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

Seroprevalence and predisposing factors of rabies antibodies in unvaccinated dogs in Sierra Leone

Abstract Objective This study determines the seroprevalence and associated factors of rabies in unvaccinated dogs in Sierra Leone. Background Rabies control is poorly coordinated in Sierra Leone which was ranked as the third hungriest country in the world. Due to limited access to rabies vaccines, the need for comprehensive serological data on dogs for control of the disease is expedient. Methods A random multistage technique considering high, medium and low incident areas of rabies cases in dog‐populated communities was adopted. Samples were collected from dogs with owners which were at least 1‐year old. Samples were analysed using a commercial ELISA in accordance to manufacturer's instructions. Results 25.2% of the total 270 samples tested positive for the presence of rabies antibodies. Kenema district had the highest number of positive samples, followed by the Bombali district and Moyamba district the least. Predisposing factors, including sex, the status of castration, the type of settlement, district and the availability of fences at locations where dogs are kept, had significant effects (p<0.05) on the exposure of dogs to rabies. The 25.2% antibody seroprevalence obtained is very low. Conclusions Concerted effort should be made to enhance rabies vaccination through an awareness campaign and provision of vaccine to dog owners. Good waste disposal and management practices to reduce open garbage disposal in communities will go a long way to limit the stray‐dog population and minimize rabies outbreaks especially in third‐world countries where rabies vaccines are not accessible

Sustainability and the Social Construction of Technology: The Case of RWH as Source of Water Supply in Greater Accra

The paper discusses the sustainability of roof rainwater harvesting (RWH) in Greater Accra, Ghana We take a holistic approach, but focus especially on the social dimension. The discussion is grounded in a research and development project including a holistic sustainability assessment of selected RWH designs based on LCA, cost-benefit analysis and a KAP survey, as well as training of local artisans, stakeholder dialogue and pilot implementation of 21 RWH systems. The performance of the systems largely met the expectation. The households could expect long-term savings, and there were benefits in terms of convenience, hygiene and water sharing. On the other hand, high initial costs, limited awareness, and lack of capacity to implement supportive policies were impediments to wide-scale adoption. The sustainability of the solutions is discussed in further detail. A social construction of technology (SCOT) perspective is applied to throw light on how the stakeholders constructed drivers, barriers, and indeed the technical solutions themselves. We find that the technology was at a stage of low stabilization, meaning-wise, and this clearly affected its sustainability in the local context. The findings suggest that more attention should be paid to social construction in sustainability research and transition efforts.publishedVersio

Review of Barriers to Effective Implementation of Waste and Energy Management Policies in Ghana: Implications for the Promotion of Waste-to-Energy Technologies

Issues of rising waste generation are calling for proper management and the sustainable control of waste. This study examines waste- and energy-relevant policies and strategies in Ghana and the stakeholders’ perceptions on such policies and strategies. It explores the gaps and challenges in national policy documents to guide the implementation of waste-to-energy projects in Ghana. The approach adopted includes a comprehensive review of relevant policy documents and key informant interviews with selected key stakeholders. Factors such as limited funding, inadequate logistics, expertise and infrastructure, growing population and negative attitudes of general public towards the environment, amongst others, are the concerns identified. Findings from the policy review revealed that capacity to harness energy from waste could be improved through appropriate technologies suitable for Ghana. Adequate institutional framework, stakeholders and mechanisms to explore opportunities to coordinate implementation of various policy strategies and interventions have been established. Streamlining strategies to constitute components to improve governance on waste management, improving financing to ensure sustainable investment in waste-to-energy projects, improving research on waste-to-energy technologies as well as enhancing public interest and education on proper waste management could enhance the implementation of national waste and energy policies for feasible up-scaling of waste-to-energy technologies in Ghana

SUSTAINABILITY AND THE SOCIAL CONSTRUCTION OF TECHNOLOGY: THE CASE OF RWH AS SOURCE OF WATER SUPPLY IN GREATER ACCRA

The paper discusses the sustainability of roof rainwater harvesting (RWH) in Greater Accra, Ghana We take a holistic approach, but focus especially on the social dimension. The discussion is grounded in a research and development project including a holistic sustainability assessment of selected RWH designs based on LCA, cost-benefit analysis and a KAP survey, as well as training of local artisans, stakeholder dialogue and pilot implementation of 21 RWH systems. The performance of the systems largely met the expectation. The households could expect long-term savings, and there were benefits in terms of convenience, hygiene and water sharing. On the other hand, high initial costs, limited awareness, and lack of capacity to implement supportive policies were impediments to wide-scale adoption. The sustainability of the solutions is discussed in further detail. A social construction of technology (SCOT) perspective is applied to throw light on how the stakeholders constructed drivers, barriers, and indeed the technical solutions themselves. We find that the technology was at a stage of low stabilization, meaning-wise, and this clearly affected its sustainability in the local context. The findings suggest that more attention should be paid to social construction in sustainability research and transition efforts.publishedVersio

Sustainability and the Social Construction of Technology: The Case of RWH as Source of Water Supply in Greater Accra

The paper discusses the sustainability of roof rainwater harvesting (RWH) in Greater Accra, Ghana We take a holistic approach, but focus especially on the social dimension. The discussion is grounded in a research and development project including a holistic sustainability assessment of selected RWH designs based on LCA, cost-benefit analysis and a KAP survey, as well as training of local artisans, stakeholder dialogue and pilot implementation of 21 RWH systems. The performance of the systems largely met the expectation. The households could expect long-term savings, and there were benefits in terms of convenience, hygiene and water sharing. On the other hand, high initial costs, limited awareness, and lack of capacity to implement supportive policies were impediments to wide-scale adoption. The sustainability of the solutions is discussed in further detail. A social construction of technology (SCOT) perspective is applied to throw light on how the stakeholders constructed drivers, barriers, and indeed the technical solutions themselves. We find that the technology was at a stage of low stabilization, meaning-wise, and this clearly affected its sustainability in the local context. The findings suggest that more attention should be paid to social construction in sustainability research and transition efforts

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

Management and Outcomes Following Surgery for Gastrointestinal Typhoid: An International, Prospective, Multicentre Cohort Study

Background: Gastrointestinal perforation is the most serious complication of typhoid fever, with a high disease burden in low-income countries. Reliable, prospective, contemporary surgical outcome data are scarce in these settings. This study aimed to investigate surgical outcomes following surgery for intestinal typhoid. Methods: Two multicentre, international prospective cohort studies of consecutive patients undergoing surgery for gastrointestinal typhoid perforation were conducted. Outcomes were measured at 30 days and included mortality, surgical site infection, organ space infection and reintervention rate. Multilevel logistic regression models were used to adjust for clinically plausible explanatory variables. Effect estimates are expressed as odds ratios (ORs) alongside their corresponding 95% confidence intervals. Results: A total of 88 patients across the GlobalSurg 1 and GlobalSurg 2 studies were included, from 11 countries. Children comprised 38.6% (34/88) of included patients. Most patients (87/88) had intestinal perforation. The 30-day mortality rate was 9.1% (8/88), which was higher in children (14.7 vs. 5.6%). Surgical site infection was common, at 67.0% (59/88). Organ site infection was common, with 10.2% of patients affected. An ASA grade of III and above was a strong predictor of 30-day post-operative mortality, at the univariable level and following adjustment for explanatory variables (OR 15.82, 95% CI 1.53–163.57, p = 0.021). Conclusions: With high mortality and complication rates, outcomes from surgery for intestinal typhoid remain poor. Future studies in this area should focus on sustainable interventions which can reduce perioperative morbidity. At a policy level, improving these outcomes will require both surgical and public health system advances