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Clostridioides difficile sequence type (ST) 35 has been found in humans and animals worldwide. However, its genomic epidemiology and clonal transmission have not been explored in detail. In this study, 176 C. difficile ST35 isolates from six countries were sequenced. Genomic diversity, clonal transmission and epidemiological data were analyzed. Sporulation and virulence capacities were measured. Four ribotypes (RT) were identified including RT046 (97.2%), RT656 (1.1%), RT427 (0.6%), and RT AI-78 (1.1%). Phylogenetic analysis of 176 ST35 genomes, along with 50 publicly available genomes, revealed two distinctive lineages without time-, region-, or source-dependent distribution. However, the distribution of antimicrobial resistance genes differed significantly between the two lineages. Nosocomial and communal transmission occurred in humans with the isolates differed by ≤ two core-genome single-nucleotide polymorphism (cgSNPs) and clonal circulation was found in pigs with the isolates differed by ≤ four cgSNPs. Notably, interspecies clonal transmission was identified among three patients with community acquired C. difficile infection and pigs with epidemiological links, differed by ≤ nine cgSNPs. Toxin B (TcdB) concentrations were significantly higher in human isolates compared to pig isolates, and ST35 isolates exhibited stronger sporulation capacities than other STs. Our study provided new genomic insights and epidemiological evidence of C. difficile ST35 intraspecies and interspecies clonal transmission, which can also be facilitated by its strong sporulation capacity.

Abstract The spatial delays of pulmonary tuberculosis (PTB) have been less explored. In this study, a total of 151,799 notified PTB cases were included, with median patient and diagnostic delays of 15 [interquartile range (IOR), 4–35] and 2 (IOR, 0–8) days, respectively. The spatial autocorrelation analysis and spatial–temporal scan statistics were used to determine the clusters, indicating that the regions in the southwestern and northeastern parts of Zhejiang Province exhibited high rates of long-term patient delay (LPD, delay ≥ 15 days) and long-term diagnostic delay (LDD, delay ≥ 2 days). Besides, the Mantel test indicated a moderately positive correlation between public awareness of suspicious symptoms and the LPD rate in 2018 (Mantel's r = 0.4, P

BackgroundChina experienced a surge of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron variants after adjusting its zero-coronavirus disease 2019 (COVID-19) policy. Although infections with Omicron variants are generally less severe than infections with previous SARS-CoV-2 variants, the clinical characteristics, persistent symptoms, and antibody responses in solid carcinoma patients (SCPs) with COVID-19 during the Omicron wave are unclear.MethodsWe conducted a cross-sectional study in April 2023, recruiting healthy controls (HCs) from the community and SCPs from Zhejiang Provincial People’s Hospital. Serum samples were collected, and a questionnaire was used to assess SARS-CoV-2 infection status, including demographic characteristics, clinical manifestations, and “long COVID” symptoms. Humoral immune responses were analyzed by enzyme-linked immunosorbent assays (ELISAs) targeting immunoglobulin G (IgG) antibodies against the receptor-binding domain (RBD; Omicron BA.4/5) protein and cell culture-based neutralization assays against Omicron variants (BA.4/5, BF.7, XBB.1.5, and EG.5).ResultsIn total, 298 SCPs and 258 HCs were enrolled. Self-reported COVID-19 case rates were significantly lower in SCPs than in HCs (78.5% vs. 93.8%, P

ObjectiveTo understand and analyze the factors relating to patient and diagnostic delays among groups with tuberculous pleurisy (TP), and its spatiotemporal distribution in Zhejiang Province.MethodsData of all tuberculous pleurisy patients were collected from the existing Tuberculosis Information Management System. A time interval of > 2 weeks between first symptom onset and visit to the designated hospital was considered a patient delay, and a time interval of > 2 weeks between the first visit and a confirmed TP diagnosis was considered a diagnostic delay. Univariate and multivariate logistic regression analyses were used to explore factors influencing patient and diagnostic delays in patients with TP. Spatial autocorrelation and spatiotemporal scan analyses were used to identify hot spots and risk clusters, respectively.ResultsIn total, 10,044 patients with TP were included. The median time and interquartile range for patients seeking medical care and diagnosis were 15 (7–30) and 1 (0–8) days, respectively. The results showed that people aged > 65 years, retirees, and residents of Jinhua, Lishui, and Quzhou were positively correlated with patient delay, whereas retreatment patients, houseworkers, unemployed people, and residents of Zhoushan or Ningbo were positively correlated with diagnostic delay. Additionally, high-risk clusters of patient delays were observed in the midwestern Zhejiang Province. The most likely clusters of TP diagnostic delays were found in southeast Zhejiang Province.ConclusionIn summary, patient delay of TP in Zhejiang province was shorter than for pulmonary tuberculosis in China, while the diagnostic delay had no difference. Age, city, occupation, and treatment history were related to both patient and diagnostic delays in TP. Interventions in central and western regions of Zhejiang Province should be initiated to improve the early detection of TP. Additionally, the allocation of health resources and accessibility of health services should be improved in the central and eastern regions of Zhejiang Province.

Abstract BackgroundSevere fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease that was first identified in mainland China in 2009 and has been reported in Zhejiang Province, China, since 2011. However, few studies have focused on the association between ticks, host animals, and SFTS. ObjectiveIn this study, we analyzed the influence of meteorological and environmental factors as well as the influence of ticks and host animals on SFTS. This can serve as a foundational basis for the development of strategic policies aimed at the prevention and control of SFTS. MethodsData on SFTS incidence, tick density, cattle density, and meteorological and environmental factors were collected and analyzed using a maximum entropy–based model. ResultsAs of December 2019, 463 laboratory-confirmed SFTS cases were reported in Zhejiang Province. We found that the density of ticks, precipitation in the wettest month, average temperature, elevation, and the normalized difference vegetation index were significantly associated with SFTS spatial distribution. The niche model fitted accurately with good performance in predicting the potential risk areas of SFTS (the average test area under the receiver operating characteristic curve for the replicate runs was 0.803 and the SD was 0.013). The risk of SFTS occurrence increased with an increase in tick density, and the response curve indicated that the risk was greater than 0.5 when tick density exceeded 1.4. The risk of SFTS occurrence decreased with increased precipitation in the wettest month, and the risk was less than 0.5 when precipitation exceeded 224.4 mm. The relationship between elevation and SFTS occurrence showed a reverse V shape, and the risk peaked at approximately 400 m. ConclusionsTick density, precipitation, and elevation were dominant influencing factors for SFTS, and comprehensive intervention measures should be adjusted according to these factors to reduce SFTS incidence in Zhejiang Province.

The global pandemic of the coronavirus disease 2019 (COVID-19) has had a serious impact on global life safety and economic development. Vaccination with the coronavirus disease vaccine (COVID-19 vaccine) is an important measure to prevent infection, reduce the incidence and severity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Currently, there are six different technological routes for COVID-19 vaccines worldwide, including protein subunit vaccines, nucleic acid vaccines (mRNA vaccines and DNA vaccines), viral vector vaccines, inactivated vaccines, virus-like particle vaccines, and attenuated vaccines. Sequential immunization strategy is a valid approach for solving vaccine shortages, responding to viral variants, and improving vaccine efficacy by administering COVID-19 vaccines of different technological routes at specific time intervals and doses. Many scholars at home and abroad have conducted research on the sequential immunization strategy of COVID-19 vaccines. This article provided an overview of the research on the sequential immunization strategy of COVID-19 vaccines at home and abroad in five aspects: COVID-19 inactivated vaccine and mRNA vaccine, COVID-19 inactivated vaccine and adenovirus vector vaccine, COVID-19 inactivated vaccine and protein subunit vaccine, COVID-19 adenovirus vector vaccine and mRNA vaccine, COVID-19 adenovirus vector vaccine and protein subunit vaccine, aiming to provide reference for the inoculation and formulation of immunization strategies for COVID-19 vaccines.

The algorithm of the scanning t-test of regression slope-coefficients in two phases is introduced to detect trend change-points, along with a coherency analysis of changes between two time series. This new algorithm is different from the previously published scanning Fmax test of trend changes. Meanwhile, the fuzzy weighted moving average (FWMA) was employed to intuitively verify the results of segment regressions. Then, these algorithms were applied to two series of monthly temperature over mainland China and the globe for January 1901–December 2020. The applied results show that significant changes in segment trends may be classified into two gradations on interdecadal and intradecadal scales. The coherency of trend changes between the two series were mostly positive, with a few differences in the change dates. The global warming "hiatus" was detected as two processes on the intradecadel scale: a sharp droop-down from July 1998 to February 2000 following a short warming up; the second weaker droop-down happened from November 2003 to July 2009. Thus, it was featured on the interdecadel scale as the warming rate slowed down to be nearly stable from October 2002 to June 2009 in globally but without turning into cooling. Mainland China seemed to slow down weaker, but lasted longer than the globe. A somewhat unexpected finding is that the warming rate over Mainland China was lower than that for the globe in the case of standardized differences. This contradicts the previous conclusion that resulted from annual anomalies of temperature. It is suggested that the anomalies in the distribution N(0, s) might be referred to the "perceptual" index to compare variations in the same series or between two series but with the same variance and distribution, while referring to the standardized differences in N(0, 1) as a "net" indicator to compare fluctuations between two series with different variances, even in different distributions.

Abstract Objectives The public health system faces major challenges due to the double burden of diabetes mellitus (DM) and tuberculosis (TB) in China. We aimed to investigate the prevalence and impact of diabetes on patients with TB. Methods Stratified cluster sampling was used to select 13 counties as study sites in the Zhejiang province. Patients who visited designated TB hospitals in these areas participated in this study between 1 January 2017 and 28 February 2019. Multiple logistic regression models were performed to investigate the association between DM and bacteriological and imaging results. A decision tree was used to predict the bacteriology and imaging results under the influence of DM. Results Of 5920 patients with newly diagnosed pulmonary tuberculosis, 643 (12.16%) had DM. Patients with pulmonary TB and DM were more likely to have pulmonary cavities (adjusted odds ratio [aOR], 2.81; 95% confidence intervals [95% CI]: 2.35–3.37) and higher rates of positive bacteriological tests (aOR, 2.32; 95% CI:1.87–2.87). Decision‐tree analysis showed similar results. Conclusions Concurrence of DM and pulmonary TB makes patients more likely to have positive bacteriological results and pulmonary cavities. Therefore, appropriate measures are necessary to promptly identify and manage patients with TB and DM.

BackgroundLimited studies have explored the impact of the Omicron variant on SARS-CoV-2 infection, hospitalization, and associated factors among people living with HIV, particularly in China. The adjustment of preventive policies since December 2022 in China presents an opportunity to evaluate the real-world factors influencing SARS-CoV-2 infection and related hospitalization among people living with HIV. ObjectiveThis study aimed to investigate SARS-CoV-2 infection, hospitalization rates, and associated factors among people living with HIV following the adjustment of preventive policies from December 2022 to February 2023 in southeastern China. MethodsA cross-sectional telephone or web-based survey was conducted among people living with HIV in 5 cities in southeastern China from December 2022 to February 2023. Demographic information, SARS-CoV-2 infection and related hospitalization, and HIV-specific characteristics were collected from existing databases and special investigations. Multivariate logistic regression analyses were conducted to determine the associated factors for infection and hospitalization rates of SARS-CoV-2. Additionally, subgroup analyses were conducted for the association between vaccination and infection across different vaccination statuses and time since the last vaccination. ResultsAmong people living with HIV with a COVID-19 testing history, the SARS-CoV-2 infection rate was 67.13% (95% CI 65.81%-68.13%), whereas the hospitalization rate was 0.71% (95% CI 0.46%-0.97%). Factors such as age, latest CD4 cell count, latest HIV viral load, and transmission route were found to be associated with SARS-CoV-2 infection, while age, cancer, latest CD4 cell count, and latest HIV viral load were associated with SARS-CoV-2 hospitalization. In terms of SARS-CoV-2 vaccination, compared to unvaccinated people living with HIV, there was a lower infection rate among those who had been vaccinated for

Abstract Data on the safety and immunity of a heterologous booster (fourth dose) after three-doses of inactivated SARS-CoV-2 vaccine in Chinese adults are limited. We evaluate the safety and immunogenicity of Ad5-nCoV in a randomized, double-blind, parallel-controlled phase 4 clinical trial in Zhejiang, China (NCT05373030). Participants aged 18–80 years (100 per group), administered three doses of inactivated SARS-CoV-2 vaccine ≥6 months earlier, are enrolled and randomized 1:1 into two groups, which are administered intramuscular Ad5-nCoV or inactivated SARS-CoV-2 vaccine (CoronaVac or Covilo). All observed adverse reactions are predictable and manageable. Ad5-nCoV elicits significantly higher RBD-specific IgG levels, with a geometric mean concentration of 2924.0 on day 14 post-booster, 7.8-fold that of the inactivated vaccine. Pseudovirus-neutralizing antibodies to Omicron BA.4/5 show a similar pattern, with geometric mean titers of 228.9 in Ad5-nCoV group and 65.5 in inactivated vaccine group. Ad5-nCoV booster maintains high antibody levels on day 90, with seroconversion of 71.4%, while that of inactivated vaccine is 5.2%, almost pre-booster levels. A fourth Ad5-nCoV vaccination following three-doses of inactivated SARS-CoV-2 vaccine is immunogenic, tolerable, and more efficient than inactivated SARS-CoV-2 vaccine. Ad5-nCoV elicits a stronger humoral response against Omicron BA.4/5 and maintains antibody levels for longer than homologous boosting.

HIV drug resistance compromises the ability of anti-retroviral therapy (ART) to suppress viral replication, resulting in treatment failure. This study investigates the prevalence of pre-treatment drug resistance (PDR) in newly diagnosed individuals in a prosperous city (Wenzhou) in Southeastern China. A cross-sectional investigation was carried out among 473 newly diagnosed ART-naive HIV-1-infected individuals between January and December 2022. The protease–reverse transcriptase (PR-RT) region and integrase (IN) region of HIV-1 were amplified by two separately nested PCRs, followed by sequencing. Drug resistance mutations (DRMs) and drug resistance to nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs) and integrase strand transfer inhibitors (INSTIs) were analyzed. The PDR prevalence was 6.5% [95% CI: 4.4–9.1] for any anti-retroviral drug, 0.9% [95% CI: 0.3–2.3] for NRTIs, 4.1% [95% CI: 2.5–6.5] for NNRTIs, 1.8% [95% CI: 0.8–3.6] for PIs and 0.5% [95% CI: 0.1–1.8] for INSTIs. According to the subtyping results of the PR-RT region, 11 different subtypes and 31 unique recombinant forms (URFs) were found. CRF07_BC was the dominant subtype (53.7%, 233/434), followed by CRF01_AE (25.3%, 110/434). V179D (1.6%) and K103N (1.4%) were the most predominant types of NNRTI DRMs. Q58E (1.2%) and M184V (0.7%) were the most frequent PI DRMs and NRTI DRMs, respectively. The INSTI-related DRMs Y143S (causes high-level resistance to RAL) and G163K (causes low-level resistance to EVG and RAL) were found in one patient each. Given the relatively high PDR prevalence of NNRTI (4.1%), non-NNRTI-based ART may be preferred in the future. It is recommended to include genotypic resistance testing before starting ART in regions where feasible.

BackgroundIn recent years, the number and proportion of newly reported HIV/AIDS cases among older adults have increased dramatically. However, research on the pattern of temporal and spatial changes in newly reported HIV/AIDS among older adults remains limited. ObjectiveThis study analyzed the spatial and temporal distribution of HIV/AIDS cases and its influencing factors among older adults in Eastern China from 2004 to 2021, with the goal of improving HIV/AIDS prevention and intervention. MethodsWe extracted data on newly reported HIV/AIDS cases between 2004 and 2021 from a case-reporting system and used a Joinpoint regression model and an age-period-cohort model to analyze the temporal trends in HIV/AIDS prevalence. Spatial autocorrelation and geographically weighted regression models were used for spatial aggregation and influence factor analysis. ResultsA total of 12,376 participants with HIV/AIDS were included in the study. The newly reported HIV infections among older adults increased from 0.13 cases per 100,000 people in 2004 to 7.00 cases per 100,000 people in 2021. The average annual percent change in newly reported HIV infections was 28.0% (95% CI –21.6% to 34.8%). The results of the age-period-cohort model showed that age, period, and cohort factors affected the newly reported HIV infections among older adults. The newly reported HIV/AIDS cases among men who have sex with men (MSM) had spatial clustering, and the hotspots were mainly concentrated in Hangzhou. The disposable income of urban residents, illiteracy rate among people aged 15 years or older, and number of hospital beds per 1000 residents showed a positive association with the newly reported HIV infections among older MSM in the Zhejiang province. ConclusionsHIV/AIDS among older adults showed an increasing trend and was influenced by age, period, and cohort effects. Older MSM with HIV/AIDS showed regional clustering and was associated with factors such as the disposable income of urban residents, the illiteracy rate among people aged 15 years or older, and the number of hospital beds per 1000 people. Targeted prevention and control measures are needed to reduce HIV infection among those at higher risk.

BackgroundIn May–June 2023, an unprecedented outbreak of human respiratory syncytial virus (HRSV) infections occurred in a kindergarten, Zhejiang Province, China. National, provincial, and local public health officials investigated the cause of the outbreak and instituted actions to control its spread.MethodsWe interviewed patients with the respiratory symptoms by questionnaire. Respiratory samples were screened for six respiratory pathogens by real-time quantitative polymerase chain reaction (RT-PCR). The confirmed cases were further sequenced of G gene to confirm the HRSV genotype. A phylogenetic tree was reconstructed by maximum likelihood method.ResultsOf the 103 children in the kindergarten, 45 were classified as suspected cases, and 25 cases were confirmed by RT-PCR. All confirmed cases were identified from half of classes. 36% (9/25) were admitted to hospital, none died. The attack rate was 53.19%. The median ages of suspected and confirmed cases were 32.7 months and 35.8 months, respectively. Nine of 27 confirmed cases lived in one community. Only two-family clusters among 88 household contacts were HRSV positive. A total of 18 of the G gene were obtained from the confirmed cases. Phylogenetic analyses revealed that 16 of the sequences belonged to the HRSV B/BA9 genotype, and the other 2 sequences belonged to the HRSV A/ON1 genotype. The school were closed on June 9 and the outbreak ended on June 15.ConclusionThese findings suggest the need for an increased awareness of HRSV coinfections outbreak in the kindergarten, when HRSV resurges in the community after COVID-19 pandemic.

ABSTRACT Vibrio cholerae O1 has caused cholera pandemics. Non-pandemic V. cholerae O1 strains, which are genetically distinctive from the pandemic clones, have been isolated from both human infections and the environment. We aimed to better understand the non-pandemic O1 strains and their pandemic potential. We sequenced 109 non-pandemic O1 isolates from Zhejiang, China (from 1963 to 1996) and compared them with 62 publicly available non-pandemic O1 genomes. The isolates from Zhejiang can be classified into three lineages (L1–L3). All grouped together with L3 sharing the most recent common ancestor with the pandemic clones. L2 and L3 emerged in the 1960s while L1 emerged in the 1970s. L1 and L2 disappeared after the 1990s, but L3 persisted until recently. All isolates contained the type VI secretion system. The Vibrio pathogenicity island was present in all L3 isolates, whereas the type III secretion system was present in all L1 isolates. L2 did not carry any unique virulence genes. An intact CTXφ was present in only two L3 isolates. An intact Vibrio seventh pandemic island 1 was present in only three L3 isolates. The blaCARB-7 gene was identified in 96.3% of L2 isolates. Each of the non-pandemic O1 lineages has unique properties contributing to their capacity to cause disease. Our findings offer new insight into the evolution of O1 V. cholerae for cholera prevention and control. IMPORTANCE It is well recognized that only Vibrio cholerae O1 causes cholera pandemics. However, not all O1 strains cause pandemic-level disease. In this study, we analyzed non-pandemic O1 V. cholerae isolates from the 1960s to the 1990s from China and found that they fell into three lineages, one of which shared the most recent common ancestor with pandemic O1 strains. Each of these non-pandemic O1 lineages has unique properties that contribute to their capacity to cause cholera. The findings of this study enhanced our understanding of the emergence and evolution of both pandemic and non-pandemic O1 V. cholerae.

Abstract Background Men who have sex with men and women (MSMW) are the most important bridge population for HIV transmission. Condom use plays an important role for HIV infection. However the predictors for condom ues with females are not well characterized. Methods This was a cross-sectional study. Participants were enrolled by four community-based organizations (CBOs) by offline (bathrooms, bars), and online (gay applications, chat room) from April to December 2019. Electronic questionnare was fulfilled after a face-to-face training led by CBOs. We identified predictors of inconsistent condom use with females by creating a risk score based on regression coefficients. We externally validated this score via an independent cross-sectional survey conducted in Zhejiang Province in 2021. A total of 917, 615 MSMW were included in analysis in 2019 and 2021, seperately. Results Among 917 MSMW, 73.2% reported heterosexual behavior in the prior 6 months and 38.3% reported inconsistent condom use with females (ICUF) over that time. Compared with heterosexual/unsure MSMW, bisexual MSMW reported more male and female sex partners, higher proportion of inconsistent condom use with males, less commercial sex with males (p

BackgroundTuberculous pleurisy (TP) presents a serious allergic reaction in the pleura caused by Mycobacterium tuberculosis; however, few studies have described its spatial epidemiological characteristics in eastern China. ObjectiveThis study aimed to determine the epidemiological distribution of TP and predict its further development in Zhejiang Province. MethodsData on all notified cases of TP in Zhejiang Province, China, from 2017 to 2021 were collected from the existing tuberculosis information management system. Analyses, including spatial autocorrelation and spatial-temporal scan analysis, were performed to identify hot spots and clusters, respectively. The prediction of TP prevalence was performed using the seasonal autoregressive integrated moving average (SARIMA), Holt-Winters exponential smoothing, and Prophet models using R (The R Foundation) and Python (Python Software Foundation). ResultsThe average notification rate of TP in Zhejiang Province was 7.06 cases per 100,000 population, peaking in the summer. The male-to-female ratio was 2.18:1. In terms of geographical distribution, clusters of cases were observed in the western part of Zhejiang Province, including parts of Hangzhou, Quzhou, Jinhua, Lishui, Wenzhou, and Taizhou city. Spatial-temporal analysis identified 1 most likely cluster and 4 secondary clusters. The Holt-Winters model outperformed the SARIMA and Prophet models in predicting the trend in TP prevalence. ConclusionsThe western region of Zhejiang Province had the highest risk of TP. Comprehensive interventions, such as chest x-ray screening and symptom screening, should be reinforced to improve early identification. Additionally, a more systematic assessment of the prevalence trend of TP should include more predictors.

IntroductionChina experienced a record surge of coronavirus disease 2019 cases in December 2022, during the pandemic.MethodsWe conducted a randomized, parallel-controlled prospective cohort study to evaluate efficacy and antibody duration after a fourth-dose booster with Ad5-nCoV or inactivated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine.ResultsA total of 191 participants aged ≥18 years who had completed a three-dose regimen of the inactivated SARS-CoV-2 vaccine 6 months earlier were recruited to receive the intramuscular Ad5-nCoV booster or the inactivated SARS-CoV-2 vaccine. The Ad5-nCoV group had significantly higher antibody levels compared with the inactivated vaccine group at 6 months after the fourth vaccination dose. After the pandemic, the breakthrough infection rate for the Ad5-nCoV and the inactivated vaccine groups was 77.89% and 78.13%, respectively. Survival curve analysis (p = 0.872) and multivariable logistic regression analysis (p = 0.956) showed no statistically significant differences in breakthrough infection between the two groups.DiscussionCompared with a homologous fourth dose, a heterologous fourth dose of Ad5-nCoV elicited a higher immunogenic response in healthy adults who had been immunized with three doses of inactivated vaccine. Nevertheless, the efficacy of the two vaccine types was equivalent after the pandemic.

Cholera caused by Vibrio cholerae O139 was first reported in Bangladesh and India in 1992. To determine the genomic epidemiology and origins of O139 in China, we sequenced 104 O139 isolates collected from Zhejiang Province, China, during 1994–2018 and compared them with 57 O139 genomes from other countries in Asia. Most Zhejiang isolates fell into 3 clusters (C1–C3), which probably originated in India (C1) and Thailand (C2 and C3) during the early 1990s. Different clusters harbored different antimicrobial resistance genes and IncA/C plasmids. The integrative and conjugative elements carried by Zhejiang isolates were of a new type, differing from ICEVchInd4 and SXTMO10 by single-nucleotide polymorphisms and presence of genes. Quinolone resistance–conferring mutations S85L in parC and S83I in gyrA occurred in 71.2% of the Zhejiang isolates. The ctxB copy number differed among the 3 clusters. Our findings provided new insights for prevention and control of O139 cholera .

Background: Although inactivated COVID-19 vaccines are proven to be safe and effective in the general population, the dynamic response and duration of antibodies after vaccination in the real world should be further assessed. Methods: We enrolled 1067 volunteers who had been vaccinated with one or two doses of CoronaVac in Zhejiang Province, China. Another 90 healthy adults without previous vaccinations were recruited and vaccinated with three doses of CoronaVac, 28 days and 6 months apart. Serum samples were collected from multiple timepoints and analyzed for specific IgM/IgG and neutralizing antibodies (NAbs) for immunogenicity evaluation. Antibody responses to the Delta and Omicron variants were measured by pseudovirus-based neutralization tests. Results: Our results revealed that binding antibody IgM peaked 14–28 days after one dose of CoronaVac, while IgG and NAbs peaked approximately 1 month after the second dose then declined slightly over time. Antibody responses had waned by month 6 after vaccination and became undetectable in the majority of individuals at 12 months. Levels of NAbs to live SARS-CoV-2 were correlated with anti-SARS-CoV-2 IgG and NAbs to pseudovirus, but not IgM. Homologous booster around 6 months after primary vaccination activated anamnestic immunity and raised NAbs 25.5-fold. The neutralized fraction subsequently rose to 36.0% for Delta (p=0.03) and 4.3% for Omicron (p=0.004), and the response rate for Omicron rose from 7.9% (7/89)–17.8% (16/90). Conclusions: Two doses of CoronaVac vaccine resulted in limited protection over a short duration. The inactivated vaccine booster can reverse the decrease of antibody levels to prime strain, but it does not elicit potent neutralization against Omicron; therefore, the optimization of booster procedures is vital. Funding: Key Research and Development Program of Zhejiang Province; Key Program of Health Commission of Zhejiang Province/ Science Foundation of National Health Commission; Major Program of Zhejiang Municipal Natural Science Foundation; Explorer Program of Zhejiang Municipal Natural Science Foundation.

Abstract Background Internal migrants have an enormous impact on tuberculosis (TB) epidemic in China. Zhejiang Province, as one of the developed areas, also had a heavy burden caused by TB. Methods In this study, we collected all cases in Zhejiang Province through the TB Management Information System from 2013 to 2017. Description analysis and Spatio-temporal analysis using R software and ArcGIS were performed to identify the epidemiological characteristics and clusterings, respectively. Results 48,756 individuals in total were notified with TB among the migrant population (TBMP), accounting for one-third of all cases identified. The primary sources of TB from migrants outside the province were from Guizhou, Sichuan, and Anhui. Wenzhou, Taizhou, and Lishui were the three mainly outflowing cities among the intra-provincial TBMP and Hangzhou as the primarily inflowing city. Also, results implied that the inconsistency of the TBMP in spatial analysis and the border area of Quzhou and Lishui city had the highest risk of TB occurrence among the migrants. Additionally, one most likely cluster and four secondary clusters were identified by the spatial–temporal analysis. Conclusion The effective control of TB in extra-provincial MP was critical to lowering the TB burden of MP in Zhejiang Province. Also, it is suggested that active TB screening for migrant employees outflowed from high epidemic regions should be strengthened, and further traceability analysis needs to be investigated to clarify the mechanism of TB transmission in clustered areas.

BackgroundPulmonary tuberculosis (PTB) is a serious chronic communicable disease that causes a significant disease burden in China; however, few studies have described its spatial epidemiological features in students.MethodsData of all notified PTB cases from 2007 to 2020 in the student population were collected in the Zhejiang Province, China using the available TB Management Information System. Analyses including time trend, spatial autocorrelation, and spatial–temporal analysis were performed to identify temporal trends, hotspots, and clustering, respectively.ResultsA total of 17,500 PTB cases were identified among students in the Zhejiang Province during the study period, accounting for 3.75% of all notified PTB cases. The health-seeking delay rate was 45.32%. There was a decreasing trend in PTB notifications throughout the period; clustering of cases was seen in the western area of Zhejiang Province. Additionally, one most likely cluster along with three secondary clusters were identified by spatial–temporal analysis.ConclusionAlthough was a downward trend in PTB notifications among students during the time period, an upward trend was seen in bacteriologically confirmed cases since 2017. The risk of PTB was higher among senior high school and above than of junior high school. The western area of Zhejiang Province was the highest PTB risk settings for students, and more comprehensive interventions should be strengthened such as admission screening and routine health monitoring to improve early identification of PTB.

Healthcare workers (HCWs) are at a high risk for latent tuberculosis infection (LTBI) because of occupational exposure, and the attitudes and behaviors of frontline tuberculosis (TB)-related HCWs toward preventive treatment of LTBI in eastern China remain unknown. This study aimed to explore the attitudes and actual behaviors of TB-related HCWs toward TB preventive treatment (TPT) and to analyze the relevant factors influencing the attitudes of HCWs. A stratified random sample of 28 TB-designated hospitals was selected in Zhejiang Province, China. All TB-related HCWs in the selected hospitals were recruited to answer questionnaires and were tested for LTBI by the TB interferon gamma release assay. TPT use was assessed two years after the survey. Univariate analysis and binary logistic regression models were used to analyze the factors influencing the TPT intention of HCWs. A total of 318 TB-related HCWs were recruited from 28 TB-designated hospitals; 62.3% of them showed positive attitudes toward TPT, while the rest were reluctant to treat positive LTBI prophylactically. binary logistic regression analysis revealed that the factors influencing the attitudes of HCWs were mainly education level, household income, history of alcohol consumption, and workplace. The IGRA test found that 35.2% (112/318) of HCWs tested positive for LTBI. Most people refused treatment because of drug side effects, followed by the belief that treatment was ineffective, wanting to wait until the onset of the disease, and that it was too much trouble to take the medication. According to the results of a follow-up survey, only one of these HCWs underwent TPT, and the consistency rate of attitudes and behaviors was 36.6% (41/112). This study reveals different attitudes toward TPT among TB-associated HCWs in eastern China and a large gap between attitudes and actual action. The management of HCWs with LTBI still needs further strengthening.

Abstract Background There could be various stakeholders who influencing multidrug-resistant tuberculosis (MDR-TB) policy development and implementation, yet their attributes and roles remain unclear in practice. This study aimed to identify key stakeholders in the process of policy-making for MDR-TB control and prevention and to analyse the attributes and relationships of the stakeholders, providing evidence for further policy research on MDR-TB control. Methods This study was conducted from October 2018 to March 2019 and applied the stakeholder analysis guidelines and domestic stakeholder analysis. An initial candidate stakeholder list was developed by policy scanning. Ten experts were invited to identify these candidate stakeholders. The major attribute of these stakeholders were analysed using the Michell scoring method. Based on these results, the intertwined relationships among groups of stakeholders were analysed and mapped through a systematic scan of the policy and literature on MDR-TB control, as well as information obtained from the interviews. Results A list of 21 types of candidate stakeholders was developed after a literature review and policy scanning, of which 11 received 100% approval. After expert evaluation and identification (the total expert authority was 0.80), 19 categories of stakeholders were approved and included in the stakeholder analysis. We categorized all of the stakeholders into three groups: (i) definitive stakeholders who are mainly involved in administrative departments and the Provincial Center for Disease Control and Prevention (CDC); (ii) expectant stakeholders who are mainly involved with MDR-TB patients, clinical departments of TB hospitals at different levels, community health care facilities, prefectural CDC and charity organizations; and (iii) latent stakeholders who mainly involved family members and neighbours of MDR-TB patients and TB related products manufacturers. Government departments and higher-level CDCs have strong decision-making power in developing MDR-TB control policies whereas the recommendations from service providers and the concerns of patients should be considered. Conclusions The MDR-TB prevention system was a multistakeholder cooperation system that was mainly led by government stakeholders. Enhancing communications with front-line service providers and patients on their unmet needs and evidence-based suggestions would highly benefit policy-making of MDR-TB prevention and control. Graphical abstract

Dengue imposes a heavy economic burden on families and society. We used surveillance data reported in 2019 to characterize the dengue epidemic in Zhejiang Province, China, which provided guidance for dengue prevention and control. Dengue epidemics mostly occurred in July to October. People aged 30–44 years, males, and commercial service workers were more likely to suffer from dengue. The epidemic areas were mainly in Hangzhou and Wenzhou. Meanwhile, we assessed the economic cost of dengue in the province from both family and organizational perspectives. The direct economic burden of dengue patients was estimated to be USD 405,038.25, and the indirect economic burden was USD 140,364.90, for a total economic burden of USD 543,213.00. The direct economic burden of dengue patients should be reduced by increasing the coverage and reimbursement of health insurance. Additionally, the total annual cost of dengue prevention and control for the government and organizational sectors was estimated to be USD 7075,654.83. Quantifying the dengue burden is critical for developing disease control strategies, allocating public health resources, and setting health policy priorities.

Background: Bedaquiline (BDQ) has been designated as a Group A drug by the World Health Organization (WHO) for the management of multi-drug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). This systematic review and meta-analysis aim to evaluate the efficacy and safety of BDQ-containing regimens for the treatment of patients with pulmonary TB. Methods: PubMed (MEDLINE), Elton B. Stephens Company (EBSCO) database, the Cochrane Register of Controlled Trials, and the China National Knowledge Infrastructure (CNKI) database were initially searched on 15 June 2022 and again on 20 March 2023. We included randomized controlled trials (RCTs) and non-randomized studies (NRSs) that administered BDQ to TB patients. The outcomes of interest were as follows: (1) efficacy, including the rate of sputum culture conversion at 8 weeks, 24 weeks, and during follow-up, as well as the rates of completion cure, death, treatment failure, and loss at follow-up and at the end of the treatment; and (2) safety, which encompassed the incidences of cardiotoxicity, hepatotoxicity, and grade 3–5 adverse events during the treatment period. Results: A total of 29 articles were included in this meta-analysis, representing 23,358 individuals. Patients who were treated with BDQ were compared with patients who were not exposed to BDQ. The use of BDQ-containing regimens demonstrated improved rates of sputum conversion in RCTs at 24 weeks (RR = 1.27, 95% CI: 1.10 to 1.46) and during follow-up (RR = 1.33, 95% CI: 1.06 to 1.66). Additionally, BDQ-containing regimens showed increased cure rates (RR = 1.60, 95% CI: 1.13 to 2.26) and decreased failure rates (RR = 0.56, 95% CI: 0.56 to 0.88). In NRSs, BDQ-containing regimens improved the sputum culture conversion rate during follow-up (RR = 1.53, 95% CI: 1.07 to 2.20), increased the rate of cure (RR = 1.86, 95% CI: 1.23 to 2.83), reduced deaths from all causes (RR = 0.68, 95% CI: 0.48 to 0.97), and reduced failure rates (RR = 0.57, 95% CI: 0.46 to 0.71). However, the use of BDQ-containing regimens was associated with increased incidences of cardiotoxicity (RR = 4.54, 95% CI: 1.74 to 11.87) and grade 3–5 adverse events (RR = 1.42, 95% CI: 1.17 to 1.73) in RCTs. NRSs also showed an association between BDQ-containing regimens and cardiotoxicity (RR = 6.00, 95% CI: 1.32 to 27.19). No significant differences were observed between intervention groups and control groups with respect to other outcomes. Conclusions: Data from both RCTs and NRSs support the efficacy of BDQ for the treatment of pulmonary tuberculosis. However, the use of BDQ is associated with a higher incidence of cardiotoxicity and serious adverse events. Comparative data on efficacy and safety are limited, and further confirmation is required, due to potential bias and discrepancies in the available studies.

Abstract Background The upsurge in HIV infections among students is a matter of particular concern. However, few studies have explored the epidemiological characteristics including the risky sexual networking of HIV-infected students in Zhejiang province, China. Methods Using the provincial surveillance data of HIV-infected students, we conducted a retrospective epidemiology study to describe the epidemiological characteristics of 628 newly diagnosed cases from 2011 to 2016 and detailed information of 124 cases from 2015 to 2016. Spatial analyses were conducted using ArcGIS software, and statistical analyses were performed using SPSS software. Results A total of 628 cases of HIV/AIDS were diagnosed among students in Zhejiang Province, China between 2011 and 2016. The cases showed an overall increasing trend over time, while the proportions of students with HIV disease status, cases diagnosed by HIV voluntary counseling and testing (VCT), and cases of homosexual transmission remained stable over time. Significant spatial heterogeneity in the cases was seen at the county level. Detailed data on 124 HIV-positive individuals collected from the local Center for Disease Control and Prevention (CDC) from 2015 and 2016, showed that the majority of them (85.5%,) engaged in homosexual behavior, and 93.4% had sex with casual partners. These partners included not only social members, but also other students. Online dating applications represented the most common means of seeking and communicating with homosexual partners. The level of awareness regarding the risk of HIV infection, and the amount coverage of face-to-face education towards students were both low. Conclusions HIV infections among students were characterized by increasing trend and spatial clustering in Zhejiang Province between 2011 and 2016, with homosexual sexual activity being the main mode of infection. Interventions are urgently required to prevent HIV infection in this population by increasing awareness of the disease. HIV testing programs and information regarding disease prevention specifically through online dating applications are needed.

BackgroundOwing to the coronavirus disease 2019 (COVID-19) pandemic and the emergency use of different types of COVID-19 vaccines, there is an urgent need to consider the effectiveness and persistence of different COVID-19 vaccines.MethodsWe investigated the immunogenicity of CoronaVac and Covilo, two inactivated vaccines against COVID-19 that each contain inactivated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The levels of neutralizing antibodies to live SARS-CoV-2 and the inhibition rates of neutralizing antibodies to pseudovirus, as well as the immunoglobulin (Ig)G and IgM responses towards the spike (S) and nucleocapsid (N) protein of SARS-CoV-2 at 180 days after two-dose vaccination were detected.ResultsThe CoronaVac and Covilo vaccines induced similar antibody responses. Regarding neutralizing antibodies to live SARS-CoV-2, 77.9% of the CoronaVac vaccine recipients and 78.3% of the Covilo vaccine recipients (aged 18–59 years) seroconverted by 28 days after the second vaccine dose. Regarding SARS-CoV-2-specific antibodies, 97.1% of the CoronaVac vaccine recipients and 95.7% of the Covilo vaccine recipients seroconverted by 28 days after the second vaccine dose. The inhibition rates of neutralizing antibody against a pseudovirus of the SARS-CoV-2 Delta variant were significantly lower compared with those against a pseudovirus of wildtype SARS-CoV-2. Associated with participant characteristics and antibody levels, persons in the older age group and with basic disease, especially a chronic respiratory disease, tended to have lower anti-SARS-CoV-2 antibody seroconversion rates.ConclusionAntibodies that were elicited by these two inactivated COVID-19 vaccines appeared to wane following their peak after the second vaccine dose, but they persisted at detectable levels through 6 months after the second vaccine dose, and the effectiveness of these antibodies against the Delta variant of SARS-CoV-2 was lower than their effectiveness against wildtype SARS-CoV-2, which suggests that attention must be paid to the protective effectiveness, and its persistence, of COVID-19 vaccines on SARS-CoV-2 variants.

Clostridioides difficile sequence type (ST) 37 (ribotype 017) is one of the most prevalent genotypes circulating in China. However, its genomic evolution and virulence determinants were rarely explored. Whole-genome sequencing, phylogeographic and phylogenetic analyses were conducted for C. difficile ST37 isolates. The 325 ST37 genomes from six continents, including North America (n = 66), South America (n = 4), Oceania (n = 7), Africa (n = 9), Europe (n = 138) and Asia (n = 101), were clustered into six major lineages, with region-dependent distributions, harbouring an array of antibiotic-resistance genes. The ST37 strains from China were divided into four distinct sublineages, showing five importation times and international sources. Isolates associated with severe infections exhibited significantly higher toxin productions, tcdB mRNA levels, and sporulation capacities (P

Abstract Background Clostridium difficile infection (CDI) has an increasing pediatric prevalence worldwide. However, molecular characteristics of C. difficile in Chinese children with acute gastroenteritis have not been reported. Methods A five-year cross-sectional study was conducted in a tertiary children’s hospital in Zhejiang. Consecutive stool specimens from outpatient children with acute gastroenteritis were cultured for C. difficile, and isolates then were analyzed for toxin genes, multi-locus sequence type and antimicrobial resistance. Diarrhea-related viruses were detected, and demographic data were collected. Results A total of 115 CDI cases (14.3%), and 69 co-infected cases with both viruses and toxigenic C. difficile, were found in the 804 stool samples. The 186 C. difficile isolates included 6 of toxin A-positive/toxin B-positive/binary toxin-positive (A+B+CDT+), 139 of A+B+CDT−, 3 of A−B+CDT+, 36 of A−B+CDT− and 2 of A−B−CDT−. Sequence types 26 (17.7%), 35 (11.3%), 39 (12.4%), 54 (16.7%), and 152 (11.3%) were major genotypes with significant differences among different antimicrobial resistances (Fisher's exact test, P

IntroductionSevere fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease, and the number of cases has increased in recent years in Zhejiang Province, China. However, whether the seasonal distribution, geographic distribution, and demographic characteristics of SFTS have changed with the increase of incidence was unclear.Materials and MethodsData on SFTS cases in Zhejiang Province and tick density in Daishan County from 2011 to 2019 were collected. The changing epidemiological characteristics of SFTS including seasonal distribution, geographical distribution, and demographic features were analyzed using descriptive statistical methods, Global Moran's I, local Getis-Ord Gi* statistic, and spatial scan statistic.ResultsA total of 463 SFTS cases including 53 (11.45%) deaths were reported from 2011 to 2019 in Zhejiang Province, and the annual number of cases showed increasing tendency. SFTS cases were reported in almost half of the counties (40/89) of Zhejiang Province. Elderly farmers accounted for most cases and the proportion of farmers has increased. Most cases (81.21%) occurred during April and August. The interval from illness onset to confirmation was significantly shortened (Z = 5.194, p < 0.001). The majority of cases were reported in Zhoushan City from 2011 to 2016, but most cases were reported in Taizhou City since 2017.DiscussionWe observed dynamic changes in the seasonal distribution, geographical distribution, and demographic features of SFTS, and comprehensive intervention measures, such as clearance of breeding sites, killing of tick adults, and health education should be strengthened in farmers of the key areas according to the changed epidemiological characteristics.

To evaluate China's current rifampin-resistant tuberculosis (RR-TB) screening strategy from stakeholders' perspectives, the perceptions, attitudes, and interests of 245 stakeholders from three eastern, central, and western China provinces on RR-TB screening strategies, were investigated through stakeholder survey and interview. The attitudes toward three RR-TB screening strategies were statistically different: inclination to choose who to screen (Z = 98.477; P < 0.001), funding for rapid diagnostic technology screening either by reimbursed health insurance or directly subsidized financial assistance (Z = 4.142, P < 0.001), and respondents' attitude during RR-TB screening implementation levels (Z = 2.380, P = 0.017). In conclusion, RR-TB screening scope could be expanded by applying rapid diagnostic technologies. Provinces with different economic status could adjust their screening policies accordingly.

Objectives To characterise low-tier female sex workers (FSWs) who engage in commercial sex with old male clients (OMCs).Design Cross-sectional study.Setting Twenty-one counties in Zhejiang province, China.Participants A total of 2647 low-tier FSWs who participated in our survey from September to November 2013, and responded to the question regarding whether they engaged in commercial sex with OMCs during the previous month.Main outcome measures Data on sociodemographic characteristics, sexual behaviours, risk perception of HIV/sexually transmitted infection (STI), ever exposure to an HIV prevention service and degree of self-efficacy regarding condom use were collected via a face-to-face questionnaire administered by trained interviewers.Results Of the 2647 participants, 1165 (44.0%) had engaged in commercial sex with OMCs in the previous month. Low-tier FSWs working out of roadside shops, those who had engaged in sex work for longer, those with a larger number of clients, those who had engaged in anal or oral sex during the previous month, those currently using contraception measures, those who had STI symptoms and those who had been exposed to HIV prevention services during the previous 6 months were more likely to engage in commercial sex with OMCs. FSWs with a high level of education; those working out of small venues other than streets, hair salons and roadside shops; those who charged more for commercial sex; those who had sex with young clients during the previous month and those who had seen a doctor during the previous 6 months were less likely to engage in commercial sex with OMCs.Conclusions Low-tier FSWs who engaged in commercial sex with OMCs reported more risky behaviours than those who did not engage in this behaviour. Attention should be paid to these behaviours in future interventions targeting low-tier FSWs.

Abstract Background As a physiological signal, EEG data cannot be subjectively changed or hidden. Compared with other physiological signals, EEG signals are directly related to human cortical activities with excellent temporal resolution. After the rapid development of machine learning and artificial intelligence, the analysis and calculation of EEGs has made great progress, leading to a significant boost in performances for content understanding and pattern recognition of brain activities across the areas of both neural science and computer vision. While such an enormous advance has attracted wide range of interests among relevant research communities, EEG-based classification of brain activities evoked by images still demands efforts for further improvement with respect to its accuracy, generalization, and interpretation, yet some characters of human brains have been relatively unexplored. Methods We propose a region-level stacked bi-directional deep learning framework for EEG-based image classification. Inspired by the hemispheric lateralization of human brains, we propose to extract additional information at regional level to strengthen and emphasize the differences between two hemispheres. The stacked bi-directional long short-term memories are used to capture the dynamic correlations hidden from both the past and the future to the current state in EEG sequences. Results Extensive experiments are carried out and our results demonstrate the effectiveness of our proposed framework. Compared with the existing state-of-the-arts, our framework achieves outstanding performances in EEG-based classification of brain activities evoked by images. In addition, we find that the signals of Gamma band are not only useful for achieving good performances for EEG-based image classification, but also play a significant role in capturing relationships between the neural activations and the specific emotional states. Conclusions Our proposed framework provides an improved solution for the problem that, given an image used to stimulate brain activities, we should be able to identify which class the stimuli image comes from by analyzing the EEG signals. The region-level information is extracted to preserve and emphasize the hemispheric lateralization for neural functions or cognitive processes of human brains. Further, stacked bi-directional LSTMs are used to capture the dynamic correlations hidden in EEG data. Extensive experiments on standard EEG-based image classification dataset validate that our framework outperforms the existing state-of-the-arts under various contexts and experimental setups.

Background: Tuberculosis (TB) is a critical global public threat, and limited epidemiology studies have been performed to explore the efficacy of active TB screening. Methods: Three sites located in eastern China were chosen in 2013, and three rounds of systematic screenings were performed in permanent residents aged older than 15 years. Results: The TB incidence showed a downtrend after several rounds of active screening at the three sites, and a significant change was observed at site A in the overall population. In the target population at sites A and B, both the elderly and people with a history of TB had a remarkable decline through the first or second round of screening. The implementation of active case-finding identified 2.36 [1.47,3.81] (2013 vs. 2012) and 1.49 [1.1,2.03] (2013–2015 vs. 2010–2012) more potential cases than the passive case-finding by the surveillance system at site A. Conclusions: Active case-finding of tuberculosis might be effective in high prevalence area with a low economic level, particularly among the elderly and people with a history of TB. Additionally, new rapid diagnosis technology should be considered to decrease the prevalence among people with a history of TB. Ultimately, active screening identified more active TB cases than passive case-finding, particularly in high prevalence area with underdeveloped economics. Keywords: Tuberculosis, Active screening, High prevalence, Target population

Abstract Background In recent years, tuberculosis outbreaks in schools have occurred more frequently in China than in other parts of the world, and have posed a public health threat to students and their families. This systematic review aimed to understand the epidemiological characteristics of tuberculosis (TB) outbreaks and analyze the factors associated with TB outbreaks in schools in China. Methods We conducted this systematic review following the standard procedures of the Cochrane Collaboration and the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. The meta-analysis was performed with STATA using a random effects model. Results We included 107 studies involving 1795 student patients with TB in mainland China. The results of the systematic analysis indicated that TB outbreaks were more frequently reported in senior middle schools and in Eastern China. The outbreaks mainly occurred during the winter and spring, and the median outbreak duration was 4 months. The meta-analysis showed that the total attack rate and the class attack rate of tuberculosis outbreaks among students were 4.60% (95% CI 3.80 to 5.70%) and 22.70% (95% CI 19.20 to 27.00%), respectively. Subgroup analysis showed that outbreaks that occurred at universities or colleges had a relatively higher attack rate than those occurred in senior middle schools. The prevalence of latent tuberculosis infection (LTBI) among close contacts was 23.70% (95% CI 19.50 to 28.90%). The median case-finding interval was 2 months, and 47.40% of the index cases had a case-finding delay. Conclusion The results of our review indicated that school TB outbreaks were reported most frequently in senior middle schools in China. The attack rates of outbreaks at universities or colleges were higher than those in senior middle schools. The TB outbreaks in schools usually occurred over prolonged periods. The case-finding delay in the index cases must be reduced to prevent transmission in classes and schools. Effective surveillance and screening of presumptive TB cases in schools should be strengthened to reduce outbreaks in schools.

The clinical application of doxorubicin (DOX) in cancer chemotherapy is limited by its life-threatening cardiotoxic effects. Chrysophanol (CHR), an anthraquinone compound isolated from the rhizome of Rheum palmatum L., is considered to play a broad role in a variety of biological processes. However, the effects of CHR׳s cardioprotection in DOX-induced cardiomyopathy is poorly understood. In this study, we found that the cardiac apoptosis, mitochondrial injury and cellular PARylation levels were significantly increased in H9C2 cells treated by Dox, while these effects were suppressed by CHR. Similar results were observed when PARP1 activity was suppressed by its inhibitors 3-aminobenzamide (3AB) and ABT888. Ectopic expression of PARP1 effectively blocked this CHR׳s cardioprotection against DOX-induced cardiomyocyte injury in H9C2 cells. Furthermore, pre-administration with both CHR and 3AB relieved DOX-induced cardiac apoptosis, mitochondrial impairment and heart dysfunction in Sprague–Dawley rat model. These results revealed that CHR protects against DOX-induced cardiotoxicity by suppressing cellular PARylation and provided critical evidence that PARylation may be a novel target for DOX-induced cardiomyopathy. KEY WORDS: Chrysophanol, Doxorubicin, PARylation, Cardiotoxicity, Apoptosis, Mitochondria

To analyze the results of HIV screening and the HIV-positive rate based on different HIV detection strategies in Zhejiang Province, China. Data were downloaded from the AIDS Prevention and Control Information System on May 1, 2019. HIV screening, prevalence, and incidence data were analyzed from 2008 to 2018. The incidence of HIV was calculated from the results of BED testing. SPSS software (ver. 19.0) was used for the analysis. The number of people screened for HIV increased by 229.7% from 2008 to 2018, while the incidence of HIV increased from 1.14‱ (2010) to 1.67‱ (2018), peak by 2015 (2.28‱). The proportion of people screened for HIV in medical institutions increased from 62.0% in 2008 to 67.1% in 2018, while of all positive tests, 47.9% were conducted at medical institutions in 2008, which increased to 63.2% in 2018. VCT and STD clinic attendees, who had only 4.5% of all those undergoing HIV tests, accounted for 23.7% of all HIV positive in 2018. The rate of HIV-positive people and incidence of HIV both increased in Zhejiang Province between 2008 and 2015. The most effective strategy for detecting HIV new cases is screening visitors to VCT and STD clinics.

Abstract Video data are usually represented by high dimensional features. The performance of video semantic recognition, however, may be deteriorated due to the irrelevant and redundant components included into the high dimensional representations. To improve the performance of video semantic recognition, we propose a new feature selection framework in this paper and validate it through applications of video semantic recognition. Two issues are considered in our framework. First, while those labeled videos are precious, their relevant labeled images are abundant and available in the WEB. Therefore, a supervised transfer learning is proposed to achieve the cross-media analysis, in which the discriminative features are selected by evaluating feature’s correlation with the classes of videos and relevant images. Second, the labeled videos are normally rare in real-world applications. In our framework, therefore, an unsupervised subspace learning is added to retain the most valuable information and eliminate the feature redundancies by leveraging both labeled and unlabeled videos. The cross-media analysis and embedded learning are simultaneously learned in a joint framework, which enables our algorithm to utilize the common knowledge of cross-media analysis and embedded learning as supplementary information to facilitate decision making. An efficient iterative algorithm is proposed to optimize the proposed learning-based feature selection, in which convergence is guaranteed. Experiments on different databases have demonstrated the effectiveness of the proposed algorithm.

Objectives: Healthcare workers (HCWs) are at high risk of latent tuberculosis infection (LTBI), and the baseline prevalence of LTBI among frontline TB HCWs in southeastern China remains unknown. The aim of this study was to assess the prevalence of LTBI among TB HCWs and to analyze factors associated with LTBI at both the individual and institutional level. Methods: Based on a cross-sectional study design, 31 out of 89 TB-designated hospitals in Zhejiang Province of China were selected. Information on TB infection control measures was collected through field visits to each of the selected hospitals. All TB HCWs from the selected hospitals were recruited to answer a questionnaire and to undergo LTBI testing by TB interferon gamma release assay. Univariate analyses and a generalized linear mixed model were applied to analyze factors associated with LTBI at both the individual and hospital level. Results: A total of 487 TB HCWs were recruited at the 31 TB-designated hospitals; 33.9% of them tested positive for LTBI. At the institutional level, a low TB epidemic level, regular infection control training for HCWs, and regular maintenance of ultraviolet disinfection equipment were found to be significantly associated with a lower LTBI rate among HCWs. At the individual level, alcohol use, a greater number of years working on TB, and a longer weekly duration of contact with TB patients were identified as associated factors for LTBI among HCWs. Conclusions: The LTBI rate among frontline TB HCWs was found to be high in southeastern China. Factors at the institutional and individual level could both affect the prevalence of LTBI among HCWs. Keywords: Tuberculosis, Latent tuberculosis infection, Healthcare workers

In general, existing research on single image super-resolution does not consider the practical application that, when image transmission is over noisy channels, the effect of any possible geometric transformations could incur significant quality loss and distortions. To address this problem, we present a new and robust super-resolution method in this paper, where a robust spatially-transformed deep learning framework is established to simultaneously perform both the geometric transformation and the single image super-resolution. The proposed seamlessly integrates deep residual learning based spatial transform module with a very deep super-resolution module to achieve a robust and improved single image super-resolution. In comparison with the existing state of the arts, our proposed robust single image super-resolution has a number of novel features, including 1) content-characterized deep features are extracted out of the input LR images to identify the incurred geometric transformations, and hence transformation parameters can be optimized to influence and control the super-resolution process; 2) the effects of any geometric transformations can be automatically corrected at the output without compromise on the quality of final super-resolved images; and 3) compared with the existing research reported in the literature, our proposed achieves the advantage that HR images can be recovered from those down-sampled LR images corrupted by a number of different geometric transformations. The extensive experiments, measured by both the peak-signal-to-noise-ratio and the similar structure index measurement, show that our proposed method achieves a high level of robustness against a number of geometric transformations, including scaling, translations, and rotations. Benchmarked by the existing state-of-the-arts SR methods, our proposed delivers superior performances on a wide range of datasets which are publicly available and widely adopted across relevant research communities.

Capturing RGB images and estimating their corresponding depth data for training deep models is a challenging task. Several deep network models have been recently reported to formulate the depth estimation process as an image reconstruction problem, in order to overcome the difficulty of scarcity of ground truth depth. These deep network models have multiple design decisions and parameters that are selected empirically, failing to capture the varying nature of the input and hence the adaptability is limited. In this paper, we propose an automatically Gaussian weighted deep model to achieve improved solutions for the problem of monocular depth estimation. In comparison with the existing state of the arts, our proposed very deep model is supported by novel components, including a hybrid and integrated loss function and a fine training strategy. The hybrid and integrated loss function maintains the balance between appropriate assessments of perceptual similarity and modest resilience for both small and large scale errors, where different loss terms are automatically weighted and hence their integration is optimized via a Gaussian distribution based modelling. The fine training strategy is proposed to adaptively screen all the training images via an error clustering mechanism to sustain an effective and efficient training process. Extensive experiments are carried out and the results show that our proposed outperforms the compared seven benchmarks, representative of the existing state of the arts, across all the assessment metrics.

Attention is a fundamental attribute of human visual system that plays important roles in many visual perception tasks. The key issue of video saliency lies in how to efficiently exploit the temporal information. Instead of singling out the temporal saliency maps, we propose a real-time end-to-end video saliency prediction model via 3D residual convolutional neural network (3D-ResNet), which incorporates the prediction of spatial and temporal saliency maps into one single process. In particular, a multi-scale feature representation scheme is employed to further boost the model performance. Besides, a frame skipping strategy is proposed for speeding up the saliency map inference process. Moreover, a new challenging eye tracking database with 220 video clips is established to facilitate the research of video saliency prediction. Extensive experimental results show our model outperforms the state-of-the-art methods over the eye fixation datasets in terms of both prediction accuracy and inference speed.

Video super-resolution aims to increase the resolution of videos by exploiting the intra-frame and inter-frame dependencies of the low-resolution video sequences. There are usually two dependent steps in the video super-resolution: the motion compensation and the super-resolution reconstruction. In this paper, we propose a new deep learning framework without the explicit motion estimation by utilizing the self-attention model to exploit the full receptive field of the input video frames. In other words, the proposed deep neural network extracts the local features at all spatial-temporal locations for combining into global features using the self-attention networks in order to reconstruct the high-resolution video frame. The proposed global-aware network outperforms the state-of-the-art deep learning-based image and video super-resolution algorithms in terms of subjective and objective quality with less computational operations, as verified by extensive experiments on public image and video datasets, including Set5, Set14, B100, Urban100, and Vid4.

A Petri net based framework is proposed for automatic high level video event description, recognition and reasoning purposes. In comparison with the existing approaches reported in the literature, our work is characterized with a number of novel features: (i) the high level video event modeling and recognition based on Petri net are fully automatic, which are not only capable of covering single video events but also multiple ones without limit; (ii) more variations of event paths can be found and modeled using the proposed algorithms; (iii) the recognition results are more accurate based on automatic built high level event models. Experimental results show that the proposed method outperforms the existing benchmark in terms of recognition precision and recall. Additional advantages can be achieved such that hidden variations of events hardly identified by humans can also be recognized.

Panoramic video with its flawless immersive tele-presence is considered to be the near-future video format of choice since they carry 360 degree coverage of the designated scenes. However, the viewers may focus their specific attention on perfectly lip-synchronized video as part of the panoramic video scene, hence only have a peripheral vision of the remaining parts of a frame. Therefore, it is intuitive to allocate stronger protection to the panoramic video region of interest. As a solution, we propose Region of Interest Aware Unequal Error Protection (ROI-UEP) for wireless transmission of high-efficiency video code (HEVC) sequences. Specifically, the ROI of a panoramic frame may be deemed to be within the 120° angular range of the viewing center, which can be estimated from the viewing trajectory of a head mounted display. Then, the most appropriate unequal forward error correction (FEC) coding rates will be found for the ROI signals by minimizing the expected video distortion. Moreover, the so-called weighted peak signal-to-noise ratio (WPSNR) is proposed for evaluating the quality of the reconstructed panoramic video, where the weights of pixels are taken into account for calculating the distortion caused by the related pixels. Our simulation results show that the ROI based equal error protection (ROI-EEP) scheme substantially outperforms the EEP by a WPSNR of more than 10 dB, while the ROI-UEP scheme further improves its ROI-EEP counterpart by a WPSNR of 9.4 dB at a channel Eb/N0 of 6 dB.

In recent years, deep convolutional neural networks (CNNs) have been widely used for image super-resolution (SR) to achieve a range of sophisticated performances. Despite the significant advancement made in CNNs, it is still difficult to apply CNNs to practical SR applications due to enormous computations of deep convolutions. In this paper, we propose two lightweight deep neural networks using depthwise separable convolution for the real-time image SR. Specifically, depthwise separable convolution divides the standard convolution into depthwise convolution and pointwise convolution to significantly reduce the number of model parameters and multiplication operations. Moreover, recursive learning is adopted to increase the depth and receptive field of the network in order to improve the SR quality without increasing the model parameters. Finally, we propose a novel technique called Super-Sampling (SS) to learn more abundant high-resolution information by over-sampling the output image followed by adaptive down-sampling. The proposed two models, named SSNet-M and SSNet, outperform the existing state-of-the-art real-time image SR networks, including SRCNN, FSRCNN, ESPCN, and VDSR, in terms of model complexity, and subjective and PSNR/SSIM evaluations on Set5, Set14, B100, Urban100, and Manga109.

Recently, there have been significant advances in image super-resolution based on generative adversarial networks (GANs) to achieve breakthroughs in generating more images with high subjective quality. However, there are remaining challenges needs to be met, such as simultaneously recovering the finer texture details for large upscaling factors and mitigating the geometric transformation effects. In this paper, we propose a novel robust super-resolution GAN (i.e. namely RSR-GAN) which can simultaneously perform both the geometric transformation and recovering the finer texture details. Specifically, since the performance of the generator depends on the discreminator, we propose a novel discriminator design by incorporating the spatial transformer module with residual learning to improve the discrimination of fake and true images through removing the geometric noise, in order to enhance the super-resolution of geometric corrected images. Finally, to further improve the perceptual quality, we introduce an additional DCT loss term into the existing loss function. Extensive experiments, measured by both PSNR and SSIM measurements, show that our proposed method achieves a high level of robustness against a number of geometric transformations, including rotation, translation, a combination of rotation and scaling effects, and a cobmination of rotaion, transalation and scaling effects. Benchmarked by the existing state-of-the-arts SR methods, our proposed delivers superior performances on a wide range of datasets which are publicly available and widely adopted across research communities.

For many practical applications, it is essential to address both geometric corrections and missing information reconstruction of face images and natural images. However, it is unfavorable to separate the problem into two sub-tasks due to error accumulations of sequential tasks. In this paper, we propose a novel robust missing information reconstruction framework via deep feature transformations to simultaneously address both geometric corrections and image completion. Specifically, our proposed framework realizes multiple channel spatial transformations to tackle geometric corrections, and address image completion through non-linear features projections. The flow of our framework includes deep feature extraction, feature enhancement, feature projection, and feature refinement, where deep features are extracted and learnt to achieve robust image completion. Experimental results show the superior performance of our framework for both face images and natural images in various databases. Compared with the conventional approaches approach to split the problem into two sub-tasks, including image inpainting and spatial transformation, our proposed framework achieves a number of advantages, including i) an unified framework to automatically correct the geometric distortions and to reconstruct the missing information simultaneously and ii) achieving much better visual quality for those recovered images.