Mpox symptoms evolved over the past 5 decades, meta-analysis finds

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mpox rash on hands
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A meta-analysis of papers published during mpox epidemics from 1970 to 2023 suggests that symptoms in affected patients have become more diverse, with a decrease in symptoms other than rash.

Researchers from the Second Affiliated Hospital of Chongqing Medical University in China searched three databases for English-language, peer-reviewed studies on mpox symptoms published from January 1970 to April 2023. The periods covered included 1970 to 2022 (period 1, within Africa), 2003 to 2021 (period 2, mostly within Africa, but clusters elsewhere), and 2022 to 2023 (period 3, worldwide).

The 61 included studies reported on 21 symptoms in 720 mpox patients from period 1, 39 symptoms from 1,756 patients from period 2, and 37 symptoms from 12,277 patients from period 3.

The findings were published late last week in JMIR Public Health and Surveillance.

Rash common to all 3 periods

The most common symptom in all three periods was rash (period 1, 92.6%; period 2, 100%; and period 3, 94.8%), followed by enlarged lymph nodes (period 1, 59.8%; period 2, 74.1%; and period 3, 61.1%). In period 1, the primary symptoms were fever (99%), enlarged lymph nodes (80.5%), and headache (69.1%), with a significant decline in these symptoms in period 3 (37.9%, 31.2%, and 28.7%, respectively).

Epidemic countries may shift their focus on the potential association among symptoms and the high synergy risk.

In period 2, chills/shivering (73.3%), fatigue (68.2%), and difficulty swallowing (61.2%) emerged as the main symptoms but fell off significantly in period 3. In period 3, most other symptoms were similarly prevalent or declined relative to periods 1 and 2.

Nausea/vomiting correlated most closely with 13 symptoms and was highly positively correlated with enlarged lymph nodes and conjunctivitis ("pink eye") in period 2. During period 3, rash and headache were both most closely correlated with 21 symptoms and were highly positively correlated with fever.

"It is necessary to surveil the evolving nature of mpox and the consequential changes in clinical characteristics," the study authors wrote. "Epidemic countries may shift their focus on the potential association among symptoms and the high synergy risk."

Flu remains elevated in the Northern Hemisphere

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Flu activity remains elevated in many parts of the Northern Hemisphere, though detections have declined at the global level, the World Health Organization (WHO) said in its latest update, which roughly covers the last week of January and the first days of February.

H3N2 flu
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Hot spots include parts of Europe and Central Asia, with very high activity reported from Russia and Slovakia. The 2009 H1N1 virus is dominant, and hospitalizations are elevated but stable. In North America, flu levels are still elevated, with slight influenza B rises in the United States and Canada.

China's flu activity is elevated but declining in both the northern and southern provinces, with most detections involving influenza B. Hong Kong's flu hospitalizations are still above the seasonal threshold.

Upward trend in South East Asia

South East Asia's flu activity showed an overall increase, especially in Malaysia, Singapore, and Thailand. In Western Asia, flu activity rose in Armenia, Georgia, Israel, and Turkey. Flu remained stable in parts of tropical Asia, but with rises in the Maldives and Nepal.

In Africa, flu detections rose in some western nations, including Mauritania and Niger, and rose slightly in Cameroon.

Globally, of respiratory samples that were positive for flu at national flu labs during the reporting period, 78.9% were influenza A, and of subtyped influenza A viruses, 54.8% were H3N2. All influenza B viruses belonged to the Victoria lineage.

Study finds antibiotics prescribed by VA dentists 'commonly unnecessary'

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Dental procedure
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More than half of the antibiotics prescribed by dentists practicing in the Department of Veterans Affairs (VA) in 2019 do not have guidelines supporting their use and were likely unnecessary, researchers reported today in Infection Control & Hospital Epidemiology.

Using 2019 VA national electronic health record data, a team of VA researchers evaluated antibiotics prescribed by dentists for appropriateness using two definitions: a guideline-based definition (labeled as "consensus") consistent with American Dental Association Guidelines for Dental Pain and Swelling and American Heart Association Guidelines for the Prevention of Infective Endocarditis and an evidence-based definition (labeled as "non-consensus"). 

Inappropriate prescriptions, excessive duration

A total of 92,224 antibiotic prescriptions were associated with 88,539 dental visits. Most study participants were White (67.8%) and male (90.6%), and 53.9% were medically compromised. Amoxicillin (57.8%) and clindamycin (11.2%) were the most prescribed antibiotics. More than half of the prescriptions were used to prevent complications in medically compromised patients (30.9%) or to prevent post-surgical complications (20.1%), areas that lack professional guidance, the authors note. Of the antibiotics prescribed, 17.5% were considered concordant based on the consensus definition and 64.3% were considered non-consensus concordant.

Patient-specific factors that predicted receipt of inappropriate antibiotics were African American race, Native Hawaiian or Pacific Islander race, and Hispanic ethnicity.

The study also found that the average duration for antibiotics prescribed—8.3 days—was excessive.

"Regardless of definition applied, antibiotics prescribed by dentists were commonly unnecessary," the study authors wrote. "Improving prescribing by dentists is critical to reach the national goal to decrease unnecessary antibiotic use."

Site in India receives responsible antibiotic manufacturing certification

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Pharmaceutical company Viatris announced today that its manufacturing site in India has received Minimized Risk of Antimicrobial Resistance (AMR) certification.

The certification, developed by the British Standards Institution (BSI) in collaboration with the AMR Industry Alliance, provides third-party, independent verification that the antibiotic waste released into the environment by antibiotic manufacturing sites is below a threshold that could promote AMR in the environment. That threshold was established in responsible manufacturing guidelines developed by BSI and the AMR Industry Alliance in 2022 to encourage sustainable production of antibiotics.

The certification scheme is targeting key antibiotic supply chain markets like India and China. According to a CIDRAP-ASP report, approximately 20,000 tons of pharmaceuticals, including antibiotics, are produced at active pharmaceutical manufacturing sites in India, which are largely unregulated. Researchers have found high levels of antibiotics and multidrug-resistant bacteria in waters near some of those sites, raising concern about the environmental risks posed by antibiotic manufacturing.

The Viatris facility is in Aurangabad, India.

"We are proud to be the first pharmaceutical site in India to achieve this important Minimized Risk of Antimicrobial Resistance certification from BSI, demonstrating our commitment to controlling antibiotic discharge," Viatris Chief Operations Officer Sanjeev Sethi said in a company press release.

Study suggests pandemic employment drop for US nurses was transitory

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A new study in JAMA Health Forum of national data on US registered nurses (RNs) finds that the rebound in the total size of the RN workforce during 2022 and 2023 indicates that RN labor shortages during the first 2 years of the pandemic were likely transitory.

In 2021, the US RN workforce decreased by more than 100,000 employees, the largest single-year drop in 40 years.

But by 2022, increases in RN hiring had picked up across the country. To assess if pandemic trends were lasting or an anomaly, researchers used data from the US Bureau of the Census Current Population Survey, including employed RNs aged 23 to 69 years from 1982 through 2023. They paired those data with a retrospective cohort analysis of employment trends by birth year and age to project the age distribution and employment of RNs through 2035.

Included in the survey were 455,085 RNs ages 23 to 69. The authors found that the total number of full-time RNs in 2022 and 2023—3.35 million—was actually 6% higher than in 2019 (3.16 million).

Workforce expected to grow to 4.5 million by 2035

Using projections based on enrollment in nursing programs and jobs data, the authors estimate that by 2035, the RN workforce will grow by 1.2 million full-time employees to 4.5 million, which matches prepandemic forecasts. RNs ages 35 to 49 will make up nearly half of the workforce (47%) in 2035. In 2022, those RNs accounted for 38% of the workforce.

"This forecast suggests that the pandemic's impact on employed RNs, at least thus far, is unlikely to have a significant impact on the future growth of the overall RN workforce," the authors said.

This forecast suggests that the pandemic's impact on employed RNs, at least thus far, is unlikely to have a significant impact on the future growth of the overall RN workforce.

The authors did note, however, that RN employment in hospital settings is shifting, and may add to the perception of staffing shortages.

"Workforce growth from 2018 to 2023 occurred almost entirely in nonhospital settings and may reflect a shift of RN employment away from hospitals and into ambulatory and community settings," they wrote. "This shift may help explain why some hospitals have reported shortages of RNs, despite robust growth of the overall workforce in 2022 and 2023."

Quick takes: Good uptake of RSV vaccines in moms and infants, first avian flu in WV poultry, global COVID

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  • New data from the Centers for Disease Control and Prevention (CDC) shows that more than half of US newborns were protected from respiratory syncytial virus (RSV) this season by either the new monoclonal antibody preventive nirsemivab (Beyfortus) or maternal RSV immunization with Abrysvo, Axios reported, citing CDC figures. Through January, 40.5% of women with babies ages 8 months and younger said their infants received Beyfortus, and 16.2% of women at 32 or more weeks gestation received Abrysvo. Beyfortus was approved in July 2023, and high demand led to shortages in the fall and winter. In August 2023, Abrysvo was approved for pregnant women as a strategy to protect newborns.
  • The US Department of Agriculture (USDA) Animal and Plant Health Inspection Service (APHIS) today announced the first detection of highly pathogenic avian influenza in West Virginia's poultry, which occurred in a backyard flock in Kanawaha County, which encompasses Charleston, the state's capital. The state's agriculture department said the poultry owner contacted authorities following the rapid onset of illness and death in the multispecies flock. It said the virus had previously been detected twice before in wild birds. The outbreaks, which began in 2022, have now affected poultry in 48 states.
  • Though few countries regularly test for COVID-19 and report their data, the World Health Organization (WHO) continues to report monthly trends, and for January, cases declined 58% compared to the previous month, while deaths declined 38%. Even fewer countries regularly report hospitalizations and intensive care unit admissions for COVID, and those markers also declined in January. The JN.1 variant remains the dominant strain—accounting for 88% of sequences—and is the only variant showing a continued increase.

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