News Scan for Dec 08, 2016

Illinois Elizabethkingia probe
Mumps in highly vaccinated group
Lab security threats from insiders
Drug-resistant TB meningitis

Report: Illinois Elizabethkingia outbreak likely reflects ongoing sporadic cases

The investigation into a cluster of Elizabethkingia anopheles infections in Illinois that were distinct from outbreaks reported in neighboring Wisconsin and Michigan found that the illnesses probably reflect ongoing sporadic infections in critically ill patients, a team from Illinois and the US Centers for Disease Control and Prevention (CDC) reported today in Morbidity and Mortality Weekly Report (MMWR).

Wisconsin officials first reported an outbreak in March, warning neighboring states and asking them to see if they had any related cases. Shortly after, Illinois reported 11 similar cases, 10 of which were caused by a different genetic cluster. E anopheles is usually antibiotic resistant, is typically found in soil and other environmental sources, and can cause opportunistic infections.

In the investigation of the Illinois cases, the team examined patient records to look for risk factors and looked at all Elizabethkingia infections that occurred in the facilities going back to 2012. They also noted three earlier outbreaks involving Illinois health facilities. Genetic comparison revealed that isolates from the states 2012-2013 outbreak clustered with those from the 10 new patients.

No common facility exposure among the patients was seen, and the number of infections in the cluster didn't seem to be higher than in previous years. Follow-up analysis at the CDC after the investigation was completed revealed one of the isolates in the cluster had a distinct pattern.

The researchers said molecular typing is useful for identifying clusters but must be interpreted carefully, especially for rare organisms. They said the findings emphasize the importance of clinical and epidemiologic information gathering in outbreak investigations.
Dec 9 MMWR report


Lessons learned from mumps outbreak in highly vaccinated college setting

Mumps outbreaks can occur, even in highly vaccinated groups, and relying on the immunoglobulin M (IgM) test alone for work-up of patients with parotitis can lead to a missed diagnosis and put others at risk, according to a report yesterday on an investigation into a large mumps outbreak in 2014 at a New York City university. The team from New York and the CDC reported its findings in Clinical Infectious Diseases.

The index case developed unilateral parotitis in the middle of January and sought care at the university's student health center, where health providers ruled out mumps based on a negative IgM test. Reverse-transcriptase polymerase chain reaction testing was not done.

A total of 56 cases were identified, 28 of them lab-confirmed. They included students (53), staff (1), and others (2) with epidemiologic links. Likely common exposures included classrooms and dorms.

The school requires documentation of two doses of measles-containing vaccine and one dose of mumps-containing vaccine, and 54 (96%) of the patients had received at least one dose of mumps vaccine. One was unvaccinated because of a religious exception, and vaccination status was unknown for another.

The researchers said the outbreak underscores some of the latest challenges of diagnosing mumps outbreaks, which include transmission in highly vaccinated populations, limited sensitivity of tests, and lack of clinical suspicion and appropriate testing. Clinicians should be aware that mumps epidemiology has shifted toward adolescents and young adults, that authors added, especially in congregate settings such as colleges, and health workers should maintain a high degree of suspicion when patients present with parotitis, regardless of vaccination status.
Dec 7 Clin Infect Dis abstract


Expert details steps to prevent insider biosecurity threats at labs

A review of attempted or actual attacks involving pathogens done last year as part of a dual-use research of concern (DURC) risk-benefit assessment for the US government found that the greatest risk to research institutions came from insiders, according to a policy forum today in Science.

The author is Kavita Berger, PhD, from Gryphon Scientific, the Maryland life sciences poly analysis group that did the risk-benefit analysis for the National Institutes of Health (NIH) National Science Advisory Board for Biosecurity (NSABB) as part of its ongoing review of controversial experiments on H5N1 avian flu and other disease threats.

Life science facilities or hospitals were targets in 26 of 93 incidents. Though most involved radical animal rights or environmental groups, some were malicious acts by insiders who sabotaged or destroyed others' work. Ten were done by scientists or health professionals.

Berger described several practices that research institutions can implement to reduce the threat, including not only physical measures, but also strategies such as behavioral risk assessment, anonymous systems for reporting suspicious incidents, strong leadership to promote secure and safe research, and ongoing mentorship to cultivate trusting relationships. She also discussed employee and student assistance programs and executive-level all-hazards risk assessment teams.
Dec 8 Science policy forum


Study finds link between drug resistance, early death in TB meningitis

A study yesterday in Clinical Infectious Diseases reports an independent association between drug resistance and early mortality in patients with tuberculosis meningitis (TBM).

The study looked at a cohort of patients reported to the TB registry in New York City from 1992 to 2001, with a focus on patients with culture-confirmed TBM and reported susceptibility results for isoniazid and rifampin—the two frontline antibiotics for treating TB. Among the 360 patients who met those criteria, 324 initiated treatment with anti-TB drugs.

Of the 324 patients who initiated anti-TB therapy, 183 (56.5%) died before completing therapy, after a median survival of less than a month. Among 67 patients with rifampin-resistant isolates, 63 died before completion of therapy after a median of 31 days. But because 95% of these patients also had HIV, the investigators were unable to estimate the independent associations of HIV infection and rifampin resistance with mortality.

When controlling for age and HIV status, however, the researchers observed that, among the 257 TBM patients without rifampin-resistant isolates, isoniazid resistance was independently associated with mortality after the first 60 days of treatment.

"These findings support the continued evaluation of rapid diagnostic techniques and the empiric addition of second-line drugs for patients with clinically suspected drug-resistant TBM," the authors write.
Dec 7 Clin Infect Dis study

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