pnemoniae, Stenotrophomonas maltophilia, and Enterobacter. Antibiotic susceptibility patterns significantly declined in many organisms, especially A baumannii, E coli, S marcescens, and Enterobacter. A baumannii susceptibility was significantly decreased to imipenem (55% to 10%), meropenem (33% to 10%), ciprofloxacin (22% to 10%), and amikacin (12% to 6%). E coli susceptibility was markedly decreased (from 75% to 50% or less) to cefuroxime, ceftazidime, cefotaxime, and cefepime. S marcescens susceptibility was markedly decreased to cefotaxime (100% to 32%), ceftazidime (100% to 35%), and cefepime (100% to 66%). Enterobacter susceptibility was markedly decreased to ceftazidime (34% to 5%), cefotaxime (34% to 6%), and pipracillin-tazobactam (51% to 35%). Respiratory samples were the most frequently indicative of multidrug-resistant pathogens (63%), followed by urinary samples (57%).

CONCLUSION

Antimicrobial resistance is an emerging problem in the KFNGH ICU, justifying new more stringent antibiotic prescription guidelines. Continuous monitoring of antimicrobial susceptibility and strict adherence to infection prevention guidelines are essential to eliminate major outbreaks in the future.

Impact of bloodstream infection on the outcome of children undergoing cardiac surgery

Bloodstream infections (BSIs) are a main cause of nosocomial infection in the critical care area. The development of BSI affects the surgical outcome and increases intensive care unit (ICU) morbidity and mortality. This prospective cohort study was undertaken to determine the incidence, etiology, risk factors, and outcome of BSI for postoperative pediatric cardiac patients in the pediatric cardiac ICU setup. All postoperative pediatric patients admitted to the pediatric cardiac ICU from January 2007 to December 2007 were included in the study. Data were prospectively collected using a standardized data collection form. Patients with BSI (group 1) were compared with non-BSI patients (group 2) in terms of age, weight, surgical complexity score, duration of central line, need to keep the chest open postoperatively, and the length of the pediatric cardiac ICU and hospital stay. Of the 311 patients who underwent cardiac surgery during the study period, 27 (8.6%) were identified as having BSI (group 1). The 311 patients included in the study had a total of 1,043 central line days and a catheter-related BSI incidence density rate of 25.8 per 1,000 central line days. According to univariate analysis, the main risk factors for the development of BSI after pediatric cardiac surgery were lower patient weight (p = 0.005), high surgical complexity score (p < 0.05), open sternum postoperatively (p < 0.05), longer duration of central lines (p < 0.0001), and prolonged pediatric cardiac ICU and hospital stay (p < 0.0001). Gram-negative organisms were responsible for 67% of the BSI in the pediatric cardiac ICU, with pseudomonas (28%) and enterobacter (22%) as the main causative organisms. The mortality rate in the BSI group was 11% compared with 2% in the non-BSI group. In our pediatric cardiac ICU, BSI developed in 8.6% of the children undergoing cardiac surgery, mainly caused by a Gram-negative organism. The main risk factors for BSI in the postoperative pediatric cardiac patient were high surgical complexity, open sternum, low body weight, longer duration of central line, and prolonged pediatric cardiac ICU stay.

Avian influenza: the tip of the iceberg

For some years now, we have been living with the fear of an impending pandemic of avian influenza (AI). Despite the recognition, in 1996, of the global threat posed by the highly pathogenic H5N1 influenza virus found in farmed geese in Guangdong Province, China, planning for the anticipated epidemic remains woefully inadequate; this is especially true in developing countries such as Saudi Arabia. These deficiencies became obvious in 1997, with the outbreak of AI in the live animal markets in Hong Kong that led to the transmission of infection to 18 humans with close contact with diseased birds; there were six reported deaths. In 2003, with the reemergence of H5N1 (considered the most likely AI virus) in the Republic of Korea and its subsequent spread to Thailand, Vietnam, Hong Kong and China. Many countries started aggressively making preparations to meet the threat. The pressure for real action from governments has increased. Most developed countries have requested increased funding for the search for a more effective vaccine, for stockpiling possibly helpful antiviral drugs, and for intensifying domestic and global surveillance. Most countries, however, continue to be inadequately prepared for such an epidemic, especially with regard to animal surveillance in the farm market and surveillance among migratory birds. Even now, most countries do not have the ability to detect disease among humans in the early stages of an outbreak nor do most hospitals comply with effective infection control measures that could curtail the spread of the virus in the early stages of an epidemic. In Saudi Arabia we are rapidly implementing many of these measures.

Avian influenza: are our feathers ruffled?

During the past century, three major influenza pandemics took place, leading to a devastating number of deaths. Pandemics occur through the emergence of a new strain of influenza virus that can infect humans, to which there is little pre-existing immunity and which spreads easily from human to human. The H5N1 influenza virus has the potential of becoming a pandemic virus, since it can infect humans and is highly pathogenic. All that remains is the final step of acquiring the genetic material to enable efficient human-to-human transmission. Therefore, the World Health Organization (WHO) has declared pandemic alert phase 3, the last phase before there is actual evidence of increased and efficient human-to-human transmission. In addition, every case of transmission of an avian influenza virus to humans is regarded by WHO as a cause for heightened alertness and surveillance. The circulation of highly pathogenic avian influenza viruses in large numbers among the poultry population in a growing number of countries is a major concern. Since the influenza viruses are highly unstable, the co-circulation of highly pathogenic animal viruses with human viruses may create opportunities for different species-specific viruses to exchange genetic material, giving rise to a new influenza virus to which humans would have little, if any, protective immunity. In this article, we highlight the current avian influenza situation from its different aspects with a special focus on the Hajj since we host over 2 million pilgrims a year in the holy cities of Mekkah and Medina.

Acute brucellosis in Saudi families: relationship between brucella serology and clinical symptoms

OBJECTIVE

To determine if screening family members of patients with acute brucellosis will enhance the detection rate of brucellosis and also to determine the relationship between symptoms and brucella serology.

MATERIALS AND METHODS

Family members from patients with acute brucellosis were interviewed and serologically screened. All seropositive family members were clinically and serologically followed for six months.

RESULTS

Twenty-five acute brucellosis patients and their 178 family members were enrolled from January 2001 to February 2002. Of the 178 family members, 40 (23%) manifested various symptoms, 138 (77%) were asymptomatic, with an overall seroprevalence rate of 34 (19%). The rate of seropositivity among the symptomatic family members was 23 (58%) and for the asymptomatic was 11 (8%) (P<0.001). The majority of the symptomatic family members (13 (57%)) had a high Brucella titer in comparison to one (9%) of the asymptomatic group (P<0.001). Acute brucellosis was diagnosed and treated in 18 (78%) of the symptomatic seropositive family members and in four (36%), of the asymptomatic seropositive family members with an acute brucellosis prevalence rate of 22 (12%). All family members with acute infection recovered without sequelae; one patient relapsed (5%).

CONCLUSION

Symptomatic family members are more likely to be seropositive with a high titer in comparison to the asymptomatic members.

Diagnostic value of Brucella ELISA IgG and IgM in bacteremic and non-bacteremic patients with brucellosis

The diagnostic value of Brucella ELISA IgG and IgM has been evaluated in patients with brucellosis. Serum samples and blood cultures were collected from 83 patients with brucellosis. The sera were tested by Brucella ELISA for Brucella IgM and IgG antibodies. All 44 controls were negative for IgG and IgM. Brucella melitensis was isolated from blood cultures of 30/83 (36.1%) patients. Among the 30 bacteremic patients, 24 (80%) had an increased IgM titer of > or = 200. Of the 53 non-bacteremic patients, 41 had IgM titer > or = 200, while 22 had IgG titer of > or = 1,600. The ELISA IgM and IgG tests achieved a specificity and sensitivity of 100% and 96% respectively, while the positive and negative predictive values were 100% and 94% respectively. The Brucella ELISA is a reliable and sensitive test in the diagnosis of brucellosis. The test is rapid, easy to perform and can be automated.