International comparisons of COVID-19 incidence rates have helped gain insights into the characteristics of the disease, benchmark disease impact, shape public health measures and inform potential travel restrictions and border control measures. However, these comparisons may be biased by differences in COVID-19 surveillance systems and approaches to reporting in each country. To better understand these differences and their impact on incidence comparisons, we collected data on surveillance systems from six European countries: Belgium, England, France, Italy, Romania and Sweden. Data collected included: target testing populations, access to testing, case definitions, data entry and management and statistical approaches to incidence calculation. Average testing, incidence and contextual data were also collected. Data represented the surveillance systems as they were in mid-May 2021. Overall, important differences between surveillance systems were detected. Results showed wide variations in testing rates, access to free testing and the types of tests recorded in national databases, which may substantially limit incidence comparability. By systematically including testing information when comparing incidence rates, these comparisons may be greatly improved. New indicators incorporating testing or existing indicators such as death or hospitalisation will be important to improving international comparisons.

Background Children in low- and middle-income countries are particularly vulnerable in the months following an initial health event (IHE), with increased risk of mortality caused mostly by infectious diseases. Due to exposure to a wide range of environmental stressors, hospitalization in itself might increase child vulnerability at discharge. The goal of this study was to disentangle the role of hospitalization on the risk of subsequent infection. Methods Data from a prospective, longitudinal, international, multicenter mother-and-child cohort were analysed. The main outcome assessed was the risk of subsequent infection within 3 months of initial care at hospital or primary healthcare facilities. First, risk factors for being hospitalized for the IHE (Step 1) and for having a subsequent infection (Step 2) were identified. Then, inpatients were matched with outpatients using propensity scores, considering the risk factors identified in Step 1. Finally, adjusted on the risk factors identified in Step 2, Cox regression models were performed on the matched data set to estimate the effect of hospitalization at the IHE on the risk of subsequent infection. Results Among the 1312 children presenting an IHE, 210 (16%) had a subsequent infection, mainly lower-respiratory infections. Although hospitalization did not increase the risk of subsequent diarrhoea or unspecified sepsis, inpatients were 1.7 (95% Confidence Intervals [1.0-2.8]) times more likely to develop a subsequent lower-respiratory infection than comparable outpatients. Conclusion For the first time, our findings suggest that hospitalization might increase the risk of subsequent lower-respiratory infection adjusted on severity and symptoms at IHE. This highlights the need for robust longitudinal follow-up of at-risk children and the importance of investigating underlying mechanisms driving vulnerability to infection.

BackgroundSevere bacterial infections (SBIs) are a leading cause of neonatal deaths in low- and middle-income countries (LMICs). However, most data came from hospitals, which do not include neonates who did not seek care or were treated outside the hospital. Studies from the community are scarce, and few among those available were conducted with high-quality microbiological techniques. The burden of SBI at the community level is therefore largely unknown. We aimed here to describe the incidence, etiology, risk factors, and antibiotic resistance profiles of community-acquired neonatal SBI in 3 LMICs.Methods and findingsThe BIRDY study is a prospective multicentric community-based mother and child cohort study and was conducted in both urban and rural areas in Madagascar (2012 to 2018), Cambodia (2014 to 2018), and Senegal (2014 to 2018). All pregnant women within a geographically defined population were identified and enrolled. Their neonates were actively followed from birth to 28 days to document all episodes of SBI. A total of 3,858 pregnant women (2,273 (58.9%) in Madagascar, 814 (21.1%) in Cambodia, and 771 (20.0%) in Senegal) were enrolled in the study, and, of these, 31.2% were primigravidae. Women enrolled in the urban sites represented 39.6% (900/2,273), 45.5% (370/814), and 61.9% (477/771), and those enrolled in the rural sites represented 60.4% (1,373/2,273), 54.5% (444/814), and 38.1% (294/771) of the total in Madagascar, Cambodia, and Senegal, respectively. Among the 3,688 recruited newborns, 49.6% were male and 8.7% were low birth weight (LBW). The incidence of possible severe bacterial infection (pSBI; clinical diagnosis based on WHO guidelines of the Integrated Management of Childhood Illness) was 196.3 [95% confidence interval (CI) 176.5 to 218.2], 110.1 [88.3 to 137.3], and 78.3 [59.5 to 103] per 1,000 live births in Madagascar, Cambodia, and Senegal, respectively. The incidence of pSBI differed between urban and rural sites in all study countries. In Madagascar, we estimated an incidence of 161.0 pSBI per 1,000 live births [133.5 to 194] in the urban site and 219.0 [192.6 to 249.1] pSBI per 1,000 live births in the rural site (p = 0.008). In Cambodia, estimated incidences were 141.1 [105.4 to 189.0] and 85.3 [61.0 to 119.4] pSBI per 1,000 live births in urban and rural sites, respectively (p = 0.025), while in Senegal, we estimated 103.6 [76.0 to 141.2] pSBI and 41.5 [23.0 to 75.0] pSBI per 1,000 live births in urban and rural sites, respectively (p = 0.006). The incidences of culture-confirmed SBI were 15.2 [10.6 to 21.8], 6.5 [2.7 to 15.6], and 10.2 [4.8 to 21.3] per 1,000 live births in Madagascar, Cambodia, and Senegal, respectively, with no difference between urban and rural sites in each country. The great majority of early-onset infections occurred during the first 3 days of life (72.7%). The 3 main pathogens isolated were Klebsiella spp. (11/45, 24.4%), Escherichia coli (10/45, 22.2%), and Staphylococcus spp. (11/45, 24.4%). Among the 13 gram-positive isolates, 5 were resistant to gentamicin, and, among the 29 gram-negative isolates, 13 were resistant to gentamicin, with only 1 E. coli out of 10 sensitive to ampicillin. Almost one-third of the isolates were resistant to both first-line drugs recommended for the management of neonatal sepsis (ampicillin and gentamicin). Overall, 38 deaths occurred among neonates with SBI (possible and culture-confirmed SBI together). LBW and foul-smelling amniotic fluid at delivery were common risk factors for early pSBI in all 3 countries. A main limitation of the study was the lack of samples from a significant proportion of infants with pBSI including 35 neonatal deaths. Without these samples, bacterial infection and resistance profiles could not be confirmed.ConclusionsIn this study, we observed a high incidence of neonatal SBI, particularly in the first 3 days of life, in the community of 3 LMICs. The current treatment for the management of neonatal infection is hindered by antimicrobial resistance. Our findings suggest that microbiological diagnosis of SBI remains a challenge in these settings and support more research on causes of neonatal death and the implementation of early interventions (e.g., follow-up of at-risk newborns during the first days of life) to decrease the burden of neonatal SBI and associated mortality and help achieve Sustainable Development Goal 3.

Background: Salmonella enterica is a leading cause of human gastroenteritis. S. enterico strains that produce ESBLs (ESBL-Salm) remain rare in Europe and North America, but less is known about their prevalence among animal-derived foods in countries with weaker food safety practices and unregulated veterinary antibiotic use. Objectives: To examine the prevalence and characteristics of ESBL-Saim from retail meats in Phnom Penh, Cambodia, Methods: We tested fish, pork and chicken from two markets for ESBL- and carbapenemase-producing Salmonella from September-December 2016, using cefotaxime- and ertapenem-supplemented media, respectively. ESBL-Salm were sequenced and their genomes characterized. We performed plasmid conjugation experiments to assess the co-transferability of ESBL-encoding genes and MDR phenotypes. Results: Twenty-six of 150 fish and meat samples (17%) were positive for ESBL-Salm, including 10/60 fish (17%), 15/60 pork (25%) and 1/30 chicken (3%). Carbapenemase-producing Salmonella strains were not detected. Pork-origin ESBL-Salm were primarily serotypes Rissen (10/15) or a monophasic variant of Typhimurium 4,5,12:i: (3/15), whereas Saintpau( (3/10) and Newport (4/10) were more common among fish. Most ESBL enzymes were encoded by bla(CTX-M-55) genes (24/26) harboured on conjugative IncA/C2 m 14) or IncHI2 (n 10) plasmids. Resistance to up to six additional drug classes was co-transferred by each plasmid type. ESBL-Salm were resistant to almost every antibiotic recommended for severe salmonellosis treatment. Conclusions: CTX-M-55-type S. enterica are highly prevalent among pork and fish from Phnom Penh markets and their spread appears to be mediated by MDR IncA/C2 and IncHI2 plasmids. Food safety must be improved and veterinary antibiotic use should be regulated to protect public health.

OBJECTIVE:To examine the variability of hospital performance within and across countries, using 30-day acute myocardial infarction (AMI) mortality, and to study the impact of hospital characteristics on performance. STUDY SETTING:Hospital-level adjusted risk standardized mortality rates (RSMR) and hospital characteristics were collected from 10 OECD and two collaborating countries including 1,163 hospitals. STUDY DESIGN:Associations between RSMR and hospital characteristics were studied using univariate and multivariate linear regressions. Clusters of hospitals were created using hierarchical clustering and mortality compared using linear regression. FINDINGS:Wide variation between countries was found for RSMR and hospital characteristics. Regression models showed large country effects. A high volume of AMI admission was associated with lower RSMR in a model using a restricted number of hospital characteristics (-0.83, p < 0.001) but not in a model using all characteristics (-1.03, p = 0.06). Analysis within countries supported this association. Hospital clusters showed clear differences in characteristic distributions but no difference in RSMR. CONCLUSIONS:The effect of volume may support policies toward a concentration of services within the hospital sector. The effect of other hospital characteristics was inconclusive and suggests the importance of system-wide characteristics or pathways of care (i.e. timeliness and nature of initial response and during transportation to a hospital, transfers between hospitals, post-discharge organization) in explaining variation.

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Health at a Glance compares key indicators for population health and health system performance across OECD members, candidate and partner countries.This 2019 edition presents the latest comparable data across 80 indicators, reflecting differences across countries in health status, risk factors and health-seeking behaviour, access, quality of care, and the financial and physical resources available for health.Alongside indicator-byindicator analysis, an overview chapter summarises the comparative performance of countries and major trends, including how much health spending is associated with staffing levels, access, quality, and health outcomes.This edition also includes a special chapter on patient-reported outcomes and experiences.The production of Health at a Glance would not have been possible without the contribution of national data correspondents from OECD countries.The OECD gratefully acknowledges their effort in supplying most of the data contained in this publication, as well as their detailed feedback to a draft of the report.Special acknowledgement is extended to members of the Patient-reported Indicator Surveys (PaRIS) Working Groups on mental health, breast cancer care, and hip and knee replacement for their contribution to Chapter 2, especially those individuals from countries, registries and health care organisations that facilitated the provision of patient-reported data.The OECD also recognises the contribution of other international organisations, notably the World Health Organization and Eurostat, for providing data and comments.The European Union

We compared extended-spectrum β-lactamase–producing Escherichia coli isolates from meat and fish, gut-colonized women, and infected patients in Cambodia. Nearly half of isolates from women were phylogenetically related to food-origin isolates; a subset had identical multilocus sequence types, extended-spectrum β-lactamase types, and antimicrobial resistance patterns. Eating sun-dried poultry may be an exposure route.

HAL is a multi-disciplinary open access archive for the deposit and dissemination of scientific research documents, whether they are published or not. The documents may come from teaching and research institutions in France or abroad, or from public or private research centers. L’archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d’enseignement et de recherche français ou étrangers, des laboratoires publics ou privés. Colonization of Extended-Spectrumβ -Lactamase-and NDM-1-Producing Enterobacteriaceae among Pregnant Women in the Community in a Low-Income Country: a Potential Reservoir for Transmission of Multiresistant Enterobacteriaceae to Neonates Fanny Chereau, Perlinot Herindrainy, Benoit Garin, Bich-Tram Huynh, Frederique Randrianirina, Michael Padget, Patrice Piola, Didier Guillemot, Elisabeth Delarocque-Astagneau

International quality measurement work is moving beyond the consideration of health system or national level variations to understand variations within countries and enable more meaningful cross-country comparison. Hospital performance is one key area where policy makers are increasing their focus on reducing variation, lifting the overall standards of care while minimizing the widespread differences in access and quality of care that are evident within health systems.In 2014 the OECD launched the Hospital Performance Project to better understand performance across countries and strengthen international comparisons. From 2015-2018 the OECD developed a method for measuring hospital level acute myocardial infarction 30-day mortality for international comparison. The methodological development and pilot data collections undertaken over this time have resulted in robust and feasible approach to ongoing routine international hospital level data collections on AMI 30-day mortality rates with potential applications to other subnational level indicators. This paper discusses the development of this measurement including technical as well as practical aspects of collecting, displaying, and analysing such data.

Background Antimicrobial resistance is widely considered an urgent global health issue due to associated mortality and disability, societal and healthcare costs. Aim To estimate the past, current and projected future proportion of infections resistant to treatment for eight priority antibiotic-bacterium combinations from 2000 to 2030 for 52 countries. Methods We collated data from a variety of sources including ResistanceMap and World Bank. Feature selection algorithms and multiple imputation were used to produce a complete historical dataset. Forecasts were derived from an ensemble of three models: exponential smoothing, linear regression and random forest. The latter two were informed by projections of antibiotic consumption, out-of-pocket medical spending, populations aged 64 years and older and under 15 years and real gross domestic product. We incorporated three types of uncertainty, producing 150 estimates for each country-antibiotic-bacterium-year. Results Average resistance proportions across antibiotic-bacterium combinations could grow moderately from 17% to 18% within the Organisation for Economic Co-operation and Development (OECD; growth in 64% of uncertainty sets), from 18% to 19% in the European Union/European Economic Area (EU/EEA; growth in 87% of uncertainty sets) and from 29% to 31% in Group of Twenty (G20) countries (growth in 62% of uncertainty sets) between 2015 and 2030. There is broad heterogeneity in levels and rates of change across countries and antibiotic-bacterium combinations from 2000 to 2030. Conclusion If current trends continue, resistance proportions are projected to marginally increase in the coming years. The estimates indicate there is significant heterogeneity in resistance proportions across countries and antibiotic-bacterium combinations.

En los ultimos anos, Mexico ha registrado avances importantes en materia de salud. La esperanza de vida ha aumentado, la mortalidad infantil ha disminuido y, gracias a la implementacion del programa Seguro Popular, la cobertura de los servicios de salud se ha ampliado considerablemente. Sin embargo, el ritmo de estos avances ha sido mas lento que en otros paises de la OCDE. Por ello el pais sigue estando por debajo del promedio de la OCDE en un gran numero de indicadores clave de desempeno, como la esperanza de vida, el gasto en salud, la mortalidad por enfermedades cardiovasculares y la incidencia de la obesidad.

Mexico has made significant progress on health in recent years. Life expectancy is up, infant mortality is down and, thanks to the introduction of the programme Seguro Popular, health care coverage has risen dramatically. Yet, progress has been slower in Mexico than in other OECD countries. For this reason, Mexico still remains well below OECD averages on a number of key performance indicators, including life expectancy, health spending, cardiovascular mortality and obesity. Low health care spending and high outof- pocket costs lead to inequalities in access to quality services and have impeded progress. The fragmentation of the health system also must be addressed in order to harmonise performance across sub-systems and states, and enhance its overall level. Obesity is a significant and growing public health problem in Mexico, resulting in high rates of diabetes and cardiovascular death. In order to deliver on the objectives set out for equality of care in the 2012 Pact for Mexico, significant reforms are necessary, including raising health spending in low-spending areas and on prevention, ensuring greater equality of care through a more harmonised system and expanded services, particularly in rural areas.

Chapter 4 on risk factors to health was prepared by

Chapter 4 on risk factors to health was prepared by

In low and middle income countries ( LMICs), where the burden of neonatal sepsis is the highest, the spread of extended spectrum beta-lactamase-producing enterobacteriaceae ( ESBL-PE) in the community, potentially contributing to the neonatal mortality, is a public health concern. Data regarding the acquisition of ESBL-PE during the neonatal period are scarce. The routes of transmission are not well defined and particularly the possible key role played by pregnant women. This study aimed to understand the neonatal acquisition of ESBL-PE in the community in Madagascar. The study was conducted in urban and semi-rural areas. Newborns were included at birth and followed-up during their first month of life. Maternal stool samples at delivery and six stool samples in each infant were collected to screen for ESBL-PE. A Cox proportional hazards model was performed to identify factors associated with the first ESBL-PE acquisition. The incidence rate of ESBL-PE acquisition was 10.4 cases/1000 newborn-days [ 95% CI: 8.0-13.4 cases per 1000 newborn-days]. Of the 83 ESBL-PE isolates identified, Escherichia coli was the most frequent species ( n = 28, 34.1%), followed by Klebsiella pneumoniae ( n = 20, 24.4%). Cox multivariate analysis showed that independent risk factors for ESBL-PE acquisition were low birth weight ( adjusted Hazard-ratio ( aHR) = 2.7, 95% CI [ 1.2; 5.9]), cesarean-section, ( aHR = 3.4, 95% CI [ 1.7; 7.1]) and maternal use of antibiotics at delivery ( aHR = 2.2, 95% CI [ 1.1; 4.5]). Our results confirm that mothers play a significant role in the neonatal acquisition of ESBL-PE. In LMICs, public health interventions during pregnancy should be reinforced to avoid unnecessary caesarean section, unnecessary antibiotic use at delivery and low birth weight newborns.

Severe bacterial infections are a leading cause of death among neonates in low-income countries, which harbor several factors leading to emergence and spread of multidrug-resistant bacteria. Low-income countries should prioritize interventions to decrease neonatal infections; however, data are scarce, specifically from the community. To assess incidence, etiologies, and antimicrobial drug-resistance patterns of neonatal infections, during 2012-2014, we conducted a community-based prospective investigation of 981 newborns in rural and urban areas of Madagascar. The incidence of culture-confirmed severe neonatal infections was high: 17.7 cases/1,000 live births. Most (75%) occurred during the first week of life. The most common (81%) bacteria isolated were gram-negative. The incidence rate for multi-drug-resistant neonatal infection was 7.7 cases/1,000 live births. In Madagascar, interventions to improve prevention, early diagnosis, and management of bacterial infections in neonates should be prioritized.

Chapter 4 on risk factors to health was prepared by

Chapter 4 on risk factors to health was prepared by