Epidemiological and clinical characteristics of international travelers with enteric fever and antibiotic resistance profiles of their isolates: A GeoSentinel analysis

Copyright © 2020 American Society for Microbiology. All Rights Reserved. Enteric fever, caused by Salmonella enterica serovar Typhi (S. Typhi) and S. enterica serovar Paratyphi (S. Paratyphi), is a common travel-related illness. Limited data are available on the antimicrobial resistance (AMR) patterns of these serovars among travelers. Records of travelers with a culture-confirmed diagnosis seen during or after travel from January 2007 to December 2018 were obtained from GeoSentinel. Traveler demographics and antimicrobial susceptibility data were analyzed. Isolates were classified as nonsusceptible if intermediate or resistant or as susceptible in accordance with the participating site’s national guidelines. A total of 889 travelers (S. Typhi infections, n = 474; S. Paratyphi infections, n = 414; coinfection, n = 1) were included; 114 (13%) were children of (41%) traveled to visit friends and relatives (VFRs) and acquired the infection in South Asia (71%). Child travelers with S. Typhi infection were most frequently VFRs (77%). The median trip duration was 31 days (interquartile range, 18 to 61 days), and 448 of 691 travelers (65%) had no pretravel consultation. Of 143 S. Typhi and 75 S. Paratyphi isolates for which there were susceptibility data, nonsusceptibility to antibiotics varied (fluoroquinolones, 65% and 56%, respectively; co-trimoxazole, 13% and 0%; macrolides, 8% and 16%). Two S. Typhi isolates (1.5%) from India were nonsusceptible to third-generation cephalosporins. S. Typhi fluoroquinolone nonsusceptibility was highest when infection was acquired in South Asia (70 of 90 isolates; 78%) and sub-Saharan Africa (6 of 10 isolates; 60%). Enteric fever is an important travel-associated illness complicated by AMR. Our data contribute to a better understanding of region-specific AMR, helping to inform empirical treatment options. Prevention measures need to focus on high-risk travelers including VFRs and children

What Values in Design? The Challenge of Incorporating Moral Values into Design

Recently, there is increased attention to the integration of moral values into the conception, design, and development of emerging IT. The most reviewed approach for this purpose in ethics and technology so far is Value-Sensitive Design (VSD). This article considers VSD as the prime candidate for implementing normative considerations into design. Its methodology is considered from a conceptual, analytical, normative perspective. The focus here is on the suitability of VSD for integrating moral values into the design of technologies in a way that joins in with an analytical perspective on ethics of technology. Despite its promising character, it turns out that VSD falls short in several respects: (1) VSD does not have a clear methodology for identifying stakeholders, (2) the integration of empirical methods with conceptual research within the methodology of VSD is obscure, (3) VSD runs the risk of committing the naturalistic fallacy when using empirical knowledge for implementing values in design, (4) the concept of values, as well as their realization, is left undetermined and (5) VSD lacks a complimentary or explicit ethical theory for dealing with value trade-offs. For the normative evaluation of a technology, I claim that an explicit and justified ethical starting point or principle is required. Moreover, explicit attention should be given to the value aims and assumptions of a particular design. The criteria of adequacy for such an approach or methodology follow from the evaluation of VSD as the prime candidate for implementing moral values in design

The ethics of inherent trust in care robots for the elderly

The way elderly care is delivered is changing. Attempts are being made to accommodate the increasing number of elderly, and the decline in the number of people available to care for them, with care robots. This change introduces ethical issues into robotics and healthcare. The two-part study (heuristic evaluation and survey) reported here examines a phenomenon which is a result of that change. The phenomenon rises out of a contradiction. All but 2 (who were undecided) of the 12 elderly survey respondents, out of the total of 102 respondents, wanted to be able to change how the presented care robot made decisions and 7 of those 12 elderly wanted to be able to examine its decision making process so as to ensure the care provided is personalized. However, at the same time, 34% of the elderly participants said they were willing to trust the care robot inherently, compared to only 16% of the participants who were under fifty. Additionally, 66% of the elderly respondents said they were very likely or likely to accept and use such a care robot in their everyday lives. The contradiction of inherent trust and simultaneous wariness about control gives rise to the phenomenon: elderly in need want control over their care to ensure it is personalized, but many may desperately take any help they can get. The possible causes, and ethical implications, of this phenomenon are the focus of this paper

ZikaPLAN: addressing the knowledge gaps and working towards a research preparedness network in the Americas.

Zika Preparedness Latin American Network (ZikaPLAN) is a research consortium funded by the European Commission to address the research gaps in combating Zika and to establish a sustainable network with research capacity building in the Americas. Here we present a report on ZikaPLAN`s mid-term achievements since its initiation in October 2016 to June 2019, illustrating the research objectives of the 15 work packages ranging from virology, diagnostics, entomology and vector control, modelling to clinical cohort studies in pregnant women and neonates, as well as studies on the neurological complications of Zika infections in adolescents and adults. For example, the Neuroviruses Emerging in the Americas Study (NEAS) has set up more than 10 clinical sites in Colombia. Through the Butantan Phase 3 dengue vaccine trial, we have access to samples of 17,000 subjects in 14 different geographic locations in Brazil. To address the lack of access to clinical samples for diagnostic evaluation, ZikaPLAN set up a network of quality sites with access to well-characterized clinical specimens and capacity for independent evaluations. The International Committee for Congenital Anomaly Surveillance Tools was formed with global representation from regional networks conducting birth defects surveillance. We have collated a comprehensive inventory of resources and tools for birth defects surveillance, and developed an App for low resource regions facilitating the coding and description of all major externally visible congenital anomalies including congenital Zika syndrome. Research Capacity Network (REDe) is a shared and open resource centre where researchers and health workers can access tools, resources and support, enabling better and more research in the region. Addressing the gap in research capacity in LMICs is pivotal in ensuring broad-based systems to be prepared for the next outbreak. Our shared and open research space through REDe will be used to maximize the transfer of research into practice by summarizing the research output and by hosting the tools, resources, guidance and recommendations generated by these studies. Leveraging on the research from this consortium, we are working towards a research preparedness network

Corporatised Identities ≠ Digital Identities: Algorithmic Filtering on Social Media and the Commercialisation of Presentations of Self

Goffman’s (1959) dramaturgical identity theory requires modification when theorising about presentations of self on social media. This chapter contributes to these efforts, refining a conception of digital identities by differentiating them from ‘corporatised identities’. Armed with this new distinction, I ultimately argue that social media platforms’ production of corporatised identities undermines their users’ autonomy and digital well-being. This follows from the disentanglement of several commonly conflated concepts. Firstly, I distinguish two kinds of presentation of self that I collectively refer to as ‘expressions of digital identity’. These digital performances (boyd 2007) and digital artefacts (Hogan 2010) are distinct, but often confused. Secondly, I contend this confusion results in the subsequent conflation of corporatised identities – poor approximations of actual digital identities, inferred and extrapolated by algorithms from individuals’ expressions of digital identity – with digital identities proper. Finally, and to demonstrate the normative implications of these clarifications, I utilise MacKenzie’s (2014, 2019) interpretation of relational autonomy to propose that designing social media sites around the production of corporatised identities, at the expense of encouraging genuine performances of digital identities, has undermined multiple dimensions of this vital liberal value. In particular, the pluralistic range of authentic preferences that should structure flourishing human lives are being flattened and replaced by commercial, consumerist preferences. For these reasons, amongst others, I contend that digital identities should once again come to drive individuals’ actions on social media sites. Only upon doing so can individuals’ autonomy, and control over their digital identities, be rendered compatible with social media

Challenges in diagnosis and management of chikungunya and Zika virus infections

Arthropod-borne viruses (arboviruses) are viruses that can be transmitted between animal or human hosts by arthropod vectors, such as mosquitoes, ticks and sandflies. Transmission of virus occurs when the arthropod bites the host to feed on his blood. An infectious bite may then lead to a wide range of symptoms, from inapparent (asymptomatic) to severe disease and death. Approximately 150 virus species are known to cause human disease, and some of them have threatened human health for centuries. Others, like chikungunya virus (CHIKV) and Zika virus (ZIKV), have caused outbreaks on a global scale over the past decades. CHIKV and ZIKV belong to different families of viruses (Togaviridae and Flaviviridae, respectively), but they are both primarily transmitted by Aedes species mosquitoes, that are widely distributed across the continents. The emergence of CHIKV and ZIKV into new territories has emphasized that significant gaps exist in our knowledge of the natural history and clinical epidemiology of arboviral illnesses. As explained in the Introduction, these gaps present many challenges to the diagnosis and management of CHIKV and ZIKV infections. People who are infected or at risk of infection, clinicians, public health authorities and policy makers could benefit from multidisciplinary scientific efforts to advance our understanding of the risk factors, clinical presentation and diagnosis of Aedes-borne infections. The studies that were conducted in the context of this PhD thesis aim to contribute to these efforts. CHIKV was first introduced in the Caribbean and the New World in December 2013. It spread rapidly, and from October 2014 to March 2015, the outbreak affected the island Aruba in the Dutch Caribbean. The diagnostic capacity for CHIKV infections on the island at that time was limited to CHIKV-specific antibody detection by an immunofluorescence assay at the Landslaboratorium Aruba. At the Institute of Tropical Medicine in Antwerp (ITM), we retrospectively tested the sera of 498 patients who were referred to the Landslaboratorium for CHIKV diagnostics by their primary care physicians during the outbreak (Chapter 1). Two-hundred sixty-nine CHIKV cases were identified, 210 by antibody detection and in addition 59 (28%) cases using real-time reverse transcription polymerase chain reaction (RT-PCR). This finding highlights the substantial risk of under-diagnosis in field settings where RT-PCR is not available and follow-up samples are not easily obtained. Hundred seventy-one of 248 patients who were eligible for interview were contacted by telephone. We found arthralgia, fever and skin rash to be the dominant acute phase symptoms. Twenty-six percent of cases suffered from persisting joint pains that lasted longer than one year. Persistence of joint pains was predicted by female gender of the patient (odds ratio 5.9, 95% confidence interval (CI) [2.1-19.6]), the pattern and number of joints involved in the acute phase of infection (odds ratio 7.4, 95% CI [2.7-23.3]), and viremia beyond 7 days of symptom onset (odds ratio 6.4, 95% CI [1.4-34.1]). The considerable burden of long-lasting sequelae of CHIKV infection and the poor performance of antibody detection-based assays in the acute phase, emphasize the need for improved diagnostics. In Chapter 2, we evaluated a prototype immunochromatographic rapid diagnostic test that uses mouse antibodies to target the envelope protein E1 of CHIKV. When evaluated in a panel of clinical samples from returning travellers that contained ECSA genotype CHIKV (different lineages), the test had fair diagnostic sensitivity (88.9%, 95% CI [56.5 - 98.0]), but the sensitivity for samples from Aruba, containing Asian genotype CHIKV (33.3%, 95% CI [19.2-51.2]) was low. The overall specificity (83.1%, 95% CI [71.5-90.5]) of the test against sera from patients with other febrile conditions or sera that contained other alphaviruses or flaviviruses was poor. We suggest further development of a rapid test for CHIKV requires the use of antibodies that react across CHIKV genotypes and that the performance of such a new assay should be evaluated against different CHIKV genotypes. ZIKV, a member of the family Flaviviridae, was considered a cause of mild illness or, in 80% of cases, asymptomatic infection. However, its emergence in French Polynesia (2013) and the Americas (2015) has unveiled associations of ZIKV infection with neurological disease and, when pregnant women are infected, with microcephaly and other birth defects. In addition, the notion that this arbovirus can be transmitted from person to person by sexual intercourse, has caused great concern among scientists, health professionals and the general public. Precautionary advice was given to travellers from non-endemic areas, who consulted travel clinics for risk assessment prior to a journey into areas affected by the outbreak. This advice included travel restrictions for pregnant women. Upon return after travel, clinicians and laboratories were overwhelmed by the demand for diagnostic evaluations for ZIKV. The evidence base for diagnosis and management of ZIKV infection, particularly in regard to family planning, was small. In a prospective cohort study among 55 adult participants who travelled to areas with epidemic vector-borne transmission in the Americas in 2016 (Chapter 3), we observed 9 cases of ZIKV infection. The ZIKV incidence rate was 17.0% (95% CI [7.8 - 32.2]) per month of travel, and during the outbreak it ranked second only to travellers' diarrhea among travel-associated health hazards. Symptomatic infection presented as an exanthematous, rather than a febrile illness. Only one of 9 ZIKV-cases (11.1%) was asymptomatic, suggesting that asymptomatic ZIKV infection in travellers is much lower than previously reported in studies from endemic areas. The majority of reports of sexual transmission of ZIKV involved male-to-female sexual intercourse. The virus had been detected in high loads, and it was isolated from semen samples for up to 69 days after the onset of symptoms. The potential for sexual transmission of ZIKV seems therefore closely associated to viral persistence in semen, which we studied in symptomatic returning travellers with confirmed ZIKV infection (Chapter 4). ZIKV RNA was detected by RT-PCR in the semen of nine out of 15 participants (60%). It remained detectable for 83 days after symptom onset (95% CI [57–108]), and the longest duration of viral shedding in semen recorded in our cohort was 144 days after symptom onset. ZIKV was successfully isolated from one sample only, but as long as viral RNA can be detected in semen, we would not exclude the potential for sexual transmission of ZIKV. In the semen samples of 11 participants whose semen was microscopically analyzed, we found leukocytes (n=11), red blood cells (n=10) and oligospermia (n=6). These abnormalities occurred irrespective of Zika virus detection in semen and may indicate some degree of tissue damage to the male reproductive tract. At the start of the outbreak in the Americas, validated diagnostic assays for ZIKV infection were in scarce supply. At ITM, symptomatic travellers were tested with a ZIKV-specific RT-PCR on serum samples upon presentation within 7 days post symptom onset (DPSO) and on urine within 14 DPSO and an anti-ZIKV Immunoglobulin (Ig)M and IgG Enzyme Linked Immunosorbent Assay (ELISA). All positive or equivocal anti-ZIKV IgM/IgG results were considered diagnostic only when confirmed by ZIKV virus neutralization testing (VNT). Asymptomatic travellers were tested using ELISA only, preferably from 20 days after the last exposure. In Chapter 5 we performed a cross-sectional cohort analysis to evaluate our approach to the diagnosis of Zika infection in non-pregnant travellers. During a 12 month period, we evaluated 462 travellers. ZIKV infection was confirmed in 49, and was frequent in symptomatic cases (46/227, 20.3%), but not in asymptomatic persons (3/235, 1.3%). Asymptomatic travellers had similar baseline characteristics, but they had reproductive concerns more often (75.8% vs. 24.2%). Rash (positive likelihood ratio (LRP) 5.6) and conjunctivitis (LRP 10.8) predicted ZIKV infection. The post-test probability of a negative ELISA result at 20-25 days was below 0.1%. We consider negative ELISA results at 20-25 days after exposure a safe strategy to rule out ZIKV infection. Testing for ZIKV-specific antibodies within this timeframe could be particularly valuable in the management of returning travellers who wish to conceive.status: publishe