News Scan for Jul 20, 2020

News brief

Ebola infects 3 more in the DRC, lifting cases to 60

Three more Ebola infections were confirmed in the Democratic Republic of the Congo (DRC) Equateur province over the weekend, raising the total to 60 cases, the World Health Organization (WHO) African regional office said on Twitter today. Of the total, 56 are confirmed and 4 are listed as probable.

Two more deaths were reported, raising the total to 24.

At a media briefing today, Mike Ryan, MD, who directs the WHO's health emergencies program, said the outbreak is worrying, given the dispersed nature of the outbreak, which is spread across 21 health areas in seven health zones. Also, he said nine people with confirmed infections are still in the community, a factor known to raise the risk of further transmission.

Investigations so far suggest that about one in three cases are linked to attending funeral, also a known transmission risk. Others have been linked to exposure in healthcare settings and among family members.

Ibrahima Soce Fall, MD, the WHO's assistant director-general for emergency response, said there are teams on the ground and the response is still scaling up, with participation by a range of partners, which is challenging in the context of the COVID-19 pandemic.
Jul 20 WHO African regional office tweet

Australian study shows low rate of appropriateness for pre-surgery antibiotics

Analysis of data from a survey of surgical antimicrobial prophylaxis (SAP) conducted in Australian hospitals found a low rate of appropriateness and identified several factors that influence appropriateness, Australian researchers reported in JAC-Antimicrobial Resistance.

The researchers analyzed all procedures audited from April 2016 through April 2019 in the Surgical National Antimicrobial Prescribing Survey (NAPS), which collects data on all antimicrobial prescriptions for surgical procedures, along with clinical information, procedure-related factors, and patient and hospital demographics. The aim of the study was to describe the patient, hospital, and surgical factors associated with appropriateness of antimicrobial choice for procedural SAP, with a focus on the top five antimicrobials and antimicrobial classes prescribed. SAP is the most common indication for antimicrobial use in Australian hospitals.

A total of 12,419 procedures with 14,150 prescribed initial procedural SAP doses were included for analysis. Appropriateness varied across the choice of antimicrobial agent but was low overall (57.7%).

The most common reason for inappropriate antimicrobial choice was that the spectrum of the selected antimicrobial was too broad (55.7%), which is associated with patient harms and is a potential driver of antimicrobial resistance. Allergy status, surgical procedure group, and the presence of prosthetic material were positively associated with cefazolin and aminoglycoside appropriateness (P < 0.05). There were no significant positive associations with glycopeptides and third- and fourth-generation cephalosporins.

"Identification of these prescribing trends supports an ongoing examination of SAP prescribing practices in Australia and identification of potential targets for interventions across multiple health sectors such as AMS [antimicrobial stewardship], guideline development, and hospital policy," the authors wrote.
Jul 18 JAC-Antimicrob Resist study

Focus groups reveal primary care docs less concerned about antibiotic resistance

In a series of focus groups conducted with primary care providers in four US cities, most participants consistently identified antibiotic resistance as a lower priority compared with other health concerns, and suggested that urgent care, retail clinics, and patient demand were the key drivers of inappropriate prescribing, researchers reported last week in BMJ Open.

The eight focus groups, which were conducted by the Pew Charitable Trusts and the American Medical Association in Chicago, Los Angeles, Philadelphia, and Birmingham, included family medicine and internal medicine physicians and pediatricians. In each focus group, an independent moderator asked the participants to rank a number of public health issues in terms of importance, then asked questions aimed at understanding physicians' attitudes and perceptions around antibiotic use and stewardship. A total 52 primary care providers participated in the recorded discussions.

Two of the main themes that emerged from the conversations were that antibiotic resistance is seen as less of a problem than issues such as obesity, diabetes, and opioid use, and that it does not affect the participants' patients or their daily practice.

Many felt resistance was a more pressing issue for sicker, hospitalized patients. When it came to inappropriate prescribing, participants suggested that urgent care and retail medicine clinics were to blame for prescribing antibiotics too frequently, and often returned to the theme of patient demand and fear of receiving poor patient satisfaction scores.

"We're under pressure all day," one pediatrician in Birmingham said. "You don't want to get written up, potentially, for being insensitive, or not taking care of them, or physician ratings."

Participants reacted positively to stewardship efforts aimed at patient and clinician education but were more skeptical of activities focused on measuring inappropriate prescribing and expressed distrust of tracking and reporting systems.

The authors of the study say it will be important to address these perceptions when designing stewardship interventions for outpatient settings.
Jul 14 BMJ Open study

H1N1v flu case reported in German child who had swine exposure

In a monthly update on zoonotic influenza infections, the WHO said Germany on Jul 3 notified it of a swine influenza variant H1N1 (H1N1v) infection, which involved a young child.

The 2-year-old boy started having symptoms on June9, and a sample was collected as part of routine flu surveillance. An unsubtypable virus was detected on Jun 15, and whole-genome sequencing on Jul 1 identified a Eurasian avian-like swine virus.

The patient recovered, and no similar infections were found among his contacts. Investigators found that the boy had visited a pig farm and had close contact with pigs 2 days before his symptoms began.

Antigenic studies on the virus isolated from the boy suggest some cross-reactivity with the seasonal 2009 H1N1 virus, which could point to some immunity in the general population against similar viruses.

The WHO update also covered to two earlier reported H9N2 infections in Chinese children and a variant H1N2 infection in a Brazilian swine slaughterhouse worker.
Jul 10 WHO flu at the human-animal interface report

COVID-19 Scan for Jul 20, 2020

News brief

Death rate in Italy rose 104.5% during COVID-19 pandemic, analysis finds

The official COVID-19 death count from the pandemic in Italy is likely a significant undercount, according to a research letter published today in JAMA Internal Medicine.

After comparing National Health Authority coronavirus death data from Feb 23 to Apr 4, 2020, with preliminary death data from the Italian National Institute of Statistics from Jan 12 to Apr 4 in 2015 to 2019, the researchers concluded that the annual all-cause death count in March and early April 2020 rose 104.5% to 41,329, from, on average, 20,214 in previous years.

On average, from 2015 to 2019, 9,395 men and 10,819 women died each year in March and early April. But from Mar 1 to Apr 4, 2020, 21,266 men and 20,063 women died, increases of 126.4% and 85.4%, respectively.

And 5,417 people aged 65 to 74 years died from Mar 1 to Apr 4 this year, compared with, on average, 2,566, a 111.1% increase. In 2020, 32,829 people aged 74 years and older died, versus 15,677 in the previous years, a 109.4% increase.

Of the 41,329 all-cause deaths reported from Mar 1 to Apr 4, 2020, 19,824 occurred in the hard-hit northern region of Lombardy, versus 7,248 in 2019, an increase of 173.5%. Of the 19,824 deaths, 10,415 involved men (compared with 3,328 in 2019) and 9,409 involved women (compared with 3,920).

In Italy, deaths are attributed to COVID-19 only for patients who test positive in hospitals and some nursing homes, not for those who died at home or in nursing homes that didn't perform testing.

Noting that many other countries are also concerned about coronavirus death undercounts, the authors said that several factors may explain the findings, "including additional deaths directly related to the virus, deaths related to underlying health conditions exacerbated by the virus, and delayed care from the avoidance of hospitals or the demands on hospitals of caring for COVID-19 patients," they wrote. "The differences for men, for people 65 years and older, and for the Lombardy region are particularly noteworthy."
Jul 20 JAMA Intern Med research letter

South Korean study finds high coronavirus transmission in older kids

A study of contacts of South Korean coronavirus patients found that the highest rate of household transmission occurred with index patients ages 10 to 19, while the lowest was in households with younger children, researchers from the Korean Centers for Disease Control and Prevention reported last week in Emerging Infectious Diseases.

In the study, the researchers monitored 59,073 contacts of 5,706 index patients for an average of 9.9 days after SARS-CoV-2 (the virus that causes COVID-19) was detected in the index patient. Of the contacts, 10,592 were in the same household as the index patient, and 48,481 were non-household contacts. The researchers grouped the index patients by age: 0 to 9, 10 to 19, 20 to 29, 30 to 39, 40 to 49, 50 to 59, 60 to 69, 70 to 79, and 80 years and older.

A total of 11.8% (95% confidence interval [CI], 11.2% to 12.4%) of household contacts of index patients had COVID-19, compared with only 1.9% of non-household contacts. In households with index patients 10 to 19 years of age, 18.6% (95% CI, 14.0% to 24.0%) of contacts had COVID-19, which was higher than any other age group. The lowest rate of transmission was seen in households where the index patient was 0 to 9 years (5.3%; 95% CI, 1.3% to 13.7%).

The authors of the study note several limitations, including the fact that they could not determine the direction of transmission, asymptomatic cases might not have been identified, and detected cases could have been exposed outside the household. But they suggested the results of the study, which was conducted when schools were closed in South Korea, need to be considered as schools are reopened.

"Although the detection rate for contacts of preschool-aged children was lower, young children may show higher attack rates when the school closure ends, contributing to community transmission of COVID-19," they wrote. "The role of household transmission of SARS-CoV-2 amid reopening of schools and loosening of social distancing underscores the need for a time-sensitive epidemiologic study to guide public health policy."
Jul 16 Emerg Infect Dis study

Mosquitoes unlikely to transmit SARS-CoV-2, study finds

New research by scientists from Kansas State University's College of Veterinary Medicine shows that mosquitoes are unlikely to be a vector for transmission of SARS-CoV-2, the virus that causes COVID-19, according to a study published late last week in Scientific Reports.

The scientists inoculated three common species of mosquito—Aedes aegypti, Aedes albopictus, and Culex quinquefasciatus—with SARS-CoV-2, with the hypothesis that if the virus did not replicate in the mosquitoes under an extreme viral challenge, the lack of replication would preclude the possibility of biological transmission.

While samples collected within 2 hours of inoculation confirmed efficient delivery of the virus, no virus was detected in the 277 mosquitoes collected and titrated at any time after 24 hours, "suggesting a rapid loss of infectivity and the lack of replication after injection."

"Based upon the lack of detectable infectious virus in any of the 277 samples collected at all time points beyond 24 h post-inoculation, we conclude that SARS-CoV-2 is unable to replicate in mosquitoes and that even if a mosquito fed on a person with virus in the blood, that the mosquito would not be a vector if feeding on a naïve host," the scientists wrote.
Jul 17 Sci Rep study