News Scan for Dec 10, 2014

Outbreaks from raw milk up
Malaria mortality sinking
9-strain HPV vaccine
Neonate Legionnaires' death

Outbreaks from unpasteurized milk rise dramatically

The number of disease outbreaks linked to the drinking of unpasteurized milk has risen at an alarming rate, quadrupling from the period 1993-2006 to 2007-12, as more states allow the legal sale of raw milk, according to a study today in Emerging Infectious Diseases.

Researchers from the US Centers for Disease Control and Prevention (CDC) analyzed foodborne outbreaks from 2007 to 2012 and found that in 81 of them the food vehicle was unpasteurized (raw) milk. The outbreaks occurred across 26 states and affected 979 people, 73 of whom needed hospitalization. In more than half the outbreaks, at least one child younger than 5 was sickened.

Notably, raw milk–related outbreaks increased in number even during the study period, from 30 in 2007 to 2009 (10 per year) to 51 from 2010 to 2012 (17 per year). Over the 6-year period the annual rate of outbreaks was 13.5, compared with 3.3 per year from 1993 to 2006.

Campylobacter was the cause in 62 (81%) of the outbreaks, followed by Shiga toxin–producing Escherichia coli, implicated in 13 (17%). Salmonella Typhimurium and Coxiella burnetii each caused a small number of outbreaks.

Raw milk can be sold legally in 30 states, 8 of them only since 2004, according to the authors. Cow shares, a scheme where people own shares that pay farmers to care for a cow from which they receive a percentage of the raw milk, are sold in 10 additional states, 5 of them joining that group recently, the CDC noted in an advisory today. Of the raw milk–related outbreaks in 2007-12, 81% were in states where selling raw milk is legal.

The authors conclude, "Public health officials should continue to educate legislators and consumers about the dangers associated with consuming nonpasteurized milk. . . . In addition, federal and state regulators should enforce existing regulations to prevent distribution of nonpasteurized milk."
Dec 10 Emerg Infect Dis study
Dec 10 CDC advisory


Malaria mortality rate down 47% since 2000, WHO says

The global malaria mortality rate has plunged 47% since 2000, but malaria control efforts still face challenges, including insecticide resistance in scores of countries and uneven access to treatment, the World Health Organization (WHO) said in its annual malaria report yesterday.

In a mostly upbeat statement, the agency said malaria cases are steadily declining, and the mortality rate has dropped 54% in the WHO African Region, where about 90% of malaria deaths occur.

In sub-Saharan Africa, the number of infected people fell from 173 million in 2000 to 128 million last year, even as the population grew by 43% over that period, the WHO reported.

"We can win the fight against malaria,” said WHO Director-General Margaret Chan, MD, MPH, in the statement. "We have the right tools and our defences are working. But we still need to get those tools to a lot more people if we are to make these gains sustainable."

The use of insecticide-treated bed nets in sub-Saharan Africa has soared in recent years, the agency said. In 2004 only 3% of people at risk for malaria had access to treated bed nets in 2004, but by 2013 the proportion was close to half. And another 214 million bed nets are scheduled to be delivered to malaria-endemic countries by the end of this year. (See related CIDRAP News scan from yesterday.)

Access to accurate diagnostic tests and effective treatment has also improved substantially, the WHO said. The number of rapid diagnostic tests supplied globally reached 319 million in 2013, compared with 46 million in 2008. Also in 2013, 392 million courses of artemisinin-based combination therapies (ACTs), a key treatment tool, were procured, up from 11 million in 2005, the agency said.

The WHO also said a growing number of countries are moving toward malaria elimination, while regional groups are setting ambitious elimination goals. Most recently, participants in the East Asia Summit set a goal to eliminate malaria from the Asia-Pacific region by 2030.

Last year Azerbaijan and Sri Lanka reported no indigenous cases for the first time, and 11 other countries maintained zero cases.

On the other hand, a third of households in malaria areas of sub-Saharan Africa had no treated bed nets, indoor mosquito spraying has decreased in recent years, insecticide resistance has been reported in 49 countries, and millions of people still lack access to testing and treatment, the agency said.

Also, although malaria funding has tripled since 2005, it is still only half of the $5.1 billion annually that is needed to achieve global goals, the WHO added. Further, progress against malaria is threatened by the Ebola epidemic in West Africa.
Dec 9 WHO statement
World Malaria Report 2014 home page
Dec 11, 2013, CIDRAP News item on WHO's 2013 malaria report


FDA approves Merck's 9-strain HPV vaccine

The US Food and Drug Administration (FDA) today approved Merck's nine-strain human papillomavirus (HPV) vaccine, which protects against five more HPV strains than the company's already-approved Gardasil vaccine.

The vaccine, called Gardasil 9 (Human Papillomavirus 9-valent Vaccine, Recombinant), may prevent about 90% of cervical, vulvar, vaginal, and anal cancers, the FDA said in a press release. It is approved for female patients 9 through 26 years old and male patients 9 through 15.

It is approved for preventing those four cancers caused by HPV types 16 and 18 and for preventing genital warts caused by types 6 and 11, which are the four strains in Gardasil. In addition, Gardasil 9 protects against the four above-mentioned cancers caused by HPV types 31, 33, 45, 52, and 58. Those five strains cause about 20% of cervical cancers and are not included in either Gardasil or the other FDA-approved HPV vaccine, GSK's Cervarix, which covers types 16 and 18.

A randomized, controlled trial involving 14,000 girls and women aged 16 through 26 showed Gardasil 9 to be 97% effective in preventing cervical, vulvar, and vaginal cancers caused by the five additional HPV types, the FDA said. It was also shown to be as effective as Gardasil for preventing disease caused by the four shared HPV types.

Because of the low incidence of anal cancer caused by the five additional HPV types, the indication for preventing anal cancer is based on Gardasil's demonstrated effectiveness of 78% and "additional data on antibodies" in males and females who received Gardasil 9, the agency said.

The safety of Gardasil 9 was evaluated in about 13,000 patients of both sexes, and the most commonly reported adverse effects were injection-site pain, swelling, and redness and headaches, the FDA said. As with Gardasil, Gardasil 9 will be administered in three separate doses, with an initial dose followed by shots 2 and 6 months later.
Dec 10 FDA news release


Infant dies from Legionnaires' contracted during water birth

An infant less than 4 weeks old died from legionellosis-related complications following a water birth in Texas, according to an Emerging Infectious Disease article today.

The infant was born in January in a home pool and hospitalized with sepsis and respiratory failure 6 days after birth. The child was diagnosed as having Legionella pneumophila and died 19 days after being hospitalized, the report said.

Staff from a local midwifery center supervised the birth and provided the tub, which was a recreational-grade pool filled with well water. Water circulated at 98.6°F for 2 weeks prior to the birth, after which it was drained and refilled. The well water was purified with non-chlorinated enzyme drops and underwent no chemical disinfection or filtration.

Although investigators were unable to culture Legionella samples from the tub, which had been cleaned since the birth, health officials determined that the water birth environment and procedures contributed to the neonate's infection and death, the article said.

Following the incident, the Texas Department of State Health Services developed infection control recommendations for midwifery agencies and relevant organizations. Guidelines include selection and cleaning protocol for birthing tubs, disinfection practices, and standards for monitoring water acidity and temperature.

Texas reported 763 cases of legionellosis from 2008 to 2013, although none were in infants less than 1 month old. Infants are especially susceptible to legionellosis complications, such as pneumonia, because of their underdeveloped lungs and immune systems.
Dec 10 Emerg Infect Dis article

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