COVID-19 vaccination in prison settings: a model to design tailored vaccine delivery strategies

Introduction

Vaccinations are one of the most powerful preventive tools discovered by modern medicine. Although expanded programmes of immunization are well established in EU/EEA, significant immunity gaps and suboptimal coverage are registered among specific populations, including people living in prisons (PLP). PLP are also at increased risk to vaccine-preventable diseases (VPD) with potential outbreak in prison, e.g. flu, COVID-19, as well as other VPDs such as HBV. The EU-funded project RISE-Vac, aimed at collecting models of care developed during the pandemic to design tailored vaccine delivery strategies that could be extended beyond the sole COVID-19 vaccine.

Methods

Through a survey to healthcare staff working in prisons in six countries of the EU/EEA (Cyprus, France, Germany, Italy, Moldova, UK) we collected information on the implementation of COVID-19 vaccination program. The following areas were investigated: challenges & barriers encountered, workload distribution, education & training activities for prison staff and PLP, referral strategies after release, immunization information system.

Results

The respondents reported that in prisons COVID-19 programs have been implemented efficiently. Strategies for optimal management of the vaccination campaign included: week-day dedicated to vaccination services when vaccines were delivered and immediately administered to overcome cold chain challenges; new staff recruitment & task shifting; administration of booster doses within prison premises for released individuals; distribution of informational material both to PLP & prison staff.

Conclusions

Our results show that universal immunisation campaigns are feasible, acceptable and effective in places of detention when there is commitment to implementing them. Evidence from the pandemic situation may inform future provision of expanded immunization programmes.

Systematic review on Screening for antimicrobial-resistant Gram-negative bacteria in inpatients

Background

Infections with antimicrobial-resistant Gram-negative bacteria (AMR-GNB) are increasingly being reported worldwide. Early identification of carriage at hospital admission is essential to reduce the risk of onward transmission within the health facility. This systematic review aimed at exploring screening practices for AMR-GNB faecal colonization among patients on admission to hospital in high-income countries and estimating its prevalence.

Methods

We searched on Pubmed, Scopus and Cochrane databases for studies published from 2010 up to April 2019. We included studies reporting on patients ≥18 years old and hospitalised (excluding long-term care facilities).

Results

The search retrieved 9496 articles, 85 were included after screening: 10 reported screening activities in outbreak situations (not included in the analysis); 75 in non-outbreak situations. Based on the target patient groups and setting we identified four subsets of screening approaches: all admitted (AA) in high risk (HR) wards (36 studies, 48%), HR patients in HR wards (12, 16%), HR patients in low risk wards (LRW) (11; 15%) and AA - LRW (15, 20%). HR patients-based screening targeted patients with certain clinical conditions (mostly oncologic patients, 37%), travellers 29%, previously hospitalised and individuals with multiple risks 34%. HR wards-based screening was performed mostly in ICU (73%), while LRW-based screening in hospital-wide setting (58%). We investigated the overall prevalence rates of AMR-GNB (15.1%; 95%CI: 9.5-21.6), Klebsiella spp (KB) (4.1%; 3.1-5.3), E. coli (9.6%; 7.7-11.7) P. Aeruginosa (7.6%; 1.7-16.8), A. Baumannii (2.1%; 0.5-4.4) and other Enterobacterales (0.8%; 0.59-1.1). Reported KB-prevalence varied according to screening approaches, with statistically significant higher prevalence in HR wards.

Conclusions

According to our data, screening for AMR-GNB mostly followed targeted approaches. Overall prevalence of AMR-GNB carriage at hospital admission was considerable.

Key messages

This systematic review gives un overview on the screening procedures for AMR-GNB faecal colonization among patients on hospital admission in high-income countries. According to our results, overall prevalence of AMR-GNB carriage was considerable (15.1%), varying among specific pathogens but with no significant correlation with screening approaches, except for KB.

Risk of infection in antimicrobial-resistant Gram-negative bacteria carriers: A systematic review

Background

Antimicrobial-resistant Gram-negative bacteria (AMR-GNB) have emerged as important health care-associated pathogens. Infections with AMR-GNB are associated with high patient morbidity and attributable mortality. Colonization is a prerequisite for infection, however the extent to which colonized patients develop infection is unclear. This systematic review explored the risk of developing infection during hospitalisation among AMR-GNB faecal carriers. Also, we investigated the acquisition rate for AMR-GNB colonization among patients not colonized at admission.

Methods

We searched on PubMed, Scopus and Cochrane databases for studies published from 2010 up to April 2019. We included studies reporting on hospitalised patients ≥18 years old in high-income countries (excluding long-term care facilities).

Results

Out of 9496 articles, 55 studies fulfilled our inclusion criteria. Forty-two studies reported data from EU/EEA, 6 from USA and 7 from other regions. Almost all studies (n = 45) were conducted in university hospitals. Most studies (n = 41;74.5%) were performed in high-risk wards (ICU, haematology, burn units and transplant units). Out of 55 studies, 8 examined AMR-GNB, 27 Enterobacteriaceae, while the others investigated specific pathogens: Klebsiella spp. (n = 11), E. Coli (n = 2), A. Baumannii (n = 3) and P. Aeruginosa (n = 4). The rate of AMR-GNB carriage acquisition was 10.5% (n = 40 studies; 95% CI:8.2-13.1). The risk of progression to infection among patients colonized at hospital admission was 13.9% (n = 15; 5.4-24.9), while the infection rate in patients who acquired carriage during hospitalization was 23.0% (n = 7; 5.9-45.2). Patients with an undefined time of colonization presented an infection rate of 16.9% (n = 13; 11.2-23.4). Considering these three populations as a whole, the risk of developing infection was 16.0% (11.0-21.0).

Conclusions

Our results suggest that risk of progression to infection in AMR-GNB colonized patients in hospital setting is high.

Key messages

The aim of our study was to estimate the risk of progression to infection, during hospital stay, in patients colonized by AMR-GNB at hospital admission in high-income countries. Our results suggest that faecal colonization with AMR-GNB poses a 16.0% risk of subsequent AMR-GNB infection. This risk in higher (23.0%) in patients who acquired colonization during hospitalisation.

Student empowerment through the use of interactive television

Videoconferencing, also known as interactive television (ITV), is gaining popularity in the delivery of post-secondary education. Recent experience with this new technology in delivering programs to undergraduate students in a sparsely populated region of British Columbia, Canada, has provided useful insights. It highlights the need to incorporate technological change on the basis of student feedback. More importantly, it demonstrates ITV’s potential to empower students within the classroom.

Neurokinin3-R agonism in aged rats has anxiolytic-, antidepressant-, and promnestic-like effects and stimulates ACh release in frontal cortex, amygdala and hippocampus

Neurokinin-3 receptors (NK(3)-R) are localized in brain regions which have been implicated in processes governing learning and memory as well as emotionality. The effects of acute subcutaneous (s.c.) senktide (0.2 and 0.4 mg/kg), a NK(3)-R agonist, were tested in aged (23-25 month old) Wistar rats: (a) in an episodic-like memory test, using an object discrimination task (this is the first study to test for deficits in episodic-like memory in aged rats, since appropriate tests have only recently became available); (b) on parameters of anxiety in an open field test, (c) on indices of depression in the forced swimming test and (d) on the activity of cholinergic neurons of the basal forebrain, using in vivo microdialysis and HPLC. Neither the saline-, nor senktide-treated aged animals, exhibited episodic-like memory. However, the senktide-, but not the vehicle-treated group, exhibited object memory for spatial displacement, a component of episodic memory. Senktide injection also had anxiolytic- and antidepressant-like effects. Furthermore, the active doses of senktide on behavior increased ACh levels in the frontal cortex, amygdala and hippocampus, suggesting a relationship between its cholinergic and behavioral actions. The results indicate cholinergic modulation by the NK(3)-R in conjunction with a role in the processing of memory and emotional responses in the aged rat.

Hemodynamic instability after extracranial carotid stenting

OBJECTIVE

Hemodynamic instability (hypertension, hypotension and bradycardia) is a well-known complication of carotid endarterectomy. Carotid angioplasty and stenting (CAS) is becoming a valuable alternative treatment for patients with severe carotid stenosis and increased surgical risk. CAS implies instrumentation of the carotid bulb, so baroceptor dysfunction may provoke hemodynamic instability. The aim of this work was to calculate the incidence of this complication and to detect factors to predict it.

METHODS

Medical records and angiograms of 51 consecutive patients submitted to CAS for severe atherosclerotic stenosis (40 cases) or postsurgical restenosis (11 cases) were retrospectively reviewed in order to detect the occurrence of intra- and post-procedural hypertension (systolic blood pressure >160 mmHg), hypotension (systolic blood pressure <90 mmHg) and bradycardia (heart rate <60 beats/min). The relationship between clinical, procedural and angiographic factors and the occurrence of hemodynamic instability was assessed with univariate and multivariate analysis (logistic regression).

RESULTS

Transient mild systolic post-procedural hypertension occurred in five cases (10%); preprocedural hypertension, asymptomatic stenosis and ipsilateral post-surgical restenosis predicted this. Hypotension with bradycardia also occurred in five cases (10%), one with neurological sequelae. Transient periprocedural bradycardia occurred in 19 cases (37%). Severe bradycardia without hypotension arose in one case only. Factors predicting post-procedural hypotension included the presence of a fibrous plaque and the ratio between the pre- and post-stenting diameter of the internal carotid artery. Peri-procedural bradycardia predicted post-procedural bradycardia. None of these factors were confirmed by multivariate analysis as a significant prognostic predictor.

CONCLUSION

Mild systolic hypertension may occur after CAS, but is resolved by medical treatment. Prolonged hypotension and bradycardia may also arise and this can be dangerous because it may cause neurological deterioration due to hypoperfusion. These complications cannot be predicted by clinical, procedural, and angiographic factors.

Surgery and stenting As combined treatment of a symptomatic tandem stenosis of the carotid artery

International co-operative studies have demonstrated a benefit from surgery for symptomatic and asymptomatic patients affected by internal carotid artery stenosis of 60-70%. The presence of a tandem lesion, intracranial or extracranial, may annul the benefit of surgery. Such patients may thus represent a challenging problem for management if age, good general conditions and a normal neurological status favour a therapy. A 54-year-old man developed transient ischaemic attacks of the left hemisphere; his general condition was good, and neurological status was normal. Angiography showed a tight stenosis at the left common carotid artery near the ostium and at the homolateral carotid bifurcation. At first, a self-expanding wall stent was placed at the level of the common carotid artery stenosis, and immediately after a standard endarterectomy under general anaesthesia was performed. The postoperative course was normal and was complicated only by the presence of a mild deficit of the hypoglossal nerve due to the presence of a high bifurcation. The early and late outcome of our case suggests that stenosis of the proximal common carotid artery may be successfully treated by stenting. While awaiting additional data about this new technology, endovascular techniques and surgery may be complementary in the management of patients suffering from such tandem lesions.

Composite graft (Medtronic-Hall) replacement of the ascending aorta and aortic valve in aortic aneurysms: what is adequate follow-up?

Between 1987 and 1994, 39 patients underwent 41 replacements (2 reoperations) of the aortic valve and ascending aorta by composite grafts with mechanical valves. One patient had annuloaortic ectasia, one had a sinus of valsalva aneurysm, 13 patients had a Debakey type I acute dissection, 10 had a Debakey type II acute dissection including two Marfan patients, and 14 had atherosclerotic aneurysms. 6 patients (15%) died within a postoperative period of 30 days. The mean follow-up time was 40 months (1-82 months). Twenty-six patients were restudied by clinical examinations and computed tomography of the chest (CT). Two patients required emergency reoperation due to disruption of the proximal aortic anastomosis and right coronary anastomosis. Both patients had been diagnosed to have Marfan disease. Anastomotic dehiscence of composite grafts has a potentially high risk of lethal complications. In follow-up examination computed tomography was performed as a simple and accurate method to detect complications such as pseudoaneurysms, but up to now did not give the indications for reoperation. We suggest that complications may occur not only in the early postoperative period so that regular CT-scan control studies (every 6 to 12 months) should be performed in all patients who undergo composite graft replacement.