{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T15:33:19Z","timestamp":1787585599760,"version":"build-2736575974"},"reference-count":30,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T00:00:00Z","timestamp":1787184000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T00:00:00Z","timestamp":1787529600000},"content-version":"vor","delay-in-days":4,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"Medizinische Hochschule Hannover (MHH)"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Infect Dis"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Nosocomial outbreaks among immunocompromised patients are serious events. We conducted a descriptive analysis of nosocomial outbreaks in hematology and oncology, drawing on data from 196 outbreaks included in the Worldwide Outbreak Database. Our analysis includes patient characteristics, pathogens, outbreak sources, routes of transmission, and infection control measures. Furthermore, it determines risk factors for increased infection control effort by using the Weighted Cumulative Hygiene Score (WCHS). Bloodstream infections and lower respiratory tract infections were most often observed in the outbreak patient population. The primary infectious agents were Pseudomonas aeruginosa and other non-fermenting Gram-negative rods as well as enterococci. An index person (patient\/staff) and the environment were the main reservoirs for transmission. Noteworthy, the exact source could not be identified in nearly half of the outbreak events. Infection control measures were usually implemented as bundles including but not limited to screening of patients, changes in the disinfection or sterilization regime and enforcement of proper hand hygiene. Multivariable regression analysis revealed the following factors being independently associated with a high infection control effort: causative agent fungi (other than molds) (OR=6.26; CI95:1.60\u201324.44), multi-drug resistant bacteria (OR=6.01; CI95:2.56\u201314.09), antibiotic therapy (OR=2.97; CI95:1.05\u20138.38), a high number (\u2265 10) of patients involved in the outbreak (OR=2.54; CI95:1.11\u20135.81), and the transmission route being direct contact (OR=3.42; CI95:1.43\u20138.16). The occurrence of lower respiratory tract infections was strongly associated with mortality (OR=7.95; CI95:2.06\u201330.73). Staff working in hematology and oncology should be aware of these details in order to approach a nosocomial outbreak appropriately at a most early time point.<\/jats:p>","DOI":"10.1186\/s12879-026-14279-2","type":"journal-article","created":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T04:55:32Z","timestamp":1787201732000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Lessons learned from a structured and descriptive analysis of nosocomial outbreaks in hematology-oncology"],"prefix":"10.1186","volume":"26","author":[{"given":"Sara-Lena","family":"Posselt","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3895-5446","authenticated-orcid":false,"given":"Claas","family":"Baier","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6666-725X","authenticated-orcid":false,"given":"Frank","family":"Schwab","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7706-8511","authenticated-orcid":false,"given":"Ralf-Peter","family":"Vonberg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,8,20]]},"reference":[{"issue":"2","key":"14279_CR1","doi-asserted-by":"publisher","first-page":"127","DOI":"10.1016\/j.jhin.2017.07.023","volume":"98","author":"C Baier","year":"2018","unstructured":"Baier C, Ipaktchi R, Ebadi E, Limbourg A, Mett TR, Vogt PM, Bange FC. A multimodal infection control concept in a burn intensive care unit - lessons learnt from a meticillin-resistant Staphylococcus aureus outbreak. J Hosp Infect. 2018;98(2):127\u201333. https:\/\/doi.org\/10.1016\/j.jhin.2017.07.023.","journal-title":"J Hosp Infect"},{"issue":"1","key":"14279_CR2","doi-asserted-by":"publisher","first-page":"88","DOI":"10.1186\/s13756-022-01120-z","volume":"11","author":"C Baier","year":"2022","unstructured":"Baier C, Huang J, Reumann K, Indenbirken D, Thol F, Koenecke C, Ebadi E, Heim A, Bange FC, Haid S, Pietschmann T, Fischer N. Target capture sequencing reveals a monoclonal outbreak of respiratory syncytial virus B infections among adult hematologic patients. Antimicrob Resist Infect Control. 2022;11(1):88. https:\/\/doi.org\/10.1186\/s13756-022-01120-z.","journal-title":"Antimicrob Resist Infect Control"},{"issue":"3","key":"14279_CR3","doi-asserted-by":"publisher","first-page":"405","DOI":"10.1017\/ice.2020.1431","volume":"43","author":"L Saidel-Odes","year":"2022","unstructured":"Saidel-Odes L, Nesher L, Nativ R, Borer A. An outbreak of coronavirus disease 2019 (COVID-19) in hematology staff via airborne transmission. Infect Control Hosp Epidemiol. 2022;43(3):405\u20137. https:\/\/doi.org\/10.1017\/ice.2020.1431.","journal-title":"Infect Control Hosp Epidemiol"},{"issue":"1","key":"14279_CR4","doi-asserted-by":"publisher","first-page":"102","DOI":"10.3324\/haematol.2019.219345","volume":"105","author":"M Stahl","year":"2020","unstructured":"Stahl M, Bewersdorf JP, Giri S, Wang R, Zeidan AM. Use of immunosuppressive therapy for management of myelodysplastic syndromes: a systematic review and meta-analysis. Haematologica. 2020;105(1):102\u201311. https:\/\/doi.org\/10.3324\/haematol.2019.219345.","journal-title":"Haematologica"},{"issue":"1","key":"14279_CR5","doi-asserted-by":"publisher","first-page":"13","DOI":"10.1097\/CJI.0000000000000390","volume":"45","author":"NR Wilson","year":"2022","unstructured":"Wilson NR, Lockhart JR, Garcia-Perdomo HA, Oo TH, Rojas-Hernandez CM. Management and Outcomes of Hematological Immune-related Adverse Events: Systematic Review and Meta-analysis. J Immunother. 2022;45(1):13\u201324. https:\/\/doi.org\/10.1097\/CJI.0000000000000390.","journal-title":"J Immunother"},{"issue":"8","key":"14279_CR6","doi-asserted-by":"publisher","first-page":"1364","DOI":"10.1002\/jmv.24800","volume":"89","author":"D Nabeya","year":"2017","unstructured":"Nabeya D, Kinjo T, Parrott GL, Uehara A, Motooka D, Nakamura S, Nahar S, Nakachi S, Nakamatsu M, Maeshiro S, Haranaga S, Tateyama M, Tomoyose T, Masuzaki H, Horii T, Fujita J. The clinical and phylogenetic investigation for a nosocomial outbreak of respiratory syncytial virus infection in an adult hemato-oncology unit. J Med Virol. 2017;89(8):1364\u201372. https:\/\/doi.org\/10.1002\/jmv.24800.","journal-title":"J Med Virol"},{"issue":"9","key":"14279_CR7","doi-asserted-by":"publisher","first-page":"1117","DOI":"10.1017\/ice.2017.136","volume":"38","author":"C Rock","year":"2017","unstructured":"Rock C, Curless MS, Cantara M, Mehta S, Marrone KA, Carroll KC, Simner P, Maragakis LL. Resolution of Carbapenemase-Producing Klebsiella pneumoniae Outbreak in a Tertiary Cancer Center; the Role of Active Surveillance. Infect Control Hosp Epidemiol. 2017;38(9):1117\u20139. https:\/\/doi.org\/10.1017\/ice.2017.136.","journal-title":"Infect Control Hosp Epidemiol"},{"issue":"4","key":"14279_CR8","doi-asserted-by":"publisher","first-page":"326","DOI":"10.1111\/myc.13048","volume":"63","author":"A Barac","year":"2020","unstructured":"Barac A, Cevik M, Colovic N, Lekovic D, Stevanovic G, Micic J, Rubino S. Investigation of a healthcare-associated Candida tropicalis candidiasis cluster in a haematology unit and a systematic review of nosocomial outbreaks. Mycoses. 2020;63(4):326\u201333. https:\/\/doi.org\/10.1111\/myc.13048.","journal-title":"Mycoses"},{"issue":"12","key":"14279_CR9","doi-asserted-by":"publisher","first-page":"e00473","DOI":"10.1016\/j.heliyon.2017.e00473","volume":"3","author":"N Ulrich","year":"2017","unstructured":"Ulrich N, Vonberg RP, Gastmeier P. Outbreaks caused by vancomycin-resistant Enterococcus faecium in hematology and oncology departments: A systematic review. Heliyon. 2017;3(12):e00473. https:\/\/doi.org\/10.1016\/j.heliyon.2017.e00473.","journal-title":"Heliyon"},{"issue":"4","key":"14279_CR10","doi-asserted-by":"publisher","first-page":"357","DOI":"10.1097\/QCO.0b013e3283013933","volume":"21","author":"P Gastmeier","year":"2008","unstructured":"Gastmeier P, Vonberg RP. Outbreaks of nosocomial infections: lessons learned and perspectives. Curr Opin Infect Dis. 2008;21(4):357\u201361. https:\/\/doi.org\/10.1097\/QCO.0b013e3283013933.","journal-title":"Curr Opin Infect Dis"},{"issue":"9","key":"14279_CR11","doi-asserted-by":"publisher","first-page":"603","DOI":"10.1016\/j.ajic.2006.01.014","volume":"34","author":"P Gastmeier","year":"2006","unstructured":"Gastmeier P, Stamm-Balderjahn S, Hansen S, Zuschneid I, Sohr D, Behnke M, Vonberg RP, Ruden H. Where should one search when confronted with outbreaks of nosocomial infection? Am J Infect Control. 2006;34(9):603\u20135. https:\/\/doi.org\/10.1016\/j.ajic.2006.01.014.","journal-title":"Am J Infect Control"},{"issue":"1","key":"14279_CR12","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1007\/s15010-010-0064-6","volume":"39","author":"RP Vonberg","year":"2011","unstructured":"Vonberg RP, Weitzel-Kage D, Behnke M, Gastmeier P. Worldwide Outbreak Database: the largest collection of nosocomial outbreaks. Infection. 2011;39(1):29\u201334. https:\/\/doi.org\/10.1007\/s15010-010-0064-6.","journal-title":"Infection"},{"issue":"4","key":"14279_CR13","doi-asserted-by":"publisher","first-page":"e0249837","DOI":"10.1371\/journal.pone.0249837","volume":"16","author":"B Pannewick","year":"2021","unstructured":"Pannewick B, Baier C, Schwab F, Vonberg RP. Infection control measures in nosocomial MRSA outbreaks-Results of a systematic analysis. PLoS ONE. 2021;16(4):e0249837. https:\/\/doi.org\/10.1371\/journal.pone.0249837.","journal-title":"PLoS ONE"},{"issue":"11","key":"14279_CR14","doi-asserted-by":"publisher","first-page":"3162","DOI":"10.1093\/jac\/dky311","volume":"73","author":"JM Azzi","year":"2018","unstructured":"Azzi JM, Kyvernitakis A, Shah DP, El Haddad L, Mahajan SN, Ghantoji SS, Heredia-Ariza E, Chemaly RF. Leukopenia and lack of ribavirin predict poor outcomes in patients with haematological malignancies and respiratory syncytial virus infection. J Antimicrob Chemother. 2018;73(11):3162\u20139. https:\/\/doi.org\/10.1093\/jac\/dky311.","journal-title":"J Antimicrob Chemother"},{"issue":"2","key":"14279_CR15","doi-asserted-by":"publisher","first-page":"263","DOI":"10.1016\/j.ccm.2016.12.005","volume":"38","author":"JL Wong","year":"2017","unstructured":"Wong JL, Evans SE. Bacterial Pneumonia in Patients with Cancer: Novel Risk Factors and Management. Clin Chest Med. 2017;38(2):263\u201377. https:\/\/doi.org\/10.1016\/j.ccm.2016.12.005.","journal-title":"Clin Chest Med"},{"issue":"1","key":"14279_CR16","doi-asserted-by":"publisher","first-page":"589","DOI":"10.1186\/s12879-024-09271-7","volume":"24","author":"L Arnold","year":"2024","unstructured":"Arnold L, Bimczok S, Schutt H, Lisak-Wahl S, Buchberger B, Stratil JM. How to protect long-term care facilities from pandemic-like events? - A systematic review on the effectiveness of non-pharmacological measures to prevent viral respiratory infections. BMC Infect Dis. 2024;24(1):589. https:\/\/doi.org\/10.1186\/s12879-024-09271-7.","journal-title":"BMC Infect Dis"},{"issue":"1","key":"14279_CR17","doi-asserted-by":"publisher","first-page":"S4","DOI":"10.3949\/ccjm.91.s1.02","volume":"91","author":"GA Sautto","year":"2024","unstructured":"Sautto GA, Ross TM. Respiratory viruses: Preventive and therapeutic approaches to diverse pathogens. Cleve Clin J Med. 2024;91(1):S4\u201310. https:\/\/doi.org\/10.3949\/ccjm.91.s1.02.","journal-title":"Cleve Clin J Med"},{"key":"14279_CR18","doi-asserted-by":"publisher","unstructured":"Sullivan KM, Dykewicz CA, Longworth DL, Boeckh M, Baden LR, Rubin RH, Sepkowitz KA, Centers for Disease C, Prevention. Infectious Diseases Society of A, American Society for B, Marrow Transplantation Practice G, beyond. Preventing opportunistic infections after hematopoietic stem cell transplantation: the Centers for Disease Control and Prevention Infectious Diseases Society of America and American Society for Blood and Marrow Transplantation practice guidelines and beyond.Hematol Am Soc Hematol Educ Program. 2001;392\u2013421. https:\/\/doi.org\/10.1182\/asheducation-2001.1.392.","DOI":"10.1182\/asheducation-2001.1.392"},{"issue":"4","key":"14279_CR19","doi-asserted-by":"publisher","first-page":"282","DOI":"10.1016\/S1473-3099(07)70082-8","volume":"7","author":"SP Stone","year":"2007","unstructured":"Stone SP, Cooper BS, Kibbler CC, Cookson BD, Roberts JA, Medley GF, Duckworth G, Lai R, Ebrahim S, Brown EM, Wiffen PJ, Davey PG. The ORION statement: guidelines for transparent reporting of outbreak reports and intervention studies of nosocomial infection. Lancet Infect Dis. 2007;7(4):282\u20138. https:\/\/doi.org\/10.1016\/S1473-3099(07)70082-8.","journal-title":"Lancet Infect Dis"},{"issue":"5","key":"14279_CR20","doi-asserted-by":"publisher","first-page":"476","DOI":"10.1016\/S1473-3099(17)30183-4","volume":"17","author":"K Wieland","year":"2017","unstructured":"Wieland K, Chhatwal P, Vonberg RP. Outbreak reporting a decade after ORION: where do we stand? Lancet Infect Dis. 2017;17(5):476. https:\/\/doi.org\/10.1016\/S1473-3099(17)30183-4.","journal-title":"Lancet Infect Dis"},{"issue":"6","key":"14279_CR21","doi-asserted-by":"publisher","first-page":"278","DOI":"10.1055\/a-1481-8905","volume":"233","author":"S Ockfen","year":"2021","unstructured":"Ockfen S, Egle L, Sauter K, Haber M, Becker SL, Wagenpfeil G, Graf N, Simon A. Meropenem Use in Pediatric Oncology - Audit on Indication, Appropriateness and Consumption Comparing Patient Derived and Pharmacy Dispensing Data. Klin Padiatr. 2021;233(6):278\u201385. https:\/\/doi.org\/10.1055\/a-1481-8905.","journal-title":"Klin Padiatr"},{"issue":"11","key":"14279_CR22","doi-asserted-by":"publisher","first-page":"e0208039","DOI":"10.1371\/journal.pone.0208039","volume":"13","author":"BH Tan","year":"2018","unstructured":"Tan BH, Guzman MRT, Donato LKS, Kalimuddin S, Lee WHL, Tan AL, Wong GC. Impact of an alternating first-line antibiotics strategy in febrile neutropenia. PLoS ONE. 2018;13(11):e0208039. https:\/\/doi.org\/10.1371\/journal.pone.0208039.","journal-title":"PLoS ONE"},{"issue":"4","key":"14279_CR23","doi-asserted-by":"publisher","first-page":"276","DOI":"10.22088\/cjim.8.4.276","volume":"8","author":"H Gedik","year":"2017","unstructured":"Gedik H. Antibiotic resistance status and its costs in hematological patients: A two-year analysis. Casp J Intern Med. 2017;8(4):276\u201381. https:\/\/doi.org\/10.22088\/cjim.8.4.276.","journal-title":"Casp J Intern Med"},{"issue":"1","key":"14279_CR24","doi-asserted-by":"publisher","first-page":"40","DOI":"10.1016\/j.jhin.2019.08.008","volume":"104","author":"M Coppry","year":"2020","unstructured":"Coppry M, Leroyer C, Saly M, Venier AG, Slekovec C, Bertrand X, Parer S, Alfandari S, Cambau E, Megarbane B, Lawrence C, Clair B, Lepape A, Cassier P, Trivier D, Boyer A, Boulestreau H, Asselineau J, Dubois V, Thiebaut R, Rogues AM. Exogenous acquisition of Pseudomonas aeruginosa in intensive care units: a prospective multi-centre study (DYNAPYO study). J Hosp Infect. 2020;104(1):40\u20135. https:\/\/doi.org\/10.1016\/j.jhin.2019.08.008.","journal-title":"J Hosp Infect"},{"key":"14279_CR25","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1186\/1471-2334-7-45","volume":"7","author":"G Daeschlein","year":"2007","unstructured":"Daeschlein G, Kruger WH, Selepko C, Rochow M, Dolken G, Kramer A. Hygienic safety of reusable tap water filters (Germlyser) with an operating time of 4 or 8 weeks in a haematological oncology transplantation unit. BMC Infect Dis. 2007;7:45. https:\/\/doi.org\/10.1186\/1471-2334-7-45.","journal-title":"BMC Infect Dis"},{"key":"14279_CR26","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1016\/j.jhin.2024.05.017","volume":"151","author":"K Karia","year":"2024","unstructured":"Karia K, Ali S. The need for in-house efficacy testing and assessment of the antimicrobial properties of silver nanoparticle (Ag(+))-impregnated showerheads against Pseudomonas aeruginosa intended for healthcare waters in high-risk patient settings. J Hosp Infect. 2024;151:29\u201332. https:\/\/doi.org\/10.1016\/j.jhin.2024.05.017.","journal-title":"J Hosp Infect"},{"issue":"2","key":"14279_CR27","doi-asserted-by":"publisher","first-page":"187","DOI":"10.1093\/cid\/ciac268","volume":"75","author":"PD Tamma","year":"2022","unstructured":"Tamma PD, Aitken SL, Bonomo RA, Mathers AJ, van Duin D, Clancy CJ. Infectious Diseases Society of America 2022 Guidance on the Treatment of Extended-Spectrum beta-lactamase Producing Enterobacterales (ESBL-E), Carbapenem-Resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with Difficult-to-Treat Resistance (DTR-P. aeruginosa). Clin Infect Dis. 2022;75(2):187\u2013212. https:\/\/doi.org\/10.1093\/cid\/ciac268.","journal-title":"Clin Infect Dis"},{"key":"14279_CR28","doi-asserted-by":"publisher","first-page":"104574","DOI":"10.1016\/j.jcv.2020.104574","volume":"130","author":"MM Biernat","year":"2020","unstructured":"Biernat MM, Zinczuk A, Biernat P, Bogucka-Fedorczuk A, Kwiatkowski J, Kalicinska E, Marciniak D, Simon K, Wrobel T. Nosocomial outbreak of SARS-CoV-2 infection in a haematological unit - High mortality rate in infected patients with haematologic malignancies. J Clin Virol. 2020;130:104574. https:\/\/doi.org\/10.1016\/j.jcv.2020.104574.","journal-title":"J Clin Virol"},{"issue":"1","key":"14279_CR29","doi-asserted-by":"publisher","first-page":"100335","DOI":"10.1016\/j.infpip.2023.100335","volume":"6","author":"WC van der Zwet","year":"2024","unstructured":"van der Zwet WC, Klomp-Berens EA, Demandt AMP, Dingemans J, van der Veer B, van Alphen LB, Dirks J, Savelkoul PHM. Analysis of two sequential SARS-CoV-2 outbreaks on a haematology-oncology ward and the role of infection prevention. Infect Prev Pract. 2024;6(1):100335. https:\/\/doi.org\/10.1016\/j.infpip.2023.100335.","journal-title":"Infect Prev Pract"},{"key":"14279_CR30","doi-asserted-by":"publisher","DOI":"10.1093\/cid\/ciaa1063","author":"JB Lynch","year":"2020","unstructured":"Lynch JB, Davitkov P, Anderson DJ, Bhimraj A, Cheng VC, Guzman-Cottrill J, Dhindsa J, Duggal A, Jain MK, Lee GM, Liang SY, McGeer A, Lavergne V, Murad MH, Mustafa RA, Morgan RL, Falck-Ytter Y, Sultan S. Infectious Diseases Society of America Guidelines on infection prevention for health care personnel caring for patients with suspected or known COVID-19. Clin Infect Dis: ciaa1063. 2020. https:\/\/doi.org\/10.1093\/cid\/ciaa1063.","journal-title":"Clin Infect Dis: ciaa1063"}],"container-title":["BMC Infectious Diseases"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12879-026-14279-2","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12879-026-14279-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12879-026-14279-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T15:08:59Z","timestamp":1787584139000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s12879-026-14279-2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,20]]},"references-count":30,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["14279"],"URL":"https:\/\/doi.org\/10.1186\/s12879-026-14279-2","relation":{},"ISSN":["1471-2334"],"issn-type":[{"value":"1471-2334","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,20]]},"assertion":[{"value":"28 February 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"14 August 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"20 August 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"All data included in this study was retrieved retrospectively only from articles that had already been publicly available. Thus, a study-specific approval by the ethics committee for research involving humans was not required.","order":1,"name":"Ethics","label":"Ethics approval and consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"All authors drafted the work or revised it critically for important intellectual content. All authors approved the version to be published. All authors are accountable for all aspects of the work and ensure the accuracy and integrity of any part of the work.","order":2,"name":"Ethics","label":"Consent for publication","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":3,"name":"Ethics","label":"Competing interests.","group":{"name":"EthicsHeading","label":"Declarations"}}],"article-number":"1551"}}