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Background From June 13–16, 2022, a regional epidemiological department in Kazakhstan reported an increase in acute gastroenteritis cases among people who consumed food from a wedding at a restaurant. An investigation was initiated to determine factors associated with acute intestinal infection and prevent further illness. Methods The investigation team conducted a retrospective cohort study among people who consumed event food. Participants were classified as a case if they were acutely ill with diarrhea, vomiting, fever, vomiting, or weakness from June 13–18. We interviewed people to collect information on demographics, symptoms, and food exposures at the event. We calculated food-specific attack rates and estimated adjusted relative risks (aRR) using multivariable Poisson regression, which was adjusted for sex, age, and foods consumed. Patient stool and gastric lavage samples, leftover food, and restaurant environmental samples were collected for bacterial culture and chemical analysis. Results Of the 138 participants, 66 became ill; the attack rate was 48%. The most reported symptoms were diarrhea (92%), abdominal pain (91%), and fever (89%). Symptom onset occurred between 6 h and 4 days after the event (median = 1 day). Overall, 50 (76%) cases were hospitalized; no deaths were reported. In bivariable analysis, a greater proportion of cases than non-cases ate honey cake (89% vs. 13%, p  < 0.01), and 45% of cases ate leftovers compared with 11% of non-cases ( p  < 0.01). In multivariable analysis, honey cake was the only risk factor associated with illness (aRR = 7.8, 95% confidence interval = 3.5–20.1, p  < 0.01). Honey cakes, which use raw eggs in cream layers, had been stored at room temperature for three days before the event. Salmonella enterica serovar Enteriditis (S. Enteritidis) was isolated from all patient stool samples (49/49, 100%) and honey cake samples (2/2, 100%). Staphylococcus aureus was detected in 92% (35/38) of patient gastric lavage samples. Conclusion S. Enteritidis was this outbreak’s most probable etiological agent based on clinical manifestations and isolation from participant and honey cake samples. The improper storage of cakes containing raw eggs was a key contributing factor. Leftover event food was discarded, and the restaurant was closed for disinfection. Future outbreaks could be prevented by increased food safety awareness.

Background Viral load suppression among people living with HIV is a key strategy for reducing HIV transmission. A global target for HIV elimination aims to have 95% of people living with HIV diagnosed, 95% of people diagnosed on antiretroviral therapy (ART), and 95% viral load suppression for those on ART. We aimed to assess viral load non-suppression rates and associated factors among people living with HIV on ART in the Sughd region of Tajikistan. Methods We conducted a retrospective cohort study of adults (≥ 18 years old) who were newly diagnosed with HIV in 2013–2022 and had received ART for ≥ 6 months in the Sughd Region. Data were collected from the national electronic HIV case surveillance system and cross-referenced with paper medical and laboratory records. We conducted multivariable Quasi-Poisson regression to identify factors associated with viral load non-suppression (defined as ≥ 1000 copies/mL on their latest viral load test). Results Among the 1,871 people newly diagnosed with HIV who received ART for ≥ 6 months from 2013 to 2022, 11% were not virally suppressed. Over half (57%) were male, 38% were migrants, 73% were married, and the median age was 31 years (range 18–74). One-third (32%) had advanced HIV disease at diagnosis, 58% had been on ART for < 5 years, 94% were on a dolutegravir-containing regimen (DTG), and 9% died. Viral load non-suppression was 23% among people with stage IV at diagnosis and 43% among those not on DTG. Higher risk of viral load non-suppression was observed among male migrants and male nonmigrants compared to female nonmigrants (adjusted relative risk [aRR] and 95% confidence interval = 1.61 [1.13–2.31] and aRR = 1.48 [1.03–2.14], respectively), those who never-married vs. married (aRR = 1.56 [1.05–2.25]), those on ART for < 5 years vs. longer (aRR = 1.56 [1.05–2.29]), those initiating ART in 2013–2018 compared to 2019–2020 (aRR = 1.92 [1.28–2.88]), and those not on DTG (aRR = 3.86 [2.63–5.69]). Conclusions Viral load suppression among people living with HIV in the Sughd Region remains below the global 95% target. Viral load suppression may improve with increased treatment support for people with late diagnosis or those newly initiating ART, with a special focus on men and migrants.

Background In Tajikistan, where there are about 8,000 cases annually, many new cases are being diagnosed with severe disease, indicating a delay in receiving care. We aimed to estimate the proportion with delayed care and the main factors contributing to delayed care. Methods Using a retrospective cohort design, we conducted a study that included all people aged over 15 years who were newly diagnosed with pulmonary TB in Dushanbe from 2019 to 2021. We defined ‘patient delay’ as > 14 days from TB symptom onset to the first provider visit and ‘provider delay’ as > 3 days from the first visit to treatment initiation. Data was abstracted from medical records and participants were interviewed in-person. Multivariable negative binomial regression was used to estimate adjusted risk ratios (aRR) and 95% confidence intervals (CI). Results Of 472 participants, 49% were male, 65% had lung tissue cavitation, 33% had drug resistant TB, 11% had diabetes, 4% had HIV, and. Reported cases dropped from 196 in 2019 to 109 in 2020 and increased to 167 in 2021. The proportion of people experiencing patient delays was 82%, 72%, and 90% per year, respectively. The proportion of provider delays was 44%, 41% and 29% per year. Patient delay was associated with year (aRR: 1.09 [CI:1.02–1.18] in 2021 vs. 2019), age (aRR:0.91 [0.82–0.99] for 40–59-year-olds vs. 15–39-year-olds), having HIV (aRR:1.22 [1.08–1.38]), having blood in sputum (aRR:1.19 [1.10–1.28]), chest pain (aRR:1.32 [1.14–1.54]), having at least two structural barriers vs. none (aRR:1.52 [1.28–1.80]), having one of the following barriers: long wait lines (aRR:1.36 [1.03–1.80]), feeling that healthcare services were expensive (aRR:1.54 [1.28–1.85]), or having no time or too much work (aRR:1.54 [1.29–1.84]). Provider delay was associated with year (aRR: 0.67 [0.51–0.89] in 2021 vs. 2019), patients having to pay for X-ray services (aRR: 1.59 [1.22–2.07]) and lacking direct-observed-therapy (DOTS) in facility (aRR: 1.61 [1.03–2.52]). Conclusions Patient delay was high before the COVID-19 pandemic and increased in 2021, while provider delay decreased during this time. Addressing structural barriers to healthcare services, such as increased DOTS facilities, expanded hours, and zero fees, may decrease delays.

BackgroundHigh vaccination coverage is critical for preventing disease transmission. In Bishkek (population: 1.15 million), childhood vaccination coverage was <90% in 2022. Understanding missed opportunities for vaccination (MOV) at healthcare visits was needed to increase coverage.MethodsUsing the World Health Organization MOV assessment guide, we selected 33 primary care clinics in Bishkek. We conducted sequential exit interviews with caregivers of children aged <30 months who received healthcare for any reason. Caregiver’s attitude towards vaccines was measured by asking if it was good, neutral or negative. We extracted vaccine records from the facility’s medical records. MOV was calculated as the proportion of children who were not up to date on all their vaccines by the end of the visit, among those eligible for at least one vaccine at the start of the visit. We used multivariable Poisson regression to assess characteristics associated with MOV.ResultsOf 650 participating children, 448 (69%) were eligible for vaccination. Among whom, 86% had a MOV after their visit and 6% had never been vaccinated. MOV prevalence was 81% for children aged 0–11 months (n=240) and 92% for those aged 12–30 months (n=208), ranging from 79% to 93% across the four districts. Providers did not check the immunisation status of 53% of children. Among 133 children whose primary visit purpose was vaccination, 53% were still not up to date on all their vaccines by the end of the visit. MOV risk was higher among children whose vaccination status was not checked by the provider compared with those who were checked (adjusted prevalence ratio (aPR) 1.13, 95% CI 1.05 to 1.22) and children whose caregivers had negative (aPR 1.10, 95% CI 1.03 to 1.18) or neutral attitudes (aPR 1.11, 95% CI 1.03 to 1.19) vs positive attitudes.ConclusionNearly nine in 10 children missed a vaccination opportunity during their healthcare visit. Strategies for checking immunisation status at each visit and addressing caregiver and healthcare barriers may help increase immunisation coverage.

BackgroundClinical practice guidelines were continually changing during the COVID-19 pandemic to reflect the best available evidence for a novel virus. In Kazakhstan, the national clinical guidelines for COVID-19 patient care were regularly modified and it was not known if and to what extent these guidelines were being followed in practice.MethodsWe conducted a sub-analysis of data collected from an observational study among people hospitalized with COVID-19 in a large infectious disease hospital in Almaty in four cross-sections of increased COVID-19 incidence: T1 (1 June–30 August 2020); T2 (1 October–31 December 2020); T3 (1 April–31 May 2021); and T4 (1 July–26 October 2021). Modifications to the national COVID-19 treatment guidelines were identified and clinical data were abstracted from electronic medical records. We assessed frequency of antibiotic, glucocorticoid, anticoagulant, and antiviral administered in each period and determined if these aligned with national clinical guidelines. We used multivariable logistic regression to compare practices across periods.ResultsSix modifications were made to national COVID-19 treatment guidelines during this study. Of 1,146 people hospitalized with COVID-19, 14% were in T1, 14% in T2, 22% in T3, and 50% in T4. Anticoagulant treatment was administered to 87% (range: 56%–95%), antibiotic treatment to 60% (range: 58%–64%), glucocorticoid to 55% (range: 43%–64%) and antiviral therapy 15% (range: 7%–22%). Majority of treatments were not aligned with national guidelines, including 98% of anticoagulant use, 95% of antibiotic use, 56% of glucocorticoid use, and 56% of antiviral use. There were no significant changes in practice following changes in guidelines for antibiotic use (64% in T1 to 58% in T2, p  = 0.30). There was significant increase in use of anticoagulant (84% in T2 vs. 95% in T3, p  < 0.01), glucocorticoid (43% in T2 vs. 64% in T3, p  < 0.01), and antiviral treatment (7% in T3 vs. 15% in T4, p  < 0.01) after guidelines updates.ConclusionThe majority of treatments administered to people hospitalized with COVID-19 in four periods of high incidence in Almaty were not aligned with updated clinical guidelines. Antibiotic misuse was markedly high throughout. Increased awareness and training on clinical practice guidelines as updates are released may help improve adoption of evidence-based practices.

Introduction: We assessed the influence of a result-based financing (RBF) model, which included incentives for Primary Healthcare facilities on TB treatment outcomes. Methodology: We compared TB patients > 17 years and their treatment outcomes among those who did and did not benefit from RBF-model in 14 districts of Odeska oblast, Ukraine in 2017. Log-binomial regression was used to examine factors associated with being included in RBF-model. Results: Of 2,269 reported TB patients, 308 (14%) were included in RBF-model. Most patients in the RBF-model were from rural areas 229 (74%), unemployed 218 (71%), and HIV-infected 131 (43%). Individuals from urban areas (Adjusted risk ratio, ARR =0.9, 95% Confidence Interval, CI:0.89-0.94), having drug-resistant TB (ARR = 0.3, 95% CI: 0.18-0.45), and relapse TB (ARR = 0.6, 95% CI:0.40-0.83) were less likely to be included in RBF-model. Favorable outcomes in new/relapse cases with RBF-model was 89% compared with 41% (p < 0.001) without RBF. Similarly, for other retreatment this was 83% versus 40% (p < 0.001). Failures in the no-RBF group was 29% for new and relapse cases while for other retreatment cases, it was 26% (significantly higher than in the RBF-model). Conclusion: RBF-model is effective in achieving high levels of favorable TB treatment outcomes. Almost three-in-ten TB patients in non-RBF category failed TB treatment despite having drug-susceptible TB. Efforts are now needed to include it within ongoing public health reforms and assess the feasibility of scaling-up this intervention through implementation research and dedicated funding.

Introduction: Ukraine has gaps in Tuberculosis (TB) service coverage, especially in key populations (KPs). We compared effectiveness of three different strategies for active TB detection among KPs and their linkage to TB treatment during three time periods. Methodology: The KPs included people who inject drugs (PWID), sex workers (SW), men who have sex with men (MSM) and groups at-risk of TB (ex-prisoners, Roma and homeless). The active case finding included decentralized symptom screening and specimen collection (2014, strategy-1), decentralized screening with patient referred for specimen collection (2015-2017, strategy-2) and strategy-2 plus GeneXpert (2018, strategy-3). Results: In total 680,760 KPs were screened, of whom 68% were PWID. TB case detection per 100,000 populations was 1,191 in strategy-1, 302 in strategy-2, and 235 in strategy-3. The number needed to screen (NNS) to identify one case was respectively 84, 332, and 425. TB detection was highest among homeless (range: 1,839-2,297 per 100,000 population). The lowest detection was among the MSM and SW. Between 2014 and 2018, 82-94% of all diagnosed TB patients in KPs started TB treatment. Conclusions: The active case finding in KPs increased detection of TB cases in Ukraine, and the majority of diagnosed KPs initiated TB treatment. Centralization of diagnosis reduced the effectiveness of TB screening. Each region in Ukraine should assess the composition and the needs of KPs which will allow for adoption of specific strategies to detect TB among KPs with high TB prevalence.