Stewardship / Resistance Scan for Apr 26, 2017

News brief

India launches national plan to fight antimicrobial resistance

India's health ministry has announced the launch of a nationwide, multi-sectoral effort to curb antimicrobial resistance.

According to the British Medical Journal (BMJ), the National Action Plan on Antimicrobial Resistance aims to tackle antibiotic misuse in the country's human and animal health sectors and boost infection control and antimicrobial surveillance. The effort will involve multiple government agencies, including those that are responsible for health, the environment, agriculture, and education.

BMJ reports that the plan calls for the enforcement of regulations that prohibit the sale of antibiotics without prescriptions and promote guidelines for appropriate use, the establishment of national surveillance systems, and the introduction of lessons on antimicrobial resistance and appropriate use in schools and colleges.

The plan also proposes the phase-out of non-therapeutic antibiotic use in food animals and regulations to reduce the spread of resistance elements into the environment from farms, healthcare facilities, and pharmaceutical manufacturing plants, according to the Times of India.

Although there is scant national data on antimicrobial resistance, it's widely seen as an emerging public health crisis in India, which has one of the highest infectious disease burdens in the world, poor sanitation, and is one of the largest consumers of antibiotics for human health. In addition, antimicrobial misuse is common in the country; doctors frequently prescribe antibiotics for diarrheal diseases and upper respiratory infections for which they have limited value, and many antibiotics can be purchased over-the-counter.

A 2016 essay in PLoS Medicine by Ramanan Laxminarayan, PhD, MPH, of the Center for Disease Dynamics, Economics and Policy noted a steep increase in methicillin-resistant Staphylococcus aureus isolates (from 29% in 2009 to 47% in 2014) and high rates of resistance in Escherichia coli to ampicillin, naladixic acid, co-trimoxazole, and third-generation cephalosporins, along with rising resistance to carbapenems. Laxminarayan said the burden of resistance was likely focused on neonates and the elderly.

"Although accurate estimates of the overall burden of resistance are not available, it is estimated that 58,000 neonatal deaths are attributable to sepsis caused by drug-resistance to first-line antibiotics each year," Laxminarayan wrote.

Under a global action plan on antimicrobial resistance put forward by the World Health Organization (WHO) in 2015, WHO member states are being asked to have national plans in place by 2017.
Apr 26 BMJ article
Apr 24 Times of India article
March 2016 PLoS Med essay

High prevalence of multidrug-resistant organisms found in asylum seekers

Researchers in the Netherlands have found a high prevalence of multidrug-resistant organisms (MDROs) among asylum seekers, according to a study yesterday in PLoS One.

In a study that aimed to assess carriage rate of MRSA and multidrug-resistant Enterobacteriaceae (MDRE) among asylum seekers (mainly from the Middle East and North Africa), investigators analyzed all cultures performed in asylum seekers from January 2014 through December 2015 and compared them with cultures from Dutch patients at risk for carriage of MDROs. The cultures were obtained from screening samples and clinical samples that were collected to diagnose possible infection.

Among the isolates collected from 898 asylum seekers actively screened for MRSA and 118 who provided clinical samples, 10.3% were found to carry MRSA (9.7% in screened patients and 18.6% in clinical cultures). The general patient population (nearly 13,000 patients) was found to have a MRSA carriage rate of 2.1% (2.8% in screened patients and 1.3% in clinical cultures). Asylum seekers also had a much higher rate of MRSA strains harboring Pantone-Valentine leucocidin, a toxin associated with higher virulence.

Among the isolates from 751 asylum seekers who were screened for MDRE and 150 who provided clinical samples, 21.4% were positive for MDRE (21% in screened patients and 21.3% in clinical samples), compared to an MDRE carriage of 5.1% in more than 32,000 patients from the general population (24.4% in screened patients and 4.1% in clinical samples). Most the MDREs were extended-spectrum beta-lactamase producers.

The authors of the study suggest high MRSA and MDRE rates in asylum seekers may be due to high prevalence in their homelands, or could be the result of transmission among refugees, and say the findings support screening policies for MDROs in asylum seekers at Dutch hospitals.

"These differences justify screening of the asylum seekers’ population at admission in the hospital as these organisms may be a threat to the patient and transmission in the hospital should be prevented," the authors write.
Apr 25 PLoS One study

News Scan for Apr 26, 2017

News brief

Study finds raw milk causes 840 times more illness than pasteurized

As more and more Americans consume unpasteurized, or "raw," milk and cheese, a new study in Emerging Infectious Disease found that the unpasteurized products cause 840 times more illnesses and 45 times more hospitalizations than their pasteurized counterparts.

Raw milk products are touted by alternative health enthusiasts, and an increasing number of states have decriminalized their sale and distribution.

The study used data from 2009 to 2014 to estimate outbreaks caused by Campylobacter, Salmonella, Shiga toxin–producing Escherichia coli (STEC), and Listeria monocytogenes in raw cow's milk and cheese made from cow's milk. Researchers used outbreak data from the National Outbreak Reporting System from 2009 through, and found a total of 87 outbreaks causing 750 laboratory-confirmed illnesses and 215 hospitalizations. Unpasteurized dairy products caused 96% of all outbreaks analyzed.

The authors said these numbers underrepresent the true burden of risk as they only considered four pathogens and many mild illnesses caused by the consumption of raw milk likely went unreported.

"Unpasteurized products are consumed by a small percentage of the US dairy consumers but cause 95% of illnesses," the authors concluded. "Therefore, outbreak-related illnesses will increase steadily as unpasteurized dairy consumption grows, likely driven largely by salmonellosis and campylobacteriosis."
Apr 26 Emerg Infect Dis study

Household contact case of MERS in Saudi Arabia

The Saudi Arabian Ministry of Health (MOH) identified another case of MERS-CoV related to the Wadi Aldwasir hospital outbreak.

The patient was a 26-year-old expatriate man who is in stable condition. The patient was asymptomatic and listed as a secondary household contact of a previously reported case.

The new cases raise Saudi Arabia's overall total to 1,597 Middle East Respiratory syndrome coronavirus (MERS-CoV) cases, 661 of them fatal. Three people are still being treated for their illnesses.
Apr 26 MOH update

H9N2 avian flu infects baby in China

China has reported a new H9N2 avian influenza case to the World Health Organization (WHO), involving an 11-month-old boy from Gansu province. The WHO noted the details in its monthly report on flu transmitted between animals and humans, spanning cases reported between Mar 16 and Apr 20.

The boy's symptoms began on Feb 6, and he was hospitalized with mild symptoms and recovered. An investigation revealed that he had been exposed to backyard poultry before becoming ill. The WHO said the illness marks the first H9N2 infection from Gansu province, which is located in northwestern China. H9N2 is endemic in Chinese poultry.

China's last H9N2 infection also involved a baby, a 7-month-old girl from Guangdong province who contracted her infection in the middle of December. Unlike H7N9, many of the H9N2 cases have been in children.
Apr 20 WHO flu at the animal-human interface report

New polio vaccine shows promise in phase 2 trial

A new inactivated polio vaccine with a reduced amount of antigen was found to be safe and effective during a phase 2 trial of the drug in the Dominican Republic. Results from the trial were published today in The Lancet Infectious Diseases.

Inactivated polio vaccines (IPVs) are a cornerstone of the polio eradication campaign because, unlike oral polio vaccines, they carry no risk of vaccine-related disease. Introducing IPVs into the developing world can be a costly task, however. This study measured the effectiveness of IPV alone and with various levels of aluminium hydroxide (Al) adjuvant as a dose-sparing measure.

More than 800 healthy infants over the age of 6 months were recruited to receive one of four IPV formulations (3-times reduced dose of Al, 5-times reduced dose, 10-times reduced dose, or IPV without Al) at 6, 10, or 14 weeks of age. All three IPV-Al formulations were non-inferior to IPV, with absolute differences in percentage seroconversion for polio virus types 1, 2, and 3 to be above 94.6%.

"The results from our trial strongly support a dose sparing strategy of three doses of aluminium hydroxide adjuvanted 1/10 IPV-Al," the authors wrote. "The results of this phase 2 trial should be a first step to help achieve and sustain polio eradication in the long term by addressing the issue of availability of effective vaccine choices."
Apr 26 Lancet Infect Dis study
Apr 26 Lancet Infect Dis editorial

Chikungunya spreads to second Pakistani province

The WHO and Pakistan's health ministry over the past few weeks have been investigating a chikungunya outbreaks in Balochistan, the second area in the country to report the disease. An earlier outbreak in Karachi has been under way since December.

A statement from the WHO's Eastern Mediterranean regional office yesterday said that, of 1,962 suspected cases in Balochistan, 28 blood samples have tested positive so far. A sudden rise in acute febrile illnesses in the city of Gwadar prompted the investigation and testing. A field investigation suggests that Balochistan's first cases came from Karachi via travel and that subsequent cases reflect local transmission.

In Karachi as of Apr 14, a total of 1,419 suspected cases have been reported so far, none of them fatal.

The WHO said because chikungunya is new to the populations, there is a fear that a large number of cases could occur within a short period without the control measures needed to contain the disease.
Apr 25 WHO EMRO statement