Four more Ebola cases reported in DRC, bringing total to 3,205

With 4 more cases recorded over the weekend and through today, the Ebola outbreak in the Democratic Republic of the Congo (DRC) now stands at 3,205 cases, including 2,142 deaths.  Officials are still investigating 411 suspected cases.

In recent weeks, reports of new cases have slowed significantly, and transmission has shifted to rural villages in North Kivu and Ituri provinces.

According to daily reports from the DRC's Ebola technical committee (CMRE), the three new cases first reported late last week were from Beni, Mambasa, and Mandima. Over the weekend, the CMRE confirmed three additional cases from Oicha, Lolwa, and Mandima.
Oct 5 CMRE report
Oct 6 CMRE report
WHO Ebola


CDC reports 7 new measles cases, 1,250 for the year

Today the Centers for Disease Control and Prevention (CDC) confirmed 7  new US measles cases, bringing the total for 2019 to 1,250 infections in 31 states.

The new cases reflect a slight uptick, as the CDC recorded zero and two new cases in its previous two weekly updates. Cases have slowed dramatically in recent months, however. After posting more than 300 cases in both March and April, officials confirmed 180 in May, 77 in June, 51 in July, 29 in August, and just 5 last month.

The 1,250 total cases represent the most in a year since 1992, and the most since the disease was declared eliminated from the country in 2000. The huge increase this year threatened elimination status in the United States but so far has not reversed it.

The CDC reported one ongoing outbreak—defined as three or more related cases—in New York state, the same as last week. State health officials late last week said New York is no longer combatting any of the large outbreaks that had begun in 2018. US outbreaks this year have been linked to measles outbreaks in foreign countries, the CDC said.
Oct 7 CDC update
Oct 4 CIDRAP News story "CDC: Close-knit, vaccine-reluctant communities stoked measles"


Saudi Arabia records 2 new MERS infections, 1 death

Over the weekend Saudi Arabia's Ministry of Health (MOH) reported two new MERS-CoV cases, the second and third in October, and one of the new cases proved fatal.

The first MERS-CoV (Middle East respiratory syndrome coronavirus) case involves a 70-year-old man with unknown camel exposure in Wadi ad-Dawasir. The man died, and the MOH lists his illness as "primary," meaning it's unlikely he contracted the virus from another person.

The second case is in a 52-year-old man from Torba, who did have camel exposure. Camel exposure is a common risk factor for MERS.

As of Sep 19, the WHO's Eastern Mediterranean regional office said that, since 2012 there have been 2,468 MERS cases, at least 850 of them fatal. The vast majority of infections have been in Saudi Arabia, which reported four MERS cases in September.
Oct 5 MOH report
Oct 6 MOH report


Review of 3 years of AFM data show viral cause most likely

US surveillance data for 3 consecutive years point to a viral cause of acute flaccid myelitis (AFM) in children but no clear causative virus, though enterovirus D68 (EV-D68) is most likely, according to a study today in Pediatrics involving 193 children with AFM.

CDC researchers analyzed data on 193 confirmed pediatric AFM cases from 2015 to 2017. Of those, 143 (74%) occurred in 2016, conforming with the every-other-year pattern that the CDC has noted. And about two-thirds of the 2016 cases occurred in August through October, which was also typical in 2014 and 2018.

The team found that, of 90 patients with upper respiratory specimens tested at the CDC, 32 (36%) were positive for enterovirus or rhonovirus, and 2 were positive for parechovirus. Among 77 patients with stool specimens tested at the CDC, 15 (19%) were positive for enterovirus or rhinorvirus, and 1 was positive for parechovirus. Conversely, only 1 patient had viruses detected in cerebrospinal fluid and 2 in blood.

Of 32 enteroviruses and rhinoviruses from respiratory samples typed, 22 (69%) were identified as EV-D68.

The authors write, "We conclude that symptoms of a viral syndrome within the week before limb weakness, detection of viral pathogens from sterile and nonsterile sites from almost half of patients, and seasonality of AFM incidence, particularly during the 2016 peak year, strongly suggest a viral etiology, including EVs."

In a commentary in the same issue, University of Colorado experts write, "Although detection of a pathogen in the CSF would provide definitive proof of causation, in this study and others, no pathogen has been consistently identified in CSF from AFM cases, even with the use of highly sensitive unbiased research technologies for pathogen detection and discovery. Development of intrathecal enterovirus antibody tests for CSF may further facilitate diagnosis of enterovirus-associated AFM."
Oct 7 Pediatrics study
Oct 7 Pediatrics commentary


Three new dengue cases confirmed in Miami-Dade County 

Officials confirmed three more dengue cases in Miami-Dade County, Florida, late last week. These cases raise the total locally transmitted dengue cases in Florida in 2019 to nine. Eight of the cases have been in Miami-Dade, and neighboring Broward County has reported one.

According to the Miami Herald, health officials believe two of three new cases are related. In addition to the nine locally transmitted cases, Florida has tallied 235 cases of travel-related dengue fever in the state so far in 2019.

Since Sep 27, the Florida Department of Health in Miami-Dade County has been under a mosquito-borne illness alert, and has urged residents to practice "drain and cover," which includes draining standing water near homes and wearing long-sleeved clothing and insect repellent, the Florida Department of Health (DOH) said.

Dengue is spread via Aedes mosquitoes, the same insect that can transmit Zika and chikungunya viruses.
Oct 4 Miami-Herald article
Sep 27 Florida DOH

Stewardship / Resistance Scan for Oct 07, 2019

News brief

Study find urinary antigen testing underused in pneumonia patients

An analysis of almost 160,000 pneumonia patients in 170 US hospitals indicates that urinary antigen testing (UAT), a practice recommended by national guidelines to allow for antibiotic de-escalation in patients with community-acquired pneumonia (CAP), is not widely performed, researchers reported today in Clinical Infectious Diseases.

To determine adherence to UAT recommendations from the Infectious Diseases Society of America (IDSA) and the American Thoracic Society and to gauge whether UAT results affect prescribing behavior, researchers with Cleveland Clinic and the University of Massachusetts Medical School conducted a retrospective study of adult patients with CAP or healthcare-associated pneumonia admitted to 170 hospitals from 2010 through 2015.

Among 159,894 eligible admissions, 24,757 (15.5%) had UAT performed (18.4% of ICU and 15.3% of non-ICU patients). Among hospitals with more than 100 eligible patients, UAT testing proportions ranged from 0%-69%. Compared to patients with negative UAT, 7.2% with positive UAT more often had a positive Streptococcus pneumoniae culture (25.4% vs 1.9%, P < 0.001)—a result that should allow for rapid de-escalation of therapy—and less often had resistant bacteria (5.2% vs 6.8%, P < 0.05).

Of patients initially treated with broad-spectrum antibiotics, most were still receiving broad-spectrum therapy 3 days later, but UAT-positive patients more often had coverage narrowed (38.4% vs 17.0% UAT-negative and 14.6% untested patients, P < 0.001). In addition, the duration of vancomycin, piperacillin-tazobactam, and carbapenems were all shorter in response to a positive UAT. Hospital rate of UAT was strongly correlated with de-escalation following a positive test. Only three patients de-escalated after positive UAT were subsequently admitted to ICU.

The authors conclude, "Despite the test being inexpensive, accurate and rapid, UAT appears underused, but could be an important tool for antibiotic stewardship. Broader indications for testing featured in national guidelines might help to spread its use nationwide."
Oct 7 Clin Infect Dis abstract


Researchers suggest patients on laxatives should be tested for C diff

In another study published in Clinical Infectious Diseases, researchers with Beth Israel Deaconess Medical Center report that the recommendation against conducting Clostridioides difficile infection (CDI) stool testing on patients who've recently taken laxatives carries a potential for harm and should be re-evaluated.

To increase the relevance of a positive stool test for C difficile, the 2017 IDSA-Society for Healthcare Epidemiology of America (IDSA-SHEA) clinical guidelines emphasized testing only in patients likely to have true CDI; among the groups the guidelines recommended against testing were those who'd received a laxative in the previous 48 hours. But the authors of the study note that this recommendation rests on weak evidence, and that the guidelines don't define meaningful laxative use or allow room for clinical judgement when other features signal infection.

Out of concern that this recommendation might miss some CDI diagnoses, the researchers prospectively enrolled patients at Beth Israel Deaconess Medical Center with new-onset diarrhea and a positive C difficile nucleic acid amplification (NAAT) test, including patients who'd used a laxative within 48 hours prior to stool testing. They then assessed CDI recurrence and severe outcomes, including intensive care unit (ICU) admission, colectomy, and death, during the 40 days after diagnosis.

Overall, 209 patients with CDI were studied, 65 of whom (31%) had received laxatives. Among the patients receiving versus those not receiving laxatives, there were no significant differences in the proportion meeting severe CDI criteria by four severity scoring methods (66.2% vs 56.3%, respectively, P = 0.224). Similar rates of serious outcomes attributable to CDI, including death, ICU admission, and colectomy, were observed in the laxative and no laxative groups.   

"Had LAX 48 patients been excluded from testing as recommended by the IDSA-SHEA guidelines, diagnosis of CDI would have been missed in nearly one third of this cohort, 66.2% of whom met criteria for severe CDI by IDSA-SHEA scoring methods—including one death, one patient who required a colectomy, and seven patients who required treatment in an ICU due to CDI," the authors write. "It is likely that some of the other LAX 48 patients would also have suffered additional adverse outcomes due to delayed or missed diagnoses and treatment."

The authors say the issue should be investigated in larger multisite studies.
Oct 4 Clin Infect Dis abstract


Germany reports XDR Klebsiella pneumoniae in 4 hospitals

German public health authorities have confirmed a 17-case outbreak of extensively drug-resistant (XDR) Klebsiella pneunomiae in four hospitals, the European Centre for Disease Prevention and Control (ECDC) said today in its weekly communicable disease threats report.

Six patients are infected and 11 are carrying XDR K pneumoniae in the northeast state of Mecklenburg-West Pomerania, the ECDC said. The strain is resistant to all penicillins, ephalosporins, carbapenems, quinolones, aminoglycosides, and fosfomycin and colistin, officials said. But it is susceptible to chloramphenicol, tigecycline (though susceptibility is limited), and cefiderocol, an experimental antibiotic not yet approved in Europe.

The outbreak highlights "the worsening situation and the high risk for further spread of highly-resistant, hospital-adapted strains of carbapenem-resistant Enterobacteriaceae in the EU/EEA," the ECDC said. It added that the disease has very few remaining treatment options, and continent-wide enhanced control efforts are needed.

The ECDC said it is monitoring the event and seeking more information from German officials.
Oct 7 ECDC report

This week's top reads