News Scan for Apr 09, 2019

News brief

Saudi Arabia records 3 more MERS cases, including 1 in Khafji

Saudi Arabia's Ministry of Health (MOH) yesterday reported three more MERS-CoV cases, including another case in Khafji in the northeastern part of the country. Officials also confirmed cases in Riyadh and Najran.

The patient in Khafji is a 34-year-old woman diagnosed as having MERS-CoV (Middle East respiratory syndrome coronavirus). Her case is listed as involving secondary exposure and is likely part of a growing cluster of 10 cases in that city reported since Mar 29. It is not known if she had camel contact.

Both the cases involving a 51-year-old man from Riyadh and a 79-year-old man from Najran are listed as primary, meaning it is unlikely they contracted the disease from another person. Camel contact status is also unknown for these two patients, as well.

The 3 new illnesses lift Saudi Arabia's total since the first of the year to 126 cases, including 57 linked to a large outbreak in Wadi ad-Dawasir.
Apr 8 MOH update

NYC declares state of emergency, mandatory measles vaccinations

Today New York City (NYC) Mayor Bill de Blasio declared a state of emergency requiring mandatory vaccination for all unvaccinated people exposed to the measles virus in certain parts of Williamsburg, Brooklyn.

The emergency will allow the city's Department of Health and Mental Hygiene to check the vaccination records of any case contact and require unvaccinated individuals to receive the measles, mumps, and rubella (MMR) vaccine or pay up to $1,000 in fines.

"As a pediatrician, I know the MMR vaccine is safe and effective," said city Health Commissioner Oxiris Barbot, MD, in an NYC press release. "This outbreak is being fueled by a small group of anti-vaxxers in these neighborhoods. They have been spreading dangerous misinformation based on fake science."

The 285-case outbreak began in Brooklyn's Orthodox Jewish neighborhoods last September and is connected to a measles outbreak in Israel. Children account for 246 cases, and 39 cases are in adults, with most patients being unvaccinated or incompletely vaccinated. There have been no deaths in the outbreak, but 21 case-patients have been hospitalized, including 5 admissions to the intensive care unit.
Apr 9 NYC press release

Experts and researchers call for universal flu vaccines

Progress toward a revolutionary universal flu vaccine is gaining momentum, and one is needed to be prepared for the next pandemic. That's the takeaway from a new 15-article supplement published today by the Journal of Infectious Diseases that explains the current research on universal flu vaccines in light of a century of fighting influenza pandemics.

Unlike the seasonal flu vaccine, which needs to be administered annually, a universal flu vaccine would ideally offer long-term protection against common influenza strains. In an introduction to the supplement, Anthony Fauci, MD, director of the National Institutes of Health (NIH), said a universal flu vaccine must be put in place before the next flu pandemic.

Pandemics, of which there have been four in the past 100 years, represent novel strains of influenza and can produce a high morbidity and mortality rate. The most devastating one in that span was the 1918 "Spanish flu" H1N1 virus, which killed 50 million people worldwide from 1918 to 1920.

Even in non-pandemic seasons, Fauci said seasonal flu causes an estimated 291,243 to 645,832 deaths each year—with approximately 12,000 to 56,000 deaths in the United States alone. Though seasonal flu vaccines reduce morbidity and mortality rates, they vary in their effectiveness.
Apr 9 NIH press release
Apr 9 J Infect Dis supplement

WHO condemns polio worker's killing in Pakistan

The World Health Organization (WHO) today condemned the killing of a frontline polio worker in Pakistan's Khyber Pakhtunkhwa province. In a statement, it said the man who died, Wajid Ali, was a dedicated worker who was shot and killed while supporting polio eradication and immunization in Pakistan yesterday.

Ahmend Al-Mandhari, MD, PhD, who directs the WHO's Eastern Mediterranean regional office, said in the statement, "Health care should never be a target, and WHO and our partners will not be deterred by such attacks. We will continue our efforts to work with the Government of Pakistan, UNICEF, and other partners to eradicate polio and ensure the highest possible level of health for all the people of Pakistan."

Pakistan is one of three countries in which polio is still considered endemic. The others are Afghanistan and Nigeria. Khyber Pakhtunkhwa is in Pakistan's northwestern tribal area near the border with Afghanistan.

Ni'ma Abid, MD, acting director of the WHO's Pakistan office, said health officials are devastated by the tragic news and extend their condolences to the man's family and friends. "The only tribute we can pay to those who have sacrificed their lives to protect Pakistani children from the death and lifelong disability polio brings, is to complete their mission and eradicate polio from Pakistan."
Apr 9 WHO statement

Stewardship / Resistance Scan for Apr 09, 2019

News brief

MCR-1 E coli found in cluster of New York City liver transplant patients

A study yesterday in Antimicrobial Agents and Chemotherapy describes the detection of MCR-1-carrying Escherichia coli in three liver transplant patients at a New York City hospital.

The three patients at Columbia University Irving Medical Center were found to be colonized with MCR-1–carrying E coli in 2015 after undergoing liver transplants. MCR-1, which confers resistance to the last-resort antibiotic colistin, was first discovered in China in 2015 and has since spread to more than 30 countries. To date, 53 US cases have been reported, but this report represents the earliest documented healthcare-related cluster of MCR-1 in the country.

Two of the liver transplant patients (patients 2 and 4) were epidemiologically linked, potentially through same-day endoscopic procedures, to an index patient (patient 1) who had been infected with MCR-1 E coli and successfully treated. Patient 2 underwent endoscopic retrograde cholangiopancreatography (ECRT) on the same day as patient 1 in March 2015, and then underwent ECRT again in September 2015, on the same day that patient 4 underwent gastroduodenoscopy. Patient 3 had no epidemiologic links to the other cases. The three colonized patients did not experience infections in more than 2 years of follow-up.

Multi-locus sequence typing indicated that all the MCR-1 E coli isolates belonged to sequence type (ST)117 and were related, and whole-genome sequencing revealed that, in addition to carrying MCR-1 on identical plasmids, the isolates also harbored resistance genes for beta-lactams, aminoglycosides, sulphonamides, trimethoprim, macrolides, chloramphenicol, and tetracyclines. Retrospective molecular screening of more than 500 samples (cephalosporin-resistant E coli isolates and discarded surveillance rectal swabs) found no other MCR-1–carrying isolates.

"The detection of this cluster demonstrates the potential for silent dissemination of mcr-1 in the hospital setting through asymptomatic colonization and suggests a possible role for same-day endoscopy-related transmission, independent of using the same endoscope," the authors of the study write. "While infective episodes have the greatest impact on patient outcomes, detection of silent colonization may play an important role in stemming the spread of mcr-1."
Apr 8 Antimicrob Agents Chemother abstract

Analysis finds declining outpatient antibiotic use in Massachusetts

Researchers from the Massachusetts Department of Public Health and Harvard reported yesterday in Open Forum Infectious Diseases that outpatient antibiotic prescribing in Massachusetts fell by nearly 17% from 2011 to 2015. Their analysis also found a wide variation in antibiotic use by census tract.

Using outpatient prescription claims from the Massachusetts All-Payers Claims Database from 2011 through 2015, the researchers measured claims for antibiotic prescriptions and calculated rates per 1,000 people by calendar year, sex, and age-group. Population-wide antibiotic use was measured for major antibiotic classes and the most frequently prescribed individual antibiotics. To describe in-state geographic patterns, the investigators measured prescribing rates for the four most frequently prescribed antibiotics—penicillins, quinolones, cephalosporins, and macrolides—stratified by the US census tract of residence documented in the claim.

The study population had 17.1 million antibiotic claims prescribed for 4.9 million members over the study period. The overall annual rate of outpatient antibiotic use for individuals 64 years old and younger was 696 prescriptions per 1,000 people, falling from 759 to 652 prescriptions per 1,000 people from 2011 through 2015, a decline of 16.7%. The highest rate of prescribing was among infants, and the lowest was among children and young adults aged 10 to 19 years. In 2015, 68% of people had no antibiotic prescription, and 17% had only one.

The researchers noted dramatic variability in antibiotic use by census tract within the state, with penicillin use ranging from 31 to 265 prescriptions per 1,000 people, macrolide use ranging from 28 to 333, cephalosporin use ranging from 8 to 89, and quinolone use ranging from 13 to 118. In general, urban areas had lower antibiotic use among the four major antibiotic classes.

The authors of the study believe that the detailed characteristics of populations and providers with higher prescribing rates can be used to focus education and monitoring. They say they plan to share these results with providers and the community through online reports.

"Combining these data with clinical indications for antibiotic prescriptions, particularly in areas with higher prescribing rates, will aid in shaping stewardship interventions," they write.
Apr 8 Open Forum Infect Dis abstract