Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Lipoprotein and apolipoprotein differences in black and white girls - The National Heart, Lung, and Blood Institute Growth and Health Study

Objective: To define racial differences in lipoprotein and apolipoprotein levels in girls aged 9 to 10 years. Design: Baseline analysis of a prospective cohort study. Setting: Three clinical sites. Subjects: A total of 1871 black and white girls, aged 9 to 10 years, with complete maturation data (pubic hair and areolar development and menarche) and an 8-hour fast before blood draw. Main Outcome Measures: Anthropometric measures and serum lipid, lipoprotein, and apolipoprotein levels. Results: All analyses were adjusted for maturational differences between blacks and whites (areolar or pubic hair development and menarche). The mean body mass index was marginally higher in black girls than in white girls (18.9 vs 18.3 kg/m(2); P = .002), while the sum of skinfolds (34.5 vs 34.8 mm; P = .77) was equivalent. However, both body mass measures were skewed higher at the upper percentiles in black girls. The low-density lipoprotein cholesterol level was similar between black and white girls. Mean triglyceride values were higher in white girls than in black girls (0.92 vs 0.79 mmol/L [81 vs 70 mg/dL]; P <.001); however, these differences were most pronounced in the upper percentiles. Conversely, mean high-density lipoprotein cholesterol and apolipoprotein A-I levels were higher in black girls than in white girls (1.44 vs 1.37 mmol/L [56 vs 39 mg/dL] and 147 vs 138 mg/dL, respectively; both P <.001); and again the differences were most evident at the upper end of the distributions. Conclusions: Racial differences in the mean levels of triglycerides, high-density lipoprotein cholesterol, and body mass in girls in the National Heart, Lung, and Blood Institute Growth and Health Study (NGHS) at age 9 to 10 years were predominantly the result of differences observed at the upper end of the distributions. The reported black-white differences for mean high-density and low-density lipoprotein cholesterol and triglyceride levels in adult women are comparable to NGHS results. Distributional characteristics of these risk factors as well as trends in lipids, lipoproteins, and apolipoproteins, will be evaluated in an ongoing longitudinal assessment that covers the full maturational period

Race, socioeconomic status, and obesity in 9- to 10 year-old girls: The NHLBI Growth and Health Study

The purpose of this investigation was to determine whether measures of socioeconomic status (SES) are inversely associated with obesity in 9- to 10-year-old black and white girls and their parents. Subjects were participants in the Growth and Health Study (NGHS) of the National Heart, Lung, and Blood Institute. Extensive SES, anthropometric, and dietary data were collected at baseline on 2379 NGHS participants. The prevalence of obesity was examined in the NGHS girls and parents in relation to SES and selected environmental factors. Less obesity was observed at higher levels of household income and parental education in white girls but not in black girls. Among the mothers of the NGHS participants who were seen, lower prevalence of obesity was observed with higher levels of income and education for white mothers, but no consistent patterns were seen in black mothers. Univariate logistic models indicated that the Prevalence of obesity was significantly and inversely associated with parental income and education and number of parents in the household in white girls whereas caloric intake and TV viewing were significantly and positively associated with obesity. Among black girls, only TV viewing was significantly and positively associated with the prevalence of obesity. Multivariate logistic regression models revealed that lower parental educational attainment, one-parent household, and increased caloric intake were significantly associated with the prevalence of obesity in white girls; for black girls, only increased hours of TV viewing were significant in these models. It is concluded that socioeconomic status, as measured by education and income, was related to the prevalence of obesity in girls, with racial variation in these associations. A lower prevalence of obesity was seen at higher levels of socioeconomic status in white girls, whereas no clear relationship was detected in black girls. These findings raise new questions regarding the correlates of obesity in black girls. Ann Epidemiol 1996; 266-275