News Scan for Oct 24, 2017

News brief

MERS sickens Saudi man from Riyadh

After a 9-day lapse in cases, Saudi Arabia's Ministry of Health (MOH) today reported a MERS-CoV infection in a 77-year-old man in Riyadh who had contact with camels before he got sick.

In a statement, the MOH said the man is a Saudi citizen who has symptoms of MERS-CoV (Middle East respiratory syndrome coronavirus) and is listed in stable condition.

Today's new case lifts the country's overall MERS-CoV total to 1,732 cases, 702 of them fatal. Four people are still being treated for their infections.
Oct 24 Saudi MOH statement

Researchers use electronic health records to track C difficile exposure

Using electronic health record (EHR) data to track patient movement enabled researchers to identify a previously unrecognized source of Clostridium difficile infection (CDI) at a large university hospital, according to a research letter published yesterday in JAMA Internal Medicine.

In the study, researchers with the University of California, San Francisco Medical Center analyzed EHR data from all adult hospitalizations from January 2013 to December 2015 and followed patients for the development of CDI for 60 days from the time they passed through a given space. Their aim was to track patient movement to see whether using a hospital space—particularly a procedural or diagnostic common area—within 24 hours of a CDI patient's use was associated with an increased risk of CDI.

Patients with CDI were considered positive for infection from the time the positive test was ordered until discharge, and hospital spaces were considered potentially contaminated for 24 hours after a patient with CDI visited them. All patients who had not yet tested positive for CDI and passed through a space while it was potentially contaminated were considered exposed to C difficile, while patients who occupied the same space at any other time were part of the unexposed control group.

Overall, there were 86,648 adult hospitalizations and 434,475 patient location changes during the study period, and 1,152 CDI-positive patients moved through a mean 4.2 hospital locations.

While exposure and risk varied across those locations, the researchers observed that the computer tomography scanner in the emergency department was the only area where exposure to CDI was significantly associated with CDI developmentI (incidence, 4%; odds ratio [OR], 2.5). The association remained significant (OR, 2.7) after the researchers extended the incubation period to 72 hours and adjusted for covariates. A follow-up investigation revealed that cleaning practices for the scanner table had not been updated to match methods applied in other radiology suites.

The authors of the letter say using EHR data for spatial and temporal analytics could be a strategy for infection control at other hospitals.
Oct 23 JAMA Intern Med research letter

Uganda's Marburg outbreak marked by extensive exposure

Though no new cases have been reported in Uganda's Marburg virus outbreak, a weekly update on communicable diseases in the World Health Organization (WHO) Africa region has more details about the patients and possibly extensive exposure that could have occurred at funerals and healthcare facilities.

The only confirmed case involves a 50-year-old woman from Kween district near the border with Kenya who died from her infection after caring for and participating in the burial of her brother, a game hunter who lived near a bat-infested cave and who died of similar symptoms before any samples were taken.

According to the WHO report, the brother—considered the first case and whose illness is classified as probable—was initially admitted to one hospital for a high fever, vomiting, and diarrhea, but didn't respond to treatment for a suspected malaria infection. When he didn't improve, he was transferred to another hospital, where he died the same day.

He was buried on Sep 27 in a traditional ceremony attended by 200 people. His sister, the confirmed case-patient, was buried on Oct 13 according to local customs.

Also, their brother, who drove his sister to the hospital, has similar symptoms and is considered a probable case-patient. In addition, on Oct 19, officials at a hospital in the district reported another suspected case, involving a 2-year-old child who has similar symptoms.

Though Uganda has experience managing viral hemorrhagic fever outbreaks and the Marburg outbreak is small and localized, health officials are concerned about the extent of exposure, given the high number of contacts, the burials, and the fact that the hospitalized patients were treated on general medical wards without appropriate infection prevention and control. Also, one of the probable case-patients refused hospitalization for some time.

So far, public health workers have identified 41 contacts for follow-up, and active case-finding is under way.
Oct 24 WHO African regional office communicable disease update

Nigeria monkeypox probe finds monkey exposure, patient stigmatization

A field investigation into a suspected monkeypox cluster in Nigeria's Bayelsa state found that young boys had regularly played with a captured monkey in the neighborhood and that social media messages may have led to inaccurate perceptions about the threat.

The animal was killed and eaten about a month before patients began having symptoms, according to new details about the outbreak in the same weekly communicable disease report from the WHO's Africa regional office.

So far, just 3 cases have been confirmed, all in Bayelsa state, which has 22 suspected cases. However, 64 suspected cases have been reported in 10 other states. No deaths have been noted, but a recovering patient has committed suicide and health officials are investigating issues surrounding the death.

Contact tracing is under way, and authorities are following 204 contacts.

Aside from the need to curb a relatively rare disease that can be severe in children, health officials aired other concerns about the outbreak, including exaggerated and incorrect public health perceptions about the disease and reports of stigmatization, which they said can pose obstacles to the public health response.

Unethical use of patient photographs on social media have also led to more stigmatization and concealment, requiring stepped-up community engagement activities to counter the misperceptions, the WHO said.
Oct 24 WHO African regional office communicable disease update

Report notes biosecurity gaps, low bioterror readiness globally

In advance of the fourth Annual Global Health Security Agenda ministerial conference this week in Kampala, Uganda, the Nuclear Threat Initiative (NTI) found widespread weaknesses in biosecurity and biosafety systems worldwide and poor bioterror preparedness overall, according to an NTI report yesterday.

NTI researchers examined the biosafety and biosecurity-related World Health Organization Joint External Evaluation (JEE) scores from the 39 nations that had published JEE peer reviews as of Oct 17. They found that 74% of the countries had limited or no capacity for a government-wide biosafety and biosecurity system, 64% had little or no capacity for biosafety and biosecurity training, and 41% had low or no capacity for linking public health and security agencies during a biological emergency.

The investigators said the findings "indicate a lack of capability in areas vital to countering biological threats, including: updated inventories of dangerous pathogens and toxins; consolidation of dangerous pathogens and toxins into a minimum number of facilities; biosafety and biosecurity legislation; standards for containing and handling dangerous pathogens and toxins; use of effective modern diagnostic technologies that do not require culturing; comprehensive biosafety and biosecurity training; best practices for safe, secure, responsible conduct; and mechanisms for linking public health, animal health, and security authorities to investigate and attribute biological attacks."

They concluded, "Most countries that have been assessed through the JEE process lack core biosecurity and biosafety capabilities, which indicates a lack of preparedness for preventing, detecting, and responding to bioterrorism threats."
Oct 23 NTI report

Yellow fever virus RNA detected in man's semen, urine

Add yellow fever to the growing list of diseases that might be transmitted sexually, as a case report yesterday in Emerging Infectious Diseases describes an infected patient who had yellow fever viral RNA detected in his urine and semen after he had recovered from the disease.

Brazilian researchers described a 65-year-old man from Sao Paulo who was not vaccinated against yellow fever. After traveling in December 2016 and January 2017 to Minas Gerais state and a rural area north of Sao Paulo—both areas that had reported cases—he developed symptoms and later tested positive for yellow fever.

The scientists detected viral RNA by polymerase chain reaction testing in both his urine and semen after his symptoms had improved. They also isolated yellow fever virus in cell culture from urine samples. The isolate clustered with two viruses isolated in 2017 in Espirito Santo state, which borders Minas Gerais.

The authors conclude, "Our results suggest that semen can be a useful clinical material for diagnosis of yellow fever and indicate the need for testing urine and semen samples from patients with advanced disease. Such testing could improve diagnostics, reduce false-negative results, and strengthen the reliability of epidemiologic data during ongoing and future outbreaks."
Oct 23 Emerg Infect Dis case report

Flu Scan for Oct 24, 2017

News brief

Antiviral drugs infrequently prescribed to high-risk flu patients, study finds

A US Centers for Disease Control and Prevention–led study published yesterday in Clinical Infectious Diseases reveals that antiviral drugs are prescribed to only 15% of outpatients who have acute respiratory infections (ARIs) and a high risk for influenza.

The data underscore a need to increase appropriate prescribing, the authors said.

The team looked at antiviral prescription and clinical data for high-risk outpatients aged 6 months and older who had an ARI and were enrolled in the US Influenza Vaccine Effectiveness Network during the 2011-12 to 2015-16 flu seasons. They found that only 718 of 4,861 high-risk patients (15%) who presented within 2 days of symptom onset—when antivirals are shown to be most effective—were prescribed the drugs. In addition, only 40% of high-risk outpatients who had influenza reported within 2 days of first symptoms.

The researchers did find that earlier presentation to a clinic was associated with fourfold-higher odds of receiving antiviral medication. They also reported that a fourth of high-risk outpatients had no fever.

The team concluded, "Influenza antiviral medications were infrequently prescribed for high-risk outpatients with ARI who would benefit most from treatment. Efforts to increase appropriate antiviral prescribing are needed to reduce influenza-associated complications."
Oct 23 Clin Infect Dis study

Study of influenza C patients identifies some severe cases

Influenza C, which is not very common, is reported to typically cause mild symptoms, but a study of influenza C cases in Minnesota found some severe cases, especially among people who had comorbidities, according to a separate study in the same journal yesterday.

Experts from the University of Minnesota and the Minnesota Department of Health detected influenza C among 59 (0.58%) of 10,202 hospitalized ARI cases and 11 (0.48%) of 2,282 outpatient ARI cases from May 2013 to December 2016, with 73% of cases occurring in the 2014-15 flu season. The highest rate (1.2%) occurred among children 2 years old and younger.

Among the 59 hospitalized cases, 7 (12%) required intensive care, all of whom had comorbidities. Comorbidity prevalence among all hospitalized patients was 58%.

At least one other respiratory pathogen was detected in 40 (66%) of the hospital cases, most commonly rhinovirus or enterovirus (25%) and respiratory syncytial virus (20%). The finding of severe influenza C cases suggests a need for further study of the role of the virus in respiratory disease, the authors write.
Oct 23 Clin Infect Dis study

Study: US poultry H7N9 avian flu isolates pose low human health threat

Low-pathogenic and highly pathogenic H7N9 avian flu viruses isolated in poultry outbreaks in the southeastern United States earlier this year appear to pose a low threat to human health in their current form, according to researchers from the US Centers for Disease Control and Prevention (CDC) who conducted experiments in mice, ferrets, and human airway cells. They reported their findings yesterday in Emerging Infectious Diseases.

The outbreaks in poultry began in March in Tennessee, where highly pathogenic H7N9—not related to the strain in China—was detected. Over the next several weeks a low-pathogenic version of the virus struck poultry in Alabama, Kentucky, Georgia, and Tennessee, which led to the culling of about 270,000 birds. No human cases were reported.

Mice and ferrets experimentally infected with either of the viruses showed only mild illness. Transmissibility tests in ferrets found that only the low-pathogenic virus spread to healthy cage mates of infected animals, with the virus passing to only about a third of the animals that weren't inoculated.

Tests on human bronchial epithelial cells found that both the low-pathogenic and highly pathogenic virus replicated to high titers, with the low-path virus showing significantly higher levels—higher than an earlier North American H7N9 virus but lower than a 2013 H7N9 virus from China.

The researchers concluded that the viruses for now are a low threat to human health, but they bear watching, especially in flyway and high-poultry-density regions, given that North American H7 subtypes have shown the ability to acquire genetic changes after recombination with host RNA and have the potential to adapt to mammals.
Oct 23 Emerg Infect Dis report