Background Invasive meningococcal disease (IMD) represents a global health burden. However, its epidemiology in the Eastern Mediterranean (EM) and North Africa (NA) regions is currently not well understood. This review had four key objectives: to describe asymptomatic meningococcal carriage, IMD epidemiology (e.g. serogroup prevalence, case-fatality rates [CFRs]), IMD presentation and management (e.g. clinical diagnosis, antibiotic treatments) and economic impact and evaluation (including health technology assessment [HTA] recommendations) in EM and NA. Methods A systematic literature search (MEDLINE and EMBASE) was conducted (January 2000 to February 2021). Search strings included meningococcal disease and the regions/countries of interest. Identified publications were screened sequentially by title/abstract, followed by screening of the full-text article; articles were also assessed on methodological quality. Literature reviews, genetic sequencing or diagnostic accuracy studies, or other non-pertinent publication type were excluded. An additional grey literature search (non-peer-reviewed sources; start date January 2000) was conducted to the end of April 2019. Results Of the 1745 publications identified, 79 were eligible for the final analysis (n = 61 for EM and n = 19 for NA; one study was relevant to both). Asymptomatic meningococcal carriage rates were 0–33% in risk groups (e.g. military personnel, pilgrims) in EM (no data in NA). In terms of epidemiology, serogroups A, B and W were most prevalent in EM compared with serogroups B and C in NA. IMD incidence was 0–20.5/100,000 in EM and 0.1–3.75/100,000 in NA (reported by 7/15 countries in EM and 3/5 countries in NA). CFRs were heterogenous across the EM, ranging from 0 to 57.9%, but were generally lower than 50%. Limited NA data showed a CFR of 0–50%. Data were also limited in terms of IMD presentation and management, particularly relating to clinical diagnosis/antibiotic treatment. No economic evaluation or HTA studies were found. Conclusions High-risk groups remain a significant reservoir of asymptomatic meningococcal carriage. It is probable that inadequacies in national surveillance systems have contributed to the gaps identified. There is consequently a pressing need to improve national surveillance systems in order to estimate the true burden of IMD and guide appropriate prevention and control programmes in these regions.

Background Viral infections are often treated with empiric antibiotics due to suspected bacterial co-infections, leading to antibiotic overuse. We aimed to describe antibiotic resistance (ABR) trends and their association with the influenza season in ambulatory and inpatient settings in the US. Methods We used the BD Insights Research Database (Franklin Lakes, NJ, US) to evaluate antibiotic susceptibility profiles in 30-day non-duplicate bacterial isolates collected from patients >17 years old at 257 US healthcare institutions from 2011-19. We investigated ABR in Gram-positive (Staphylococcus aureus and Streptococcus pneumoniae) and Gram-negative (Enterobacterales [ENT], Pseudomonas aeruginosa [PSA], and Acinetobacter baumannii spp. [ACB]) bacteria expressed as the proportion of isolates not susceptible (NS; intermediate or resistant) and resistance per 100 admissions (inpatients only). Antibiotics included carbapenems (Carb), fluoroquinolones (FQ), macrolides, penicillin, extended-spectrum cephalosporins (ESC), and methicillin. Generalized estimating equations models were used to evaluate monthly trends in ABR outcomes and associations with community influenza rates. Results We identified 8,250,860 non-duplicate pathogens, including 154,841 Gram-negative Carb-NS, 1,502,796 Gram-negative FQ-NS, 498,012 methicillin-resistant S. aureus (MRSA), and 44,131 NS S. pneumoniae. All S. pneumoniae rates per 100 admissions (macrolide-, penicillin-, and ESC-NS) were associated with influenza rates. Respiratory, but not non-respiratory, MRSA was also associated with influenza. For Gram-negative pathogens, influenza rates were associated with the percent of FQ-NS ENT, FQ-NS PSA, and Carb-NS ACB. Conclusions Our study showed expected increases in rates of ABR Gram-positive and identified small but surprising increases in ABR Gram-negative pathogens associated with influenza activity. These insights may help inform antimicrobial stewardship initiatives.

Background Mass gatherings can not only trigger major outbreaks on-site but also facilitate global spread of infectious pathogens. Hajj is one of the largest mass gathering events worldwide where over two million pilgrims from all over the world gather annually creating intense congestion. Methods We developed a meta-population model to represent the transmission dynamics of Neisseria meningitidis and the impact of Hajj pilgrimage on the risk of invasive meningococcal disease (IMD) for pilgrims population, local population at the Hajj site and country of origin of Hajj pilgrims. This model was calibrated using data on IMD over 17 years (1995–2011) and further used to simulate potential changes in vaccine policy and endemic conditions. Results The effect of increased density of contacts during Hajj was estimated to generate a 78-fold increase in disease transmission that impacts not only pilgrims but also the local population. Quadrivalent ACWY vaccination was found to be very effective in reducing the risk of outbreak during Hajj. Hajj has more limited impact on IMD transmission and exportation in the pilgrim countries of origin, although not negligible given the size of the population considered. Conclusion The analysis performed highlighted the amplifying effect of mass gathering on N. meningitidis transmission and confirm vaccination as a very effective preventive measure to mitigate outbreak risks.

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Context Prompt administration of post exposure prophylaxis (PEP) is one of the key strategies for ending human deaths from rabies. Delay in seeking first dose of rabies PEP or failure to complete the recommended PEP dosage may result in clinical rabies and death. Objectives To assess the efficacy of short message system (SMS) phone texts on adherence to scheduled PEP doses among bite patients in rural eastern Kenya. Trial design and methods We conducted a single arm before-after field trial that compared adherence among bite patients presenting at Makueni Referral Hospital in October – December 2018 (control group) and January – March 2019 (intervention group that received an SMS reminder one day prior to their scheduled PEP doses). Data on demographics, socio-economic status, circumstances surrounding the bite, expenditures related to the bite were collected for all patients. Results A total of 186 bite patients were enrolled in the study, with 82 (44%) being in the intervention and 104 (56%) in the control group. The odds of PEP completion was three times (OR 3.37, 95% CI 1.28, 10.20) among patients that received the SMS reminder compared to those that did not. The intervention group had better compliance on the scheduled doses 2 to 5 with a mean deviation of 0.18 days compared to 0.79 days for the control group (p = 0.004). The main reasons for non-compliance included lack of funds (30%), forgetfulness (23%) on days for follow-up treatment, among others. Although the majority of bite patients (94%) were under the Makueni medical insurance cover and did not pay for PEP, nearly all (96%, n=179) the bite patients incurred indirect costs of transport at an average of 4 USD (0 - 45 USD) per visit. Conclusion This study suggests integrating SMS reminders in healthcare service delivery increases compliance to PEP and may strengthen rabies control and elimination strategies.

Seasonal influenza represents a huge health burden, resulting in significant mortality and morbidity. Following the 2009 H1N1 pandemic, focus has been directed on the burden of influenza globally. Country and regional disease burden estimates play important roles in helping inform decisions on national influenza intervention programmes. Despite improvements in influenza surveillance following the 2009 pandemic, many opportunities remain unexplored in the Eastern Mediterranean and North African (EMNA) region, which has a high prevalence of patients with chronic disease and thus a population at high risk of influenza complications. We conducted a systematic literature review of Embase, Medline, Scopus and the Cochrane Database of Systematic Reviews from 1 January 1998 to 31 January 2020 covering the EMNA region with the aim to describe the epidemiology of influenza in the region and assess the influenza epidemiological surveillance research landscape. Relevant data on study characteristics, population, clinical/virology characteristics and epidemiology were extracted and summarised descriptively. Of the 112 studies identified for inclusion, 90 were conducted in the Eastern Mediterranean region, 19 in North Africa and three across the EMNA region. Data were reported on 314,058 laboratory-confirmed influenza cases, 96 of which were derived from surveillance systems. Amongst the surveillance studies, the percentage of positive cases reported ranged from 1% to 100%. The predominantly identified influenza strain was strain A; H1N1 was the most prominent circulating subtype. Typing was performed in approximately 75% and subtyping in 50% of studies, respectively. Data on those considered most at risk for influenza complications were collected in 21% of studies, highlighting a regional gap for these data. Our review reveals existing gaps in regional estimates of influenza health and economic burden, hospitalisation rates and duration, and highlights the need for robust and high-quality epidemiology data to help inform public health interventions. Supplementary Information The online version contains supplementary material available at 10.1007/s40121-021-00534-3.