Carbapenemase-producing Klebsiella pneumoniae strains (CP-Kps) are currently among the most important nosocomial pathogens. An observational study was conducted during 2009 to 2010 in two hospitals ...located in a high-prevalence area (Athens, Greece). The aims were (i) to evaluate the clinical outcome of patients with CP-Kp bloodstream infections (BSIs), (ii) to identify predictors of mortality, and (iii) to evaluate the various antibiotic schemes employed. A total of 205 patients with CP-Kp BSIs were identified: 163 (79.5%) were infected with KPC or KPC and VIM, and 42 were infected with VIM producers. For definitive treatment, 103 patients received combination therapy (two or more active drugs), 72 received monotherapy (one active drug), and 12 received therapy with no active drug. The remaining 18 patients died within 48 h after the onset of bacteremia. The all-cause 28-day mortality was 40%. A significantly higher mortality rate was observed in patients treated with monotherapy than in those treated with combination therapy (44.4% versus 27.2%; P=0.018). The lowest mortality rate (19.3%) was observed in patients treated with carbapenem-containing combinations. In the Cox proportion hazards model, ultimately fatal disease (hazards ratio HR, 3.25; 95% confidence interval CI, 1.51 to 7.03; P=0.003), the presence of rapidly fatal underlying diseases (HR, 4.20; 95% CI, 2.19 to 8.08; P<0.001), and septic shock (HR, 2.15; 95% CI, 1.16 to 3.96; P=0.015) were independent predictors of death. Combination therapy was strongly associated with survival (HR of death for monotherapy versus combination, 2.08; 95% CI, 1.23 to 3.51; P=0.006), mostly due to the effectiveness of the carbapenem-containing regimens.
Greece imposed a nationwide lockdown in March 2020 to mitigate transmission of severe acute respiratory syndrome coronavirus 2 during the first epidemic wave. We conducted a survey on age-specific ...social contact patterns to assess effects of physical distancing measures and used a susceptible-exposed-infectious-recovered model to simulate the epidemic. Because multiple distancing measures were implemented simultaneously, we assessed their overall effects and the contribution of each measure. Before measures were implemented, the estimated basic reproduction number (R
) was 2.38 (95% CI 2.01-2.80). During lockdown, daily contacts decreased by 86.9% and R
decreased by 81.0% (95% credible interval CrI 71.8%-86.0%); each distancing measure decreased R
by 10%-24%. By April 26, the attack rate in Greece was 0.12% (95% CrI 0.06%-0.26%), one of the lowest in Europe, and the infection fatality ratio was 1.12% (95% CrI 0.55%-2.31%). Multiple social distancing measures contained the first epidemic wave in Greece.
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Introduction:
Contact tracing is a core public health tool used to interrupt the transmission of pathogens, including SARS-CoV-2. To increase the effectiveness of contact tracing, Greek health ...authorities used an electronic platform to aid traditional manual contact tracing to track individuals who have come in close contact with identified COVID-19 patients.
Method:
Contact tracing was implemented from the beginning of the pandemic in Greece. The aim was to identify and quarantine all the contacts of confirmed cases. The electronic database was designed following all the security protocols and national regulations on the use and protection of personal data. To assess factors associated with infectivity and susceptibility to infection in this analysis, we used contact tracing data with a sampling date between October 1 to December 9, 2020.
Results:
During the sampling period, 29,385 laboratory-confirmed SARS-CoV-2 cases and 64,608 traced contacts were identified. A median number of two persons were traced per index case. The secondary attack rate was 17.4% (95% CI: 17.0-17.8). Contacts aged 0–11 and 12–17 years were less susceptible to infection than adults 65 years or older (odds ratio (OR) 95% CI: 0.28 0.26–0.32 and 0.44 0.40–0.49, respectively). Index cases aged 65 years or older were more likely to infect their contacts than other adults or children/adolescents.
Conclusion:
Contact tracing is a key strategy to interrupt chains of transmission and to promote early diagnosis. The data collected in this process could be used to estimate epidemiological parameters of interest and to better understand factors associated with infection and susceptibility to infection. Precautions are necessary for individuals 65 or older as they have higher infectivity and susceptibility in contact with their peers.
Whether there is a change of hepatocellular carcinoma (HCC) incidence in chronic hepatitis B patients under long‐term therapy with potent nucleos(t)ide analogues is currently unclear. We therefore ...assessed the HCC incidence beyond year 5 of entecavir/tenofovir (ETV/TDF) therapy and tried to determine possible factors associated with late HCC occurrence. This European, 10‐center, cohort study included 1,951 adult Caucasian chronic hepatitis B patients without HCC at baseline who received ETV/TDF for ≥1 year. Of them, 1,205 (62%) patients without HCC within the first 5 years of therapy have been followed for 5‐10 (median, 6.8) years. HCCs have been diagnosed in 101/1,951 (5.2%) patients within the first 5 years and 17/1,205 (1.4%) patients within 5‐10 years. The yearly HCC incidence rate was 1.22% within and 0.73% after the first 5 years (P = 0.050). The yearly HCC incidence rate did not differ within and after the first 5 years in patients without cirrhosis (0.49% versus 0.47%, P = 0.931), but it significantly declined in patients with cirrhosis (3.22% versus 1.57%, P = 0.039). All HCCs beyond year 5 developed in patients older than 50 years at ETV/TDF onset. Older age, lower platelets at baseline and year 5, and liver stiffness ≥12 kPa at year 5 were independently associated with more frequent HCC development beyond year 5 in multivariable analysis. No patient with low Platelets, Age, Gender‐Hepatitis B score at baseline or year 5 developed HCC. Conclusion: The HCC risk decreases beyond year 5 of ETV/TDF therapy in Caucasian chronic hepatitis B patients, particularly in those with compensated cirrhosis; older age (especially ≥50 years), lower platelets, and liver stiffness ≥12 kPa at year 5 represent the main risk factors for late HCC development. (Hepatology 2017;66:1444–1453).
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Elimination of hepatitis C virus (HCV) among people who inject drugs (PWID) is a costly investment, so strategies should not only focus on eliminating the disease, but also on preventing disease ...resurgence. The aims of this study are to compute the minimum necessary antiviral therapies to achieve elimination with and without the additional expansion of harm reduction (HR) programs and to examine the sustainability of HCV elimination after 2030 if treatment is discontinued.
We considered two types of epidemic (with low (30%) and high (50%) proportion of PWID who engage in sharing equipment (sharers)) within three baseline chronic HCV (CHC) prevalence settings (30%, 45% and 60%), assuming a baseline HR coverage of 40%. We define sustainable elimination strategies, those that could maintain eliminations results for a decade (2031-2040), in the absence of additional treatment.
The model shows that the optimum elimination strategy is dependent on risk sharing behavior of the examined population. The necessary annual treatment coverage to achieve HCV elimination under 45% baseline CHC prevalence, without the simultaneous expansion of HR programs, ranges between 4.7-5.1%. Similarly, under 60% baseline CHC prevalence the needed treatment coverage varies from 9.0-10.5%. Increasing HR coverage from 40% to 75%, reduces the required treatment coverage by 6.5-9.8% and 11.0-15.0% under 45% or 60% CHC prevalence, respectively. In settings with ≤45% baseline CHC prevalence, expanding HR to 75% could prevent the disease from rebounding after elimination, irrespective of the type of the epidemic. In high chronic HCV prevalence, counseling interventions to reduce sharing are also needed to maintain the HCV incident cases in low levels.
Harm reduction strategies have a vital role in HCV elimination strategy, as they reduce the required number of treatments to eliminate HCV and they provide sustainability after the elimination. The above underlines that HCV elimination strategies should be built upon the existing HR services, and argue for HR expansion in countries without services.
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To measure the prevalence of food insecurity and explore related characteristics and behaviours among people who inject drugs (PWID).
Cross-sectional analysis of a community-based programme for HIV ...infection among PWID (ARISTOTLE programme). Food insecurity was measured by the Household Food Insecurity Access Scale. Computer-assisted interviews and blood samples were also collected.
A fixed location in Athens Metropolitan Area, Greece, during 2012-2013.
In total, 2834 unique participants with history of injecting drug use in the past 12 months were recruited over four respondent-driven sampling rounds (approximately 1400/round).
More than 50 % of PWID were severely or moderately food insecure across all rounds. PWID were more likely to be severely food insecure if they were older than 40 years adjusted OR (aOR): 1·71, 95 % CI: 1·33-2·19, were women (aOR: 1·49, 95 % CI: 1·17-1·89), from Middle East countries (aOR v. from Greece: 1·80, 95 % CI: 1·04-3·11), had a lower educational level (primary or secondary school v. higher education; aOR: 1·54, 95 % CI: 1·29-1·84), had no current health insurance (aOR: 1·45, 95 % CI: 1·21-1·73), were homeless (aOR: 17·1, 95 % CI: 12·3-23·8) or were living with another drug user (aOR: 1·55, 95 % CI: 1·26-1·91) as compared with those living alone or with family/friends. HIV-infected PWID were more likely to be severely food insecure compared with uninfected (59·0 % v. 51·0 %, respectively, P = 0·002); however, this difference was attributed to the confounding effect of homelessness.
Moderate/severe food insecurity was a significant problem, reaching > 50 % in this sample of PWID and closely related to socio-demographic characteristics and especially homelessness.
The results of a simulation-based evaluation of several policies for vaccine rollout are reported, particularly focusing on the effects of delaying the second dose of two-dose vaccines. In the ...presence of limited vaccine supply, the specific policy choice is a pressing issue for several countries worldwide, and the adopted course of action will affect the extension or easing of non-pharmaceutical interventions in the next months. We employ a suitably generalised, age-structure, stochastic SEIR (Susceptible → Exposed → Infectious → Removed) epidemic model that can accommodate quantitative descriptions of the major effects resulting from distinct vaccination strategies. The different rates of social contacts among distinct age-groups (as well as some other model parameters) are informed by a recent survey conducted in Greece, but the conclusions are much more widely applicable. The results are summarised and evaluated in terms of the total number of deaths and infections as well as life years lost. The optimal strategy is found to be one based on fully vaccinating the elderly/at risk as quickly as possible, while extending the time-interval between the two vaccine doses to 12 weeks for all individuals below 75 years old, in agreement with epidemic theory which suggests targeting a combination of susceptibility and infectivity. This policy, which is similar to the approaches adopted in the UK and in Canada, is found to be effective in reducing deaths and life years lost in the period while vaccination is still being carried out.
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People who inject drugs (PWID) comprise one of the major transmission risk groups for human immunodeficiency virus (HIV) and hepatitis C virus (HCV). In 2011, Athens experienced a large HIV outbreak ...among PWID. Significant public health interventions were implemented in response to the HIV outbreak. The aims of this study were to estimate the indirect effects of the HIV interventions on HCV infection and to evaluate the concept of the association between HCV and HIV infections in the case of Athens. A dynamic, stochastic, individual‐based model was developed to simulate HCV transmission among PWID. We calibrated the model to reproduce the observed HCV prevalence among PWID in Greece. Two years prior to the HIV outbreak, an undetected HCV outbreak has occurred. In 2009, the incidence of HCV infection increased from 640 (495, 842) cases in 2008 to 1260 (1060, 1500). The mean time from initiation of injecting drug use to HCV acquisition decreased from 29 months in 2008 to 13 months in 2009. After HIV interventions, HCV incidence declined by 64.8% in 2012, compared to 2009. The averted HCV incidence cases attributed to the HIV‐implemented interventions were 2200 (1950, 2480), during 2012‐2015. The cumulative number incident HCV cases in Athens during 2002‐2015 was about 9900 (7800, 12 100). Our results highlight that before the 2011 HIV outbreak in Athens, an HCV outbreak occurred in 2009. Prevention measures for HIV that took place in the Athens metropolitan area in 2012 reduced significantly the incidence of HCV.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Background and Aims
The human immunodeficiency virus (HIV) outbreak among people who inject drugs (PWID) in Athens, Greece in 2011–13 was the largest recent epidemic in Europe and North America. We ...aimed to assess trends in HIV prevalence, drug use and access to prevention among PWID in Athens to estimate HIV incidence and identify risk factors and to explore HIV‐1 dispersal using molecular methods during 2014–20.
Methods
Two community‐based HIV/hepatitis C programmes on PWID were implemented in 2012–13 (n = 3320) and 2018–20 (n = 1635) through consecutive respondent‐driven sampling (RDS) rounds. PWID were uniquely identified among rounds/programmes. We obtained RDS‐weighted HIV prevalence estimates per round for 2018–20 and compared them to 2012–13. We assessed changes in HIV status, behaviours and access to prevention in PWID participating in both periods. We estimated HIV incidence in a cohort of seronegative PWID as the number of HIV seroconversions/100 person‐years during 2014–20 and used Cox regression to identify associated risk factors. Molecular sequencing and phylogenetic analysis were performed in HIV seroconverters.
Results
HIV prevalence per round ranged between 12.0 and 16.2% in 2012–13 and 10.7 and 11.3% in 2018–20 with overlapping 95% confidence intervals (95% CI). Among PWID participating in both programmes, HIV prevalence (95% CI) increased from 14.2% (11.7–17.1%) in 2012–13 to 22.0% (19.0–25.3%) in 2018–20 (P < 0.001). There was a deterioration in socio‐economic characteristics such as homelessness from 16.2% (95% CI = 13.5–19.2%) to 25.6% (22.3–29.0%), a shift in cocaine use 16.6% (13.9–19.6%) versus 28.1% (24.7–31.7%, reduced access to free syringes 51.8% (48.0–55.7%) versus 44.5% (40.7–48.3%) and a decrease in daily injecting 36.2% (32.6–39.9%) versus 28.5% (25.2–32.1%). HIV incidence (95% CI) in 2014–20 was 1.94 (1.50–2.52) new cases/100 person‐years and younger age, lower educational level, larger injection network and daily injecting were risk factors. Almost 9% of HIV seroconversions occurred within a newly expanding phylogenetic cluster.
Conclusions
In Athens, Greece, compared with the period 2012–13, in the period 2018–20 there was a deterioration in socio‐economic conditions among people who inject drugs, an increase in the use of cocaine, reduced access to needle and syringe programmes and stable low levels of human immunodeficiency virus testing. Ongoing human immunodeficiency virus transmission was documented during 2014–20 in existing as well as new transmission clusters.
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BFBNIB, DOBA, FSPLJ, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Background. The effect of hepatitis B virus (HBV) infection on the natural history of human immunodeficiency virus (HIV) disease remains uncertain. Therefore, a retrospective cohort study was ...conducted to examine the influence of HIV-HBV coinfection on AIDS development and overall mortality. Moreover, our results were added to those of previous studies in a literature-based meta-analysis. Methods. Serum samples obtained from HIV-seropositive patients from 1984 through 2003 were retrospectively tested for hepatitis B surface antigen. Multivariable analyses were performed using Poisson and logistic regression models. For meta-analytic purposes, eligible articles were identified and relevant data were abstracted. Pooled estimates of effect were calculated applying fixed and random effects models. Results. The prevalence of chronic HBV infection (documented hepatitis B surface antigen seropositivity for >6 months) among 1729 HIV-positive patients was ∼6%. The multivariable analyses in our primary study revealed no significant impact of concomitant HIV-HBV infection on progression to AIDS and all-cause mortality. However, a meta-analysis performed on data from 12,382 patients enrolled in 11 studies revealed a significant effect of HIV-HBV coinfection on overall mortality (pooled effect estimate, 1.36; 95% confidence interval, 1.12–1.64). The increased rate of death among coinfected individuals was observed in the meta-analyses of studies conducted both before (pooled effect estimate, 1.60; 95% confidence interval, 1.07–2.39) and after (pooled effect estimate, 1.28; 95% confidence interval, 1.03–1.60) commencement of highly active antiretroviral therapy. Conclusions. HIV-HBV coinfection seems to affect all-cause mortality, and strategies to reduce liver damage in patients coinfected with HIV and HBV are justified.
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