Alaska mumps outbreak keeps going despite expanded vaccination efforts

A mumps outbreak centered in Anchorage, Alaska, has chugged along for more than a year and reached nearly 400 cases despite a series of vaccination recommendations that expanded to include the entire state, according to a report released by the Centers for Disease Control and Prevention (CDC) today.

The outbreak began in May 2017 with a confirmed case in an Anchorage resident who had been exposed to a visitor with mumps-like symptoms, according to an article in Morbidity and Mortality Weekly Report (MMWR). Another seven cases were confirmed in Anchorage residents in July and August 2017, all in people who self-identified as Native Hawaiian or other Pacific Islanders (NH/PI). The cases prompted the Alaska Section of Epidemiology (SOE) to urge all Alaskans to get up to date on their measles, mumps, and rubella (MMR) vaccinations.

By mid-November the case count reached 56, with most cases in NH/PI persons. The SOE then recommended a third MMR dose for anyone at increased risk, including NH/PI individuals. But cases continued to occur, including some in people with no known links to previous case-patients. In late December, with the case count at 138, the SOE recommended a third MMR dose for all Anchorage residents.

But cases, including some statewide, continued to surface, reaching 247 by Feb 22, 2018. The SOE then extended the third-dose MMR recommendation to everyone in Alaska, the CDC reported. State health officials also conducted outreach efforts to raise awareness and promote vaccination.

"As of July 31, 2018, the outbreak is ongoing, with 391 confirmed and probable cases reported; 94% of cases have been in Anchorage residents," the report says. About half of patients identified as NH/PI, and 41% had received at least two MMR doses before they got sick.

The report notes that the initial recommendation of an additional MMR dose for high-risk people was in line with CDC guidelines. But as the outbreak evolved, it became harder to identify those at increased risk, as clinicians were often uncertain about whether their patients were involved in groups where mumps was circulating. That uncertainty led to the phased expansion of the vaccination recommendations.
Aug 24 MMWR article


FDA adds four diseases to priority review list

The US Food and Drug Administration (FDA) today added four diseases—Lassa fever, chikungunya, rabies, and cryptococcal meningitis—to the list of tropical diseases. The designation means any applications for drug or biological products to prevent or treat these diseases may qualify for a tropical disease priority review voucher (PRV).

A PRV can help an applicant receive priority review of a subsequent drug application that does not itself qualify for priority review.

"Tropical diseases cause a significant health burden globally. Yet, there has been remarkably little progress over the past 50 years in drug and biologic development to treat and prevent these diseases," said FDA Chief Scientist, Rear Admiral Denise Hinton. "Although tropical diseases generally are uncommon in the United States, tourism, immigration and military operations are increasing the direct effect these diseases can have on the health of Americans."

Tropical disease are usually endemic in low and middle-income countries, where there may be less incentive to develop drug therapies, the FDA said. The PRV can help boost the profile of these diseases.
Aug 23 FDA press release


Authorities report avian flu outbreaks in Malaysia, Taiwan

Malaysia has confirmed H5N1 avian flu in a backyard flock, and Taiwan has detailed an H5N2 outbreak on a commercial farm, according to the latest reports posted by the World Organization for Animal Health (OIE).

The outbreak in Malaysia began Aug 3 in Sabah state, which is on the northernmost point of the island of Borneo. H5N1 killed 20 village chickens, and the remaining 286 were culled to prevent spread of the disease. Officials disinfected the farm and increased area surveillance, in addition to other response steps.

In Taiwan, H5N2 avian flu killed 1,303 egg-laying hens on a farm housing 20,684 poultry in Pingtung County in the south. The outbreak began Aug 13, according to an OIE report yesterday. The H5N2 subtype was confirmed by the national laboratory at the Animal Health Research Institute.

Outbreak response steps included euthanizing the remaining birds and cleaning and disinfecting the premises. A 3-kilometer radius of intensified surveillance around the farm has been set up for 3 months.
Aug 18 OIE report on Malaysia
Aug 22 OIE report on Taiwan

Stewardship / Resistance Scan for Aug 23, 2018

News brief

UK officials issue draft guidance for acute cough treatment

Draft guidance issued today by the UK National Institute for Health and Care Excellence (NICE) recommends against offering antibiotics for acute cough associated with upper respiratory infection.

In lieu of antibiotics, the guidelines recommended that clinicians advise patients who are not systematically unwell or at risk of higher complications to manage their symptoms with self-care, including honey, the herbal remedy pelargonium, and cough medicines containing the expectorant guaifenesin or the antitussive dextromethorphan (for patients over 12). They also advise clinicians to explain why antibiotics aren't necessary and encourage patients to return if symptoms worsen rapidly or do not improve after 3 to 4 weeks.

For people who are identified at a face-to-face clinical examination as systematically very unwell, the guidelines recommend an immediate prescription of doxycycline (in patients 18 and older) or amoxicillin (in patients under 18). For those identified as having a higher risk of complications, including patients with a pre-existing condition, young children born prematurely, and patients over the age of 65 with prior hospitalization and comorbidities, the guidelines suggest an immediate antibiotic should be considered.

A public comment period on the draft guidance ends on Sep 20. Publication of the new guidelines is expected in February 2019.
Aug 23 NICE draft guideline for acute cough


Multiplex assay reduces antibiotic treatment in kids with CNS infections

A single-center study conducted in Australia found that a cerebrospinal fluid multiplex assay performed on children with a confirmed central nervous system (CNS) infection reduced time to organism identification, antibiotic treatment, and duration of hospitalization, researchers report in the Pediatric Infectious Disease Journal.

The researchers at Australia's Royal Darwin Hospital looked at two cohorts of patients: A 15-month prospective cohort from February 2016 to May 2017 and a 15-month retrospective cohort from November 2014 to February 2016, when the multiplex assay, which can identify up to 14 potential pathogens in cerebrospinal fluid, was introduced. The researchers then compared the time to organism identification and antibiotic management before and after multiplex assay introduction.

Sixty-five cases of pediatric CNS infection were diagnosed over the 30-month period, with 36 diagnosed before the introduction of the assay and 29 diagnosed after. Young infants were the most commonly affected, with 80% of cases occurring in children 3 months or younger. The assay was performed on 26 of the 29 cerebrospinal isolates from children diagnosed as having a CNS infection in the prospective cohort, with enterovirus identified as the most common causative organism (14 children), followed by human parechovirus (4 children). The assay performed with 93.8% sensitivity and 90% specificity when compared with microbiologic culture or reference laboratory results.

After the assay was introduced, the median time to organism identification was reduced from 6 days to 2 days (P < 0.001), median duration of antibiotic therapy fell from 3 days to 2 days (P < 0.001), and median duration of hospitalization fell from 5 days to 3 days (P = 0.016).

The authors of the study say the reduction in the duration of broad-spectrum antibiotic use could reduce short- and long-term adverse drug effects, including disruption of the neonatal gut microbiome. They suggest the multiplex assay could be of most value to hospitals that don't have an onsite molecular laboratory.
September Pediatr Infect Dis J abstract

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