A comparative analysis of experienced uncertainties in relation to risk communication during COVID19: a four-country study

Background

During outbreaks, uncertainties experienced by affected communities can influence their compliance to government guidance on public health. Communicators and authorities are, hence, encouraged to acknowledge and address such uncertainties. However, in the midst of public health crises, it can become difficult to define and identify uncertainties that are most relevant to address. We analyzed data on COVID-19-related uncertainties from four socio-economic contexts to explore how uncertainties can influence people’s perception of, and response to Risk Communication and Community Engagement (RCCE) strategies.

Results

This qualitative study, which adopts an interpretative approach, is based on data from a documentary review, key informant interviews (KII), and focus group discussions (FGD) with members of the general public and people with barriers to information from Germany, Guinea, Nigeria, and Singapore. Transcripts from the KII and FGD were coded and analyzed thematically. We interviewed a total of 155 KIs and conducted 73 FGD. Our analysis uncovered a divergence between uncertainties deemed relevant by stakeholders involved in policy making and uncertainties that people reportedly had to navigate in their everyday lives and which they considered relevant during the pandemic. We identified four types of uncertainties that seemed to have influenced people’s assessment of the disease risk and their trust in the pandemic control strategies including RCCE efforts: epidemiological uncertainties (related to the nature and severity of the virus), information uncertainties (related to access to reliable information), social uncertainties (related to social behavior in times of heightened risk), and economic uncertainties (related to financial insecurities).

Conclusion

We suggest that in future outbreaks, communicators and policy makers could improve the way in which affected communities assess their risk, and increase the trust of these communities in response efforts by addressing non-epidemiological uncertainties in RCCE strategies.

Blood CD9+ B cell, a biomarker of bronchiolitis obliterans syndrome after lung transplantation

Bronchiolitis obliterans syndrome is the main limitation for long-term survival after lung transplantation. Some specific B cell populations are associated with long-term graft acceptance. We aimed to monitor the B cell profile during early development of bronchiolitis obliterans syndrome after lung transplantation. The B cell longitudinal profile was analyzed in peripheral blood mononuclear cells from patients with bronchiolitis obliterans syndrome and patients who remained stable over 3 years of follow-up. CD24^hi CD38^hi transitional B cells were increased in stable patients only, and reached a peak 24 months after transplantation, whereas they remained unchanged in patients who developed a bronchiolitis obliterans syndrome. These CD24^hi CD38^hi transitional B cells specifically secrete IL-10 and express CD9. Thus, patients with a total CD9⁺ B cell frequency below 6.6% displayed significantly higher incidence of bronchiolitis obliterans syndrome (AUC = 0.836, PPV = 0.75, NPV = 1). These data are the first to associate IL-10-secreting CD24^hi CD38^hi transitional B cells expressing CD9 with better allograft outcome in lung transplant recipients. CD9-expressing B cells appear as a contributor to a favorable environment essential for the maintenance of long-term stable graft function and as a new predictive biomarker of bronchiolitis obliterans syndrome-free survival.

[Selection of lung transplant candidates in France in 2019]

INTRODUCTION

In 2015, the International Society for Heart and Lung Transplantation (ISHLT) published a consensus document for the selection of lung transplant candidates. In the absence of recent French recommendations, this guideline is useful in order to send lung transplant candidates to the transplantation centers and to list them for lung transplantation at the right time.

BACKGROUND

The main indications for lung transplantation in adults are COPD and emphysema, idiopathic pulmonary fibrosis and interstitial diseases, cystic fibrosis and pulmonary arterial hypertension (PAH). The specific indications for each underlying disease as well as the general contraindications have been reviewed in 2015 by the ISHLT. For cystic fibrosis, the main factors are forced expiratory volume in one second, 6-MWD, PAH and clinical deterioration characterized by increased frequency of exacerbations; for emphysema progressive disease, the BODE score, hypercapnia and FEV1; for PAH progressive disease or the need of specific intravenous therapy and NYHA classification. Finally, the diagnosis of fibrosing interstitial lung disease is usually a sufficient indication for lung transplantation assessment.

OUTLOOK AND CONCLUSION

These new recommendations, close to French practices, help clinicians to find the right time for referral of patients to transplantation centers. This is crucial for the prognosis of lung transplantation.

Are guidelines on the management of non-tuberculous mycobacteria lung infections respected and what are the consequences for patients? A French retrospective study from 2007 to 2014

Diagnosis and treatment of lung infections caused by non-tuberculous mycobacteria (NTM) remain challenging. Adherence of the clinicians to the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) 2007 guidelines is often incomplete. Between 2007 and 2014, in Grenoble Alpes University Hospital, France, 132 patients had NTM-positive cultures from lower respiratory tract (LRT) samples. We retrospectively collected diagnosis, treatment, and outcome data of patients, and evaluated the adherence of clinicians to ATS/IDSA guidelines and the consequences of patients' prognoses. Using the ATS/IDSA definitions, 31 out of 132 patients (23.5%) were considered infected, 57 out of 132 patients (43.2%) were considered colonised, 33 out of 132 (25%) were contaminated and 11 (8.4%) had missing data. Among the 31 NTM-infected patients, M. avium (23 out of 31, 74.2%) was most frequently involved. The main risk factor for NTM lung infection was underlying lung disease (30 out of 31, 96.8%). Treatment was not appropriate according to current guidelines in 58.1% of infected patients (18 out of 31). Mainly, the antibiotic treatment was installed based on radiological signs (p = 0.0006), sputum results and bronchoalveolar lavage results (p < 0.0001 and p = 0.003 respectively). Most antibiotic regimens included a macrolide (83.4%). Patients receiving appropriate treatment had the same cure rates as those receiving inappropriate treatment (p = 0.22) and similar relapse rates (p = 0.92). Current medical practices for the treatment of NTM lung infections in our institution are not consistent with the ATS/IDSA guidelines. This could potentially affect the prognosis of these patients and favour the emergence of macrolide resistance in NTM species.

Maternal colonization with Staphylococcus aureus and Group B streptococcus is associated with colonization in newborns

OBJECTIVES

Although Staphylococcus aureus and Group B streptococcus (GBS) are major causes of neonatal sepsis in sub-Saharan Africa, it is unclear how these bacteria are transmitted to the neonate.

METHODS

In a cohort of 377 Gambian women and their newborns, nasopharyngeal swabs were collected at delivery (day 0), and 3, 6, 14 and 28 days later. Breast milk samples and vaginal swabs were collected from the mother. Staphylococcus aureus and GBS were isolated using conventional microbiological methods.

RESULTS

Most women were carriers of S. aureus (264 out of 361 with all samples collected, 73.1%) at some point during follow up and many were carriers of GBS (114 out of 361, 31.6%). Carriage of S. aureus was common in all three maternal sites and GBS was common in the vaginal tract and breast milk. Among newborns, carriage of S. aureus peaked at day 6 (238 out of 377, 63.1%) and GBS at day 3 (39 out of 377, 10.3%). Neonatal carriage of S. aureus at day 6 was associated with maternal carriage in the breast milk adjusted OR 2.54; 95% CI 1.45-4.45, vaginal tract (aOR 2.55; 95% CI 1.32-4.92) and nasopharynx (aOR 2.49; 95% CI 1.56-3.97). Neonatal carriage of GBS at day 6 was associated with maternal carriage in the breast milk (aOR 3.75; 95% CI 1.32-10.65) and vaginal tract (aOR 3.42; 95% CI 1.27-9.22).

CONCLUSIONS

Maternal colonization with S. aureus or GBS is a risk factor for bacterial colonization in newborns.

Outbreak of Shigella sonnei in Montréal's ultra-Orthodox Jewish community, 2015

An outbreak of Shigella sonnei that occurred in the ultra-Orthodox Jewish community (UOJC) was the subject of an investigation and response by the Montréal Regional Public Health Department (DRSP), who collaborated with several health and community partners. A total of 27 confirmed cases were reported in this outbreak, which lasted from February to June 2015. The epidemic curve was compatible with a point source with secondary person-to-person transmission. In 11 of the 27 cases, pulsed-field gel electrophoresis (PFGE) analysis of strains found a single PFGE pattern newly identified in Quebec. Almost all strains tested showed resistance to ampicillin and trimethoprim-sulfamethoxazole (TMP/SMX). All the cases resided in Montréal Centre-West. Most of the cases were under 5 years old and attended a daycare centre, an environment recognized to be conducive to the transmission of enteric diseases. DRSP sent timely information to families, daycare and school stakeholders, community partners and synagogues in the UOJC, which helped reduce the transmission of shigellosis in the community.

Oral azithromycin given during labour decreases bacterial carriage in the mothers and their offspring: a double-blind randomized trial

Bacterial sepsis remains a leading cause of death among neonates with Staphylococcus aureus, group B streptococcus (GBS) and Streptococcus pneumoniae identified as the most common causative pathogens in Africa. Asymptomatic bacterial colonization is an intermediate step towards sepsis. We conducted a phase III, double-blind, placebo-controlled randomized trial to determine the impact of giving one oral dose of azithromycin to Gambian women in labour on the nasopharyngeal carriage of S. aureus, GBS or S. pneumoniae in the newborn at day 6 postpartum. Study participants were recruited in a health facility in western Gambia. They were followed for 8 weeks and samples were collected during the first 4 weeks. Between April 2013 and April 2014 we recruited 829 women who delivered 843 babies, including 13 stillbirths. Sixteen babies died during the follow-up period. No maternal deaths were observed. No serious adverse events related to the intervention were reported. According to the intent-to-treat analysis, prevalence of nasopharyngeal carriage of the bacteria of interest in the newborns at day 6 was lower in the intervention arm (28.3% versus 65.1% prevalence ratio 0.43; 95% CI 0.36–0.52, p <0.001). At the same time-point, prevalence of any bacteria in the mother was also lower in the azithromycin group (nasopharynx, 9.3% versus 40.0%, p <0.001; breast milk, 7.9% versus 21.6%, p <0.001; and the vaginal tract, 13.2% versus 24.2%, p <0.001). Differences between arms lasted for at least 4 weeks. Oral azithromycin given to women in labour decreased the carriage of bacteria of interest in mothers and newborns and may lower the risk of neonatal sepsis.

Trial registrationClinicalTrials.gov Identifier NCT01800942.

[Epidemiology and maternal prognosis of eclampsia in the intensive care unit at the University Hospital of Point G, Bamako]

OBJECTIVE

This research aimed to analyze the epidemio- clinical characteristic and the prognosis of patients with eclampsia admitted to the intensive care unit at the University Hospital of Point G.

MATERIALS AND METHODS

The clinical records of all patients admitted to intensive care for eclampsia from September 2009 to February 2011 were retrospectively collected. We analyzed the following parameters: age, parity, gravidity, the admission deadline, the beginning of eclampsia compared to the term of pregnancy, the number of seizure, mode of delivery, score of Glasgow, blood pressure, proteinuria, complications and evolution.

RESULTS

Among 702 admissions, 158 patients, with a mean age of 20 ± 4 were hospitalized for eclampsia (22.5%). We recorded 106 cases of first pregnancies (67.1%) and 104 primiparous (65.8%). The admission period after the first seizure was over 6 hours for 90 patients (57%). The first seizure had occurred in ante-partum period for 69 patients, in per-partum period for 4 patients and in postpartum period for 85 patients.

Ninety-three patients (59%) had consciousness disorders at admission, 12 patients received oxygen treatment .Vaginal delivery was the mode of delivery for 93 patients and cesarean section for 65 patients.Eclampsia was associated with renal failure in 25 patients, HELLP syndrome for 15 patients, the stroke for 5 patients, acute pulmonary edema for 3 patients, the coagulation disorders for one patient; and the sepsis for 6 patients. Maternal and perinatal lethality was 9.5% and 10.8% respectively.

CONCLUSION

Eclampsia is a frequent medical and obstetric emergency in intensive care unit of the University Hospital of Point G and affects young patients during their first pregnancy and delivery. Maternal and perinatal lethality remains high, due to the delay in the cases management and the associated factors of gravity. Strong actions are needed to raise awareness for early medical visit and to prepare medical teams for better cases management.

[Severe pneumonia due to cytomegalovirus in chronic obstructive pulmonary disease]

Severe pneumonia due to cytomegalovirus in chronic obstructive pulmonary disease.

INTRODUCTION

We describe two cases of immunocompetent patients with chronic obstructive pulmonary disease (COPD) who developed severe cytomegalovirus (CMV) pneumonia. The clinical and radiological context and CMV replication in broncho-alveolar lavage suggested a diagnosis of CMV pneumonia.

CASE HISTORIES

We report two cases in patients with moderate chronic obstructive pulmonary disease not treated with long-term steroid therapy who developed bilateral pneumonia with hypoxaemia. The only pathogen identified was CMV with replication of the virus in the broncho-alveolar lavage. Investigation failed to detect any associated immune deficiency.

CONCLUSION

Severe cytomegalovirus pneumonia could be encouraged by the existence of chronic obstructive pulmonary disease due to local inflammatory changes.

[Loco-regional anesthesia practices in 1261 cases]

GOAL

The aim of this study was to take stock of the practice of the loco-regional anesthesia (LRA) at the University Hospital Center of Point G from January 2004 to December 2008.

MATERIALS AND METHOD

This is a retrospective study, assessing the practice of LRA. The demographic data, the surgery, the technical characteristics of the procedure made, the type of local anesthetic used, adverse events were evaluated.

RESULTS

The LRA involved 1261 patients - 8.30% of the total number of surgical procedures occurring during the studied period. The American Society of Anesthesiology (ASA) classification was used for the evaluation of patients in scheduled surgery. The patients belonged to class 1 (50.40%) and Class 2 (49.60%). The main surgical procedures were: 26.20% surgical prostatic adenomectomy, 23.80% of caesarean section, and the fistulogram test for 19.04%. The LRA techniques performed were: spinal anesthesia, 87.60%, epidural anesthesia, 12%. Three hundred and three adverse events (24%) have been reported, three (1%) of them have resulted in the death of the patient. The incidence of arterial hypotension was 94.40%, and 4.6% for bradycardia. The three heart attacks were fatal (0.024 ‰). Patients operated under spinal anesthesia and patients aged 60 years and older had more adverse events with 20% and 10.38% for p <0.05 respectively. Sixty eight failures (5.4%) were observed.

CONCLUSION

The practice of LRA at the University Hospital of Point G is characterized by adverse events and a low number of deaths. Patients operated under spinal anesthesia and patients aged 60 years and older are at greatest risk of adverse events.

[Prescription errors in a pediatric hospital department in Dakar, Senegal]

Prescription is the main source of medication error in daily medical practice. The purpose of this study was to determine the distribution and cost of drugs used and causes of prescription errors in one department of the Albert Royer National Children's Hospital Center in Dakar, Senegal. Study was focused on patients admitted from December 1 to March 3, 2009. Based on 792 expected hospitalizations, 1 out of 2 patients was randomly selected to obtain a cohort of 400 patients for whom a total of 1267 prescriptions were written by pediatricians and interns on duty. Prescriptions were evaluated by pediatric professors to identify errors. The types of errors taken into account in this study involved indication, dosage schedule, and treatment duration. A total of 216 (17.0%) errors were identified including 121 cases (9.5%) involving indication mainly for antibiotics (30.5%) and antimalarial drugs (28.9%). Dosage schedule errors were observed in 58 cases (4.5%) involving antibiotics (24.1%) and antifungals (25.8%). These findings confirm the need for an intensive information campaign to prevent medication misuse in countries such as Senegal. Campaigns should be based on training of relevant therapeutic staff to optimize health care and improve availability for everyone.

[Pneumocystis jiroveci infection associated with organizing pneumonia in a kidney transplant patient]

The authors report the association of organizing pneumonia (OP) and a Pneumocystis jiroveci infection in a woman who benefited from a kidney transplant 13 years before and was under corticoids, cyclosporine and mycophenolate mofetil. The diagnosis was based on progressive dyspnoea with fever with an alteration in the general state associated with diffuse micronodular pneumopathy suggesting bronchiolitis. The conformation was obtained by the analysis of the alveolar bronchial washings and the histological examination of the distal biopsies revealing endo-alveolar vegetant fibromas. Transbronchial biopsies may be used for the diagnosis and thereby, avoid an invasive surgical pulmonary biopsy. The aetiology of OP may be related to the immunosuppressant treatment or infection by Pneumocystis jiroveci. The evolution in this case was favourable with trimethoprime and sulfamethoxazole associated with a transient increase in the corticoid treatment. This association is rarely described in patients undergoing solid organ transplants.

Carotenoid biosynthesis: Isolation and characterization of a bifunctional enzyme catalyzing the synthesis of phytoene

Phytoene is the first C(40) intermediate in the biogenesis of carotenoids. It is formed by two enzyme activities, catalyzing (i) the coupling of two molecules of geranylgeranyl diphosphate to yield prephytoene diphosphate and (ii) the conversion of prephytoene diphosphate into phytoene. We show now, with Capsicum chromoplast stroma, that the overall activity resides in a single protein, which has been purified to homogeneity by affinity chromatography. The monomeric structure and the molecular size (M(r) 47,500) were demonstrated by NaDodSO(4)/PAGE and glycerol gradient centrifugation. Further characterization was achieved by using specific antibodies which allowed immunofractionation and immunoprecipitation of the enzymatic activity from chromoplast stroma. The two reactions followed conventional Michaelis-Menten kinetics, with K(m) values of 0.30 muM and 0.27 muM, respectively, for geranylgeranyl diphosphate and prephytoene diphosphate. The activity of the enzyme depends strictly upon the presence of Mn(2+). This selectivity may be one of the factors regulating the competition with potentially rival enzymes converting geranylgeranyl diphosphate into other plastid terpenoids. The two enzymatic reactions were inhibited by inorganic pyrophosphate and by the arginine-specific reagent hydroxyphenylglyoxal. In no instance were the two reactions kinetically uncoupled. These properties strongly suggest that the same enzyme catalyzes the two consecutive reactions, and we propose to name it phytoene synthase.

[Impact of malaria on HIV infection]

Malaria and HIV are two major public health issues, especially in sub-Saharan Africa. HIV infection increases the incidence of clinical malaria, inversely correlated with the degree of immunodepression. The effect of malaria on HIV infection is not as well established. Malaria, when fever and parasitemia are high, may be associated with transient increases in HIV viral load. The effect of subclinical malaria on HIV viral load is uncertain. During pregnancy, placental malaria is associated with higher plasma and placental HIV viral loads, independently of the severity of immunodeficiency. However, the clinical impact of these transient increases of HIV viral load remains unknown. Although some data suggests that malaria might enhance sexual and mother-to-child transmissions, no clinical study has confirmed this. Nevertheless pregnant women and children with malaria-induced anemia are also exposed to HIV through blood transfusions. Integrated HIV and malaria control programs in the regions where both infections overlap are necessary.

Long-term effects of bosentan in patients with HIV-associated pulmonary arterial hypertension

Bosentan has proven 4-month efficacy in patients with HIV-associated pulmonary arterial hypertension (PAH-HIV). Herein, the long-term outcome of unselected PAH-HIV patients treated with first-line bosentan is described. Data for 59 consecutive World Health Organization (WHO) functional class II-IV PAH-HIV patients treated with first-line bosentan between May 2002 and July 2007 were analysed. HIV status, 6-min walk distance and haemodynamics were assessed at baseline, after 4 months and every 6-12 months thereafter. After 4 months, 6-min walk distance increased from 358+/-98 to 435+/-89 m and pulmonary vascular resistance decreased from 737+/-328 to 476+/-302 dyn x s x cm(-5). At the final evaluation (29+/-15 months), 6-min walk distance remained stable and pulmonary vascular resistance decreased further to 444+/-356 dyn x s x cm(-5). Haemodynamics normalised in 10 patients. At their last evaluation, these 10 patients were in WHO functional class I, with a 6-min walk distance of 532+/-52 m. Overall survival estimates were 93, 86 and 66% at 1, 2 and 3 yrs, respectively. Bosentan was safe when combined with highly active antiretroviral therapy, with no negative impact on HIV infection control. The present data confirm the long-term benefits of bosentan therapy in HIV-associated pulmonary arterial hypertension patients with improvements in symptoms, 6-min walk distance and haemodynamics, and with favourable overall survival.

[Infection due to Mycobacterium malmoense in an immunocompetent patient]

INTRODUCTION

Mycobacterium malmoense (MM) is an atypical mycobacterium responsible for opportunistic infection. The clinical and radiological picture is non-specific. The infection develops most frequently in a dystrophic lung.

CASE REPORT

A patient of 52 years was admitted with an extensive multifocal pneumonia which later proved to be due to infection with MM. Empirical treatment was started with the combination of rifampicin, isoniazid, pyrazinamide (rifater) and ethambutol (myambutol). Subsequently, cultures showed sensitivity to rifampicin, ethambutol, oxfloxacin, clarithromycin (MIC < 2 mg/l) and rifabutin (MIC < 0.5 mg/l). More than two weeks after the start of treatment, material aspirated at fibroscopy showed the persistence of numerous acid-alcohol fast bacilli, an increase, compared with the original examination, from 5 to 25 per field on day 2, to 20 to 100 per field on day 19. Despite the late addition of clarithromycin there was a progressive deterioration in the pulmonary condition.

CONCLUSION

There is little correlation between the in vivo and in vitro sensitivities of MM to antibiotics. In our patient the progress was unfavourable, even though the mycobacterium was sensitive to the combination of antibiotics used, with the exception of isoniazid that was not tested. In vitro isoniazid does not seem to be active against MM. There is no consensus of opinion on the antibiotic treatment of MM infections.

[Quinquina and man]

Many great discoveries have been made by chance but some have been the result of human perseverance and ingenuity. A sterling example of the second case is quinquina that was discovered in Peru and is now produced in Java. Quinquina has gone through centuries without losing its medical efficacy that efficacy allowed the exploration and colonization of Africa and played a key role in the ability to conduct overseas military campaigns. Because of its strategic importance, it was a coveted resource. It led to the discovery of homeopathy and dyes, allowed the development of organic chemistry, and has been used to make alcoholic bitters and soft drinks.