News Scan for Jul 23, 2020

News brief

Survey shows increase in stewardship programs in English primary care

A 2019 survey of clinical commissioning groups in England showed an increase in antimicrobial stewardship (AMS) programs compared with the previous survey, according to a report yesterday from UK nonprofit The Patients Association.

The group sent freedom-of-information requests with a range of questions about AMS programs to all clinical commissioning groups, which are groups of primary care practices in an area that come together to commission the best services for their population, in England. A previous survey had been conducted in 2016, and progress was judged by comparing the results. Out of 191 clinical commissioning groups that received the survey, a total of 107 responded.

About 79% reported having an AMS program for more than a year, an increase of 19% from the 2016 survey, and only 17% said they did not have a named individual responsible for implementation of their program, down from 33% in 2016. In addition, 64% of respondents said they were currently achieving their antibiotics reduction target, and the number of respondents who reported implementing the full TARGET (Treating Antibiotics Responsibly, Guidance, Education, Tools) toolkit more than doubled compared with 2016.

But only 5% said they had a protected budget for AMS programs, only 15% reported using point-of-care diagnostic tests to determine whether antibiotics were necessary, and 73% said that they could do more to achieve the aims of their AMS programs.

"While good progress has been made, more needs to be done," the report said.

Recommendations include improved metrics and targets, more research into geographic disparities in antibiotic prescribing rates, establishment of dedicated funding, and a better understanding of barriers to point-of-care testing.
Jul 22 Patients Association report

Nearly 60% of US parents say they won't vaccinate their kids against HPV

Nearly 60% of the parents of about 4.3 million US children don't intend to have them vaccinated against the highly infectious and sexually transmitted human papillomavirus (HPV), according to survey results published earlier this week in The Lancet Public Health.

Researchers at the University of Texas at Houston analyzed the data of parents of 82,297 children 13 to 17 years old from the 2017-18 National Immunization Study. They found even higher vaccine hesitancy rates (higher than 65%) in Idaho, Kansas, Michigan, Montana, Nebraska, North Dakota, Oklahoma, and Utah.

The authors said that the vaccine hesitancy is troubling because improving HPV vaccination coverage is the only way to stem rising numbers of certain preventable cancers. HPV, which is associated with 34,800 new cancer cases a year, causes more than 90% of all cervical and anal cancers, 60% of penile cancers, and about 70% of all oral cancers.

The HPV vaccine is given in a Centers for Disease Control and Prevention–recommended series of two doses for children who received the first dose before age 15 years or three doses for those starting the regimen at ages 16 to 26. But only about 51.1% of teens are fully vaccinated.

The investigators also found that parents of one in four teens who received their first HPV vaccine dose said they would not complete the series, including more than 30% of parents in Arkansas, Florida, Georgia, Hawaii, Idaho, Utah, and West Virginia. The reason given by 18% of parents was that their healthcare provider didn't tell them a second dose was needed, while about 15% cited safety concerns.

In a commentary in the same journal, Robert Bednarczyk, PhD, of Emory University, said it's important for providers to educate and to anticipate issues that parents might bring up and be ready to debunk any misinformation.

"These direct steps could potentially increase intention to vaccinate for parents of approximately 2 million adolescents in the USA, which would translate to a 10% increase in vaccine coverage for adolescents aged 13–17 years," he said. "The tools are available, they just need to be widely accepted and implemented by health-care providers."
Jul 21 Lancet Public Health study and commentary

COVID-19 Scan for Jul 23, 2020

News brief

Brazilian trial finds no COVID-19 benefit from hydroxychloroquine, azithromycin

A randomized controlled trial of hospitalized COVID-19 patients in Brazil found that the use of hydroxychloroquine, with or without azithromycin, did not improve clinical status at 15 days compared with standard care, researchers reported today in the New England Journal of Medicine.

The multicenter trial, conducted at 55 hospitals in Brazil, included 667 patients with suspected or confirmed COVID-19 and mild-to-moderate illness. Participants were randomly assigned 1:1:1 to receive standard of care, standard of care plus 400 milligrams of hydroxychloroquine twice daily, or standard of care plus hydroxychloroquine and azithromycin (500 mg once daily for 7 days).

Standard of care included the use of glucocorticoids, other immunomodulators, antibiotics, and antivirals. The primary outcome was clinical status at 15 days based on the use of a seven-level ordinal scale, with a score of 1 indicating not hospitalized and 7 indicating death.

A total of 504 patients had confirmed COVID-19 and were included in the intention-to-treat analysis. Compared with standard care, the proportional odds of having a higher score on the seven-point ordinal scale at 15 days were not affected by being treated with hydroxychloroquine alone (odds ratio [OR], 1.21; 95% confidence interval [CI], 0.69 to 2.11; P = 1.00) or hydroxychloroquine plus azithromycin (OR, 0.99; 95% CI, 0.57 to 1.73; P = 1.00). There was also no effect on secondary outcomes.

In addition, more adverse events, including prolongation of the corrected QT interval and elevation of liver-enzyme levels, occurred in patients receiving hydroxychloroquine plus azithromycin (39.3%) and hydroxychloroquine alone (33.7%) than in patients receiving standard care (22.6%).
Jul 23 N Engl J Med study

Study reveals risk factors for COVID-19 deaths in nursing homes

COVID-19 infections passed from staff members to residents at 627 long-term care (LTC) facilities in Ontario, Canada, by early April were strongly associated with resident deaths from the novel coronavirus, according to a study published yesterday in JAMA Network Open.

By Apr 10, 198 of 401 [49%] of Canada's COVID-19 deaths had occurred in residents of LTC facilities, prompting researchers at the University of Toronto to conduct a cohort study comparing community-living Ontarians older than 69 years who died of coronavirus by Apr 11 with nursing home residents who died by Apr 7.

Of the 627 nursing homes, 272 (43.4%) reported COVID-19 infections in residents or employees. Of 1,731,315 community-living Ontarians older than 69 years, 229 (<0.1%) died, as did 83 (0.1%) of an estimated 79,498 nursing home residents.

Thus, the incident rate ratio (IRR) for coronavirus deaths in LTC residents was 13.1 (95% CI, 9.9 to 17.3) versus their community-living counterparts. The IRR rose dramatically over time, to 87.3 (95% credible interval, 6.4 to 769.8) by Apr 11. Staff member infections were linked to resident deaths after a 6-day lag (adjusted IRR for death per infected employee, 1.17; 95% CI, 1.11 to 1.26).

The authors said that the study adds another risk factor to the list of long-recognized drivers of nursing home deaths, such as advanced resident age, lack of access to testing, difficulty maintaining physical distance among mobile residents with dementia, crowding, low staff-to-resident ratios, staff movement among different nursing home sites, and care needs that necessitate close contact between staff and residents.

It also shows that staff are more likely to infect residents than vice versa. The authors noted that, in addition to staff-to-resident infection, fear of COVID-19 could have kept some employees home, increasing the risk of resident death from dehydration or other means.

As of Jun 10, 1,766 nursing home residents have died of COVID-19 in Ontario, constituting 71% of all deaths in the province.

"Early identification of risk requires a focus on testing, providing personal protective equipment to staff, and restructuring the LTC workforce to prevent the movement of COVID-19 between facilities," the authors wrote.
Jul 22 JAMA Netw Open study

Live COVID-19 virus isolated from human nose-throat, saliva specimens

A small study published yesterday in Clinical Microbiology and Infection found live SARS-CoV-2, the virus that causes COVID-19, in one nose-throat swab and two saliva specimens of five infected hospital patients in Korea 11 to 15 days after symptom onset.

Researchers collected nose-throat swabs, saliva, urine, and stool samples from the patients hospitalized from Feb 25 to Mar 5 on days 8, 11, 13, 15, and 30 after study enrollment. They performed quantitative reverse transcription-polymerase chain reaction (qRT-PCR) to detect SARS-CoV-2 RNA and cell culture to detect viable virus.

No live virus—only viral RNA—was isolated on cell culture from five urine, two saliva, four nose-throat, and three fecal specimens.

The researchers also inoculated two groups of ferrets intranasally with two patient urine specimens and one fecal specimen found to contain SARS-CoV-2 RNA on qRT-PCR. Nasal washes were collected from the ferrets every 2 days until 8 days after infection. Live virus was isolated from the nasal washes of one feces-treated ferret and two urine-treated ferrets. All treated ferrets showed moderate increases in temperature and nasal discharge and decreased activity at days 4 and 6.

Median patient age was 63 years, and three patients were men. One patient had mild illness, three had severe disease and needed supplementary oxygen, and one patient was critically ill with respiratory failure and septic shock. Four of the five patients had recovered by the time of specimen sampling, while the fifth still required mechanical ventilation.

The authors noted that, because of the lack of collection of specimens from coronavirus patients over time, the study couldn't provide information about changing viral loads. Also, the findings in ferrets may not apply to humans for several reasons, one of them being that the viral dose that can infect a ferret might be different than that in humans.
Jul 22 Clin Microbiol Infect study