News Scan for Dec 08, 2020

News brief

Study suggests childcare workers not at higher risk for COVID-19

A large study of childcare providers in Pediatrics today found that childcare staff were not at higher risk for COVID-19 during the early months of the US pandemic.

Recent research suggests that children are unlikely to be the source of COVID-19 household outbreaks, but the role of children in the spread of SARS-CoV-2, the virus that causes COVID-19, has not been fully defined. A number of studies show low rates of pediatric SARS-CoV-2 infection and spread and mild symptoms in infected children. But other research shows that children shed virus at levels comparable to adults, suggesting that children could be a significant source of community transmission and leading to concerns about spread in childcare settings.

Researchers gathered email survey data from 57,335 self-identified childcare providers in all 50 states from May 22 to Jun 8, using national childcare association databases and state registries. Participants self-reported testing positive or being hospitalized for SARS-CoV-2 (427 cases), as well as their degree of exposure to childcare.

Nearly half of all childcare programs (48.6%) did not close or reopened during the study period. Programs that remained open were typically operating at lower capacity and with significant mitigation efforts—hand hygiene, surface disinfection, symptom screening, grouping children by age-group, and social distancing.

The study authors found no association between exposure to childcare and risk of contracting COVID-19 after adjusting for confounding variables (matched odds ratio, 0.94; 95% confidence interval [CI], 0.73 to 1.21). Home-based providers showed a higher risk of COVID-19 (OR, 1.59; 95% CI, 1.14 to 2.23) but did not show an association with childcare exposure. Risk of COVID-19 in childcare workers was strongly associated with high levels of community transmission, measured by county-level COVID-19 deaths (OR, 1.60; 95% CI, 1.19 to 2.15; P=0.002).

Experts in a commentary in the same journal caution against extrapolating the study's conclusions to kindergarteners to 12th-graders. "Student, teacher, and classroom dynamics differ from child care settings in ways that meaningfully influence infection transmission," they noted. "The results from this study should give confidence to center-based child care providers that the risk of COVID-19 infection from young children is low when community transmission is low and multiple risk mitigation strategies are employed."
Dec 8 Pediatrics study
Dec 8 Pediatrics commentary

Every week of lockdown increased binge drinking odds by 19%, data show

The likelihood of binge drinking increased 19% every week during the US spring COVID-19 lockdown, according to a study published yesterday in the American Journal of Drug and Alcohol Abuse. The 1,982-person survey also revealed that the most predictive factors of increased drinking were pre-pandemic drinking habits and history of depression.

The researchers collected data from mid-March to mid-April, and binge drinking was defined as more than four drinks per occasion for women and more than five drinks per occasion for men.

Overall, increased alcohol consumption during the pandemic was 60% more likely for binge drinkers and 28% more likely for non-binge drinkers. If respondents reported a previous depression diagnosis and were currently experiencing depressive symptoms, they were 80% more likely to increase their drinking during lockdown—227% more likely if they were already binge drinkers. Living with children minimized odds of any drinking by 26%.

"We hope that public health and clinical experts consider these additional associations of the pandemic and develop programs and opportunities to overcome them," Sitara Weerakoon, MPH, first and corresponding study author, said in a University of Texas press release. "This may include increasing awareness and access to virtual counseling sessions and mental health services. Additionally, public health organizations should prioritize providing healthy alternatives for stress relief, such as virtual meetups and social activities."

Before the pandemic, binge drinkers said they drank a maximum of 6.5 drinks per occasion, and 31.1% practiced the same alcohol consumption during the pandemic's first wave. Non-binge drinkers had a 2.1-drink upper limit, and 55.8% of them said their intake did not change. Respondents were mostly affluent (75% had a household income of at least $80,000), had an average age of 42, and were predominantly white (89%).
Dec 7 Am J Drug Alcohol Abuse study
Dec 7 University of Texas press release

Universal flu vaccine found safe, immune-producing in phase 1 trial

Universal flu vaccine candidates created with chimeric hemagglutinin (cHA) produced a broad immune response for 1.5 years, reports a study yesterday in Nature Medicine. Traditional flu vaccines target the virus' head of hemagglutinin (HA), but some researchers hope that creating a vaccine that targets the less-frequently mutating stalk will provide longer and broader protection.

The researchers were able to sidestep issues of the virus's immunodominant head by using first H8 then H5 HA viral heads in their vaccination sequence, both with the same H1 HA stalk. Past studies have shown that by using the same stalk but different heads in vaccination regimens, subjects receive rising levels of immunity to the stalk itself. Most adults have already been primed at least once for the H1 stalk through previous exposure.

The placebo-controlled, phase 1 trial used three different intervention groups and two control groups of 18- to 39-year-old, healthy US adults. Variables included intranasal or intramuscular prescription, live-attenuated influenza virus vaccines (LAIVs) or inactivated influenza virus vaccines (IIVs), and the presence of an adjuvant.

All regimens included a booster of some kind on day 85. Out of 65 study participants, most adverse events were mild or moderate, with common effects across all intervention groups being headache, fatigue, and muscle soreness.

Using 1,280 stalk antibody area under the curve (AUC) levels as an acceptable level of immune response, the most promising long-term regimen was an intramuscular, adjuvanted IIV expressing cH8/1N1 on day 1 and a booster of adjuvanted cH5/1N1. Between 66.7% and 73.3% of participants still remained in this immune threshold considered to be protective between days 242 and 588, approximately 2.25-fold above baseline.

The other two regimens used LAIVs, and while the addition of an IIV booster vaccination produced long-term immune response in only 7.7% of recipients, 40.9% of those who received an IIV booster with an adjuvant had sufficient titer levels for immunity.
Dec 7 Nat Med study

H5N8 avian flu strikes more poultry, wild birds in Europe

Two countries—France and Poland—reported more highly pathogenic H5N8 avian flu outbreaks in poultry, and France and two other European countries reported more detections of the virus in wild birds, according to the latest notifications from the World Organization for Animal Health (OIE).

In France, the virus struck a duck farm during the open-air prefeeding phase in Landes department in the far southwest of the country. The event began on Dec 5, killing 400 of 6,000 birds. An investigation into the source of the virus is still under way, but the farm is near a wetland area where migratory birds stop.

Poland reported H5N8 at a layer farm in Pomorskie province in the northwestern part of the country. The outbreak started on Dec 3 and killed 6,000 of 176,871 chickens at the facility.

In wild bird reports, France reported H5N8 detections in waterfowl in Loire-Atlantique department in the northwest and Meurthe et Moselle department in the northeast. Slovenia reported more H5N8 in waterfowl, this time from Ljubljana, its capital and largest city. And the Netherlands reported three more outbreaks in waterfowl, two in South Holland province and one in Utrecht province.
Dec 8 OIE report on H5N8 in French poultry
Dec 8 OIE report on H5N8 in Polish poultry
Dec 8 OIE report on H5N8 in French wild birds
Dec 7 OIE report on H5N8 in Slovenia
Dec 7 OIE report on H5N8 in the Netherlands

Stewardship / Resistance Scan for Dec 08, 2020

News brief

Primary care stewardship cuts antibiotics, costs for respiratory infections

A cluster-randomized controlled trial conducted in Spanish primary care settings suggests a multifaceted stewardship intervention helped reduce antibiotic prescribing for acute respiratory infections (ARIs) and was cost-effective, Spanish researchers reported yesterday in Antimicrobial Resistance and Infection Control.

The intervention was introduced among primary care providers in Galicia, a region of northwest Spain where at least one third of all antibiotic prescriptions are for ARIs but only half are thought to be appropriate. It included a one-hour educational outreach visit tailored to physician knowledge gaps identified in a previous study, an online course integrated in practiced accreditation, and a clinical decision support system.

To evaluate the intervention, after a median of 19 months, researchers looked at antibiotic prescribing among 1,217 physicians recruited from seven intervention clusters and 1,393 from control clusters. The main outcomes measured were overall antibiotic prescribing for ARIs, antibiotic use by class, the ratio of consumption of broad- to narrow-spectrum antibiotics, and the savings attributed to the intervention.

The results showed a 4.23% decline in overall antibiotic prescribing in the intervention group compared with the control group, highlighted by a 6.51% reduction in penicillin use. The ratio of consumption of broad- to narrow-spectrum penicillins, cephalosporins, and macrolides fell by 8.97%. Because of the reduction in antibiotic prescriptions, Spain's National Health Service directly saved €311 (USD $377) per physician and patients directly saved €573 ($694).

"The results of this study indicate that low-cost interventions based on the previously identified gaps can be effective and, in addition, have a positive cost-benefit relationship over a short time horizon, something that could be highly relevant for their application by healthcare systems," the authors wrote.
Dec 7 Antimicrob Resist Infect Control study

VA stewardship interventions linked to reduced antibiotic use for ARIs

Implementation of the Centers for Disease Control and Prevention's Core Elements of Outpatient Antibiotic Stewardship at Veterans Affairs (VA) emergency departments and primary care clinics was associated with reduced antibiotic prescribing for uncomplicated ARIs and a drop in hospitalizations, US researchers reported today in Clinical Infectious Diseases.

Key elements of the intervention included physician education and diagnosis-based audit and feedback reports.

The quasi-experimental, controlled study compared the effects of Core Elements' implementation at 10 VA sites—four emergency departments and six primary care clinics—with prescribing data from 40 control sites over a 5-year period.

There were 16,712 and 51,275 uncomplicated ARI visits at the intervention and control sites, respectively, from 2014 through 2019. Antibiotic prescribing rates fell from 59.7% pre-intervention to 41.5% post-intervention, compared with 73.5% to 67.2% at the control sites. The proportion of visits with appropriate therapy increased from 53.8% to 69.1% at the intervention sites (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.31 to 2.14), but was unchanged at the control sites (OR, 1.04; 95% CI, 0.91 to 1.19).

There was no statistical difference in ARI-related return visits post-implementation (-1.3% vs -2.0%), but all-cause hospitalization was lower within the intervention sites (-0.5% vs -0.2%). The OR to diagnose upper respiratory tract infection not otherwise specified compared to other non-ARI diagnosis increased post-implementation for intervention sites (1.27) but not control sites (0.97).

The authors conclude that healthcare systems interested in improving antibiotic prescribing should embrace the Core Elements framework and consider implementation of similar interventions.
Dec 8 Clin Infect Dis abstract

More improper antibiotics noted for ARIs in rural vs city Tennessee kids

In another study on antibiotic prescribing for respiratory infections, researchers in Tennessee reported today in Open Forum Infectious Diseases that inappropriate antibiotic use for ARIs was significantly higher in children from rural counties compared with urban counties.

The study cohort consisted of children aged 2 months to 5 years who were enrolled in Tennessee Medicaid from 2007 through 2012 and diagnosed with an ARI in the outpatient setting during that period. Using electronic medical record and pharmacy data, researchers from Vanderbilt University Medical Center and Atrium Health compared rates of ARI and related antibiotic use among children in completely rural, mostly rural, and mostly urban counties. Multivariable regression models were used to measure associations between rurality of residence and the rate of study outcomes.

Compared with children from mostly urban areas, children from mostly rural and completely rural counties had higher rates of ARIs (adjusted incidence rate ratio [aIRR], 1.07 1.07, respectively), ARI-related antibiotic use (aIRR, 1.15 and 1.17), and ARI-related inappropriate antibiotic use (aIRR, 1.34 and 1.33).

Although the proportion of ARIs associated with overall and inappropriate antibiotic use decreased over time, they remained higher in children living in rural counties compared to urban counties throughout the study period. The strength of the association between rurality and rate of antibiotic use was higher among black children and those from households with lower median incomes.

"These findings should inform targeted outpatient stewardship efforts to reduce inappropriate antibiotic use and its consequences," the authors concluded.
Dec 8 Open Forum Infect Dis abstract