News Scan for Jun 21, 2021

News brief

COVID vaccination site deserts may affect rollout, study reveals

In Brooklyn, New York, communities with higher rates of poverty and minorities may have less access to COVID-19 vaccination sites, according to a JAMA Network Open research letter late last week.

The researchers looked at Brooklyn's 18 communities and found 87 COVID-19 vaccination sites for its population of 2,604,747. A little over half of the people (51.7%) were Latino or Black, 52.6% were female, and the median age was 35.1 years.

In districts where the population was at least 40% White, there was a median of 6 vaccination sites—compared with 4 in districts where White people made up less than 40%. Additionally, of the 9 districts with the highest poverty levels, the median population density per square mile per site was 11,263.4; the 9 districts with lower poverty levels had to serve about half that number (6,793.6 persons per square mile per site). The researchers add that district 16 had the highest percentage of population below the poverty threshold (29.4%) but no vaccination sites.

"With many preliminary barriers to vaccination uptake, including supply issues, scheduling multiple doses, and a delay for scheduling appointments, vaccine rollout has been slow," the researchers write. "Furthermore, early COVID-19 vaccination efforts in NYC have been focused primarily in White, middle-to-upper class neighborhoods, with the greatest access occurring in these areas. The analysis presented is generally suggestive of disparities in vaccination site access."

The study does not report any direct data on Brooklyn COVID-19 vaccination rates, although the researchers say that, as of Mar 10, 2021, 19% of White people were at least partially vaccinated for COVID-19, compared with 9% of those of Black or Hispanic descent in New York City as a whole.
Jun 18 JAMA Netw Open study

Birthdays associated with more COVID-19 outbreaks

Birthdays—a potential indicator of small, informal social gatherings—were associated with COVID-19 case increases, according to a study today in JAMA Internal Medicine.

The researchers looked at nationwide data covering about 2.9 million households and 6.5 million people with private health insurance from Jan 1 to Nov 9, 2020, and found that households with a birthday up to 2 weeks prior were associated with increased positive diagnoses. The COVID-19 prevalence rate for birthday households was 8.6 more diagnoses per 10,000 individuals. Compared with households in the 90th percentile for COVID-19 cases, which had 27.8 cases per 10,000 individuals, this was still a 31% relative increase.

The data also showed that household birthdays were associated with 0.9 more diagnoses per 10,000 individuals for counties in at least the 80th percentile of COVID-19 cases. No differences were seen for milestone birthdays, county precipitation levels (which could have moved outdoor gatherings inside), county political leanings, or state shelter-in-place orders.

"For each decile of COVID-19 prevalence, the change in household COVID-19 infection rates was larger in magnitude for households with a child’s birthday than for households with an adult birthday," the researchers add, noting that risk was probably unevenly distributed as many households may have followed COVID mitigations. "Thus, the 31% relative increase is likely to be disproportionately borne by a smaller number of households, implying that the increased relative risk associated with a single additional gathering could be considerably larger."
Jun 21 JAMA Intern Med study

Guinea's Ebola outbreak declared over after 4 months

Guinea's health ministry on Jun 19 declared the end of the country's Ebola outbreak, which lasted about 4 months and was the first since West Africa's massive outbreak of 2014-2016.

The outbreak began on Feb 14 following a cluster of seven cases in the southeastern N'Zerekore prefecture, the same area near the border with Liberia and Sierra Leone where West Africa's earlier outbreak began. Genomic sequencing revealed that the virus that fueled the new outbreak was very closely related to the Ebola virus that circulated in Guinea in 2014, raising the possibility that the source was a survivor of the earlier outbreak.

In a Jun 19 statement, the World Health Organization (WHO) said in-depth epidemiological investigation into the source of the outbreak hasn't yet identified a conclusive hypothesis. The index patient wasn't a known survivor but was at risk for contracting the virus.
The outbreak resulted in 23 cases, 16 confirmed and 7 probable. Twelve deaths were reported. Five of the patients were health workers, and one was a traditional healer.

By the end of May, 10,873 people were vaccinated, including 885 contacts and 2,779 frontline health workers.

The WHO said the detection of Ebola cases in Guinea isn't surprising as the virus is endemic in some animal populations and can persist in certain body fluids of survivors. Though 42 days have passed since the last confirmed case tested negative for a second time, there's still a chance of unrecognized transmission chains in the community based on surveillance difficulties in hard-to-reach outbreak areas. The agency also said COVID-19 activity and a recent yellow fever outbreak challenge Guinea's ability to rapidly detect and respond to a new Ebola outbreak.
Jun 19 WHO statement

CDC bans imported dogs from high-risk nations after rabies variant detected

The US Centers for Disease Control and Prevention (CDC) has temporarily suspended the import of dogs from high-risk countries and recently launched a multistate investigation based on the detection of a rabies variant detected in a rescue dog from Azerbaijan.

The 1-year suspension will begin on Jul 14.

"The importation of just one dog infected with CRVV [canine rabies virus variants] risks re-introduction of the virus into the United States resulting in a potential public health risk with consequent monetary cost and potential loss of human and animal life," said a notice from the Federal Register.

Until this detection, the United States had been free of CRVV since 2007. But CRVV are still in more than 120 countries. The dog in question, a 6-month-old mixed-breed puppy, was imported in a pack of 33 rescue dogs on Jun 10 that traveled through Chicago's O'Hare Airport, according to the Washington Post. The dog was living in Pennsylvania and has since been euthanized.

At least 12 people were exposed to the dog, and other animals in that group are being kept in quarantine.

Rabies is one of the deadliest animal diseases in the world, causing an estimated 59,000 human deaths globally annually. The virus is transmitted through animal bites.
Jun 16 Federal Register notice
Jun 14 CDC notice, FAQs, and import changes
Jun 19 Washington Post story

Stewardship / Resistance Scan for Jun 21, 2021

News brief

Plunge in respiratory viruses, outpatient antibiotics during pandemic

Respiratory virus detections and ambulatory antibiotic prescribing rates for respiratory tract infections (RTIs) fell dramatically during the pandemic compared with previous years, a finding that could have implications for future antibiotic stewardship and public health strategies, researchers from the University of Wisconsin reported today in JAMA Internal Medicine.

Using surveillance data from the Wisconsin State Laboratory of Hygiene and antibiotic prescribing data from University of Wisconsin Health, the researchers compared the pre–COVID-19 pandemic period (July 2018 to February 2020) to a period covering several waves of COVID-19 activity (April 2020 to February 2021).

They found that respiratory virus detections demonstrated seasonal variation during the pre-pandemic period but not during the pandemic period, and that detections of winter seasonal viruses (influenza, respiratory syncytial virus, and seasonal coronavirus) fell from an average of 4,800 per month to 12 per month. Other respiratory virus detections fell from 560 per month pre-pandemic to 228 per month during the pandemic.

Adjusting for seasonality, monthly antibiotic prescriptions for RTIs fell 79%, from 10.5 to 2.2 prescriptions per 1,000 patient encounters. Non-influenza virus detections demonstrated the strongest correlation with antibiotic prescribing for RTI.

"The data suggest that COVID-19 transmission mitigation strategies may help curb respiratory viral diseases beyond SARS-CoV-2 and, indirectly, decrease antibiotic prescribing," the study authors wrote. "Notably, during COVID-19 surges in Wisconsin (October to December 2020), we did not observe increased ambulatory antibiotic prescriptions."

In addition to the reduced detection of viruses, the authors hypothesize highly accessible, rapid tests for SARS-CoV-2 and influenza may have helped avert unnecessary antibiotic prescriptions.
Jun 21 JAMA Internal Med study

US analysis finds rising multidrug-resistance in urinary E coli

An analysis of Escherichia coli isolated from US urinary cultures indicates concerning levels of resistance to first-line antibiotics, along with rising levels of multidrug resistance, researchers reported late last week in Clinical Infectious Diseases.

Using E coli isolates from female urine cultures collected at US outpatient facilities from 2011 through 2019, the researchers analyzed susceptibility to nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), and fluoroquinolones, and assessed for extended-spectrum beta-lactamase production (ESBL+) and resistance to multiple antibiotic classes. Overall, more than 1.5 million non-duplicate E coli isolates from 295 outpatient facilities were included in the primary analysis, making it the largest published sample of E coli isolated US outpatient urine cultures.

The overall prevalence of E coli that were not-susceptible to TMP-SMX, fluoroquinolones, and nitrofurantoin was 25.4%, 21.1%, and 3.8%, respectively. ESBL+ was found in 6.4% of isolates, while 14.4% were not susceptible to two or more antibiotics and 3.8% were resistant to three or more. The highest overall prevalence for most not-susceptible phenotypes was in the East South Central census region, and the lowest prevalence was consistently found in the New England region, analysis showed.

Over the 9 years studied, the ESBL+ rate increased every year (except 2018), beginning at 4.1% and increasing to 7.3%. The prevalence of TMP-SMX resistance was consistently 25% or greater, while fluoroquinolone resistance declined from 21.9% to 20.3%, but was consistently over 20%. Modelling demonstrated a relative average yearly increase of 7.7% for ESBL+ isolates and 2.7% for isolates resistant to three or more antibiotics.

The study authors say the findings are concerning because resistance rates higher than 20% and rising levels of multidrug-resistance limit the empiric therapy options for treatment of uncomplicated urinary tract infections (UTIs), and will likely create a greater burden on emergency departments and acute care settings.

"Raising awareness of current regional patterns of not-susceptible E. coli isolates from outpatient UTIs can help to guide empiric treatment decisions of physicians and demonstrate the need for both antimicrobial stewardship efforts in outpatient settings, as well as new oral antibiotics to address the growing prevalence of resistant E. coli in the US," they wrote.
Jun 18 Clin Infect Dis abstract

Prescribing in Scottish COVID-19 patients highlights need for stewardship

Antibiotic prescribing for suspected RTIs was commonly observed among COVID-19 patients in Scottish hospitals during the first wave of the pandemic, Scottish researchers reported last week in JAC-Antimicrobial Resistance.

The findings from a point prevalence survey (PPS) conducted in designated COVID-19 wards of 15 Scottish hospitals from Apr 20 to 30, 2020, show that of 820 patients surveyed, 33.3% received at least one antibiotic for suspected RTI on the survey day, and 58.8% tested positive for SARS-CoV-2. Antibiotics were empirical in 91.9% of patients, and amoxicillin (24.6%), doxycycline (20.5%), and co-amoxiclav (15%)—the antibiotics recommended in local guidelines for RTI—were most frequently prescribed.

Multivariable logistic regression analysis revealed that antibiotic prescribing for RTIs was independently and positively associated with COPD/chronic lung disease, purulent/bloody sputum, abnormal chest x-ray, and a C-reactive protein value of 100 milligrams per liter or higher. Probable and definite hospital-acquired COVID-19 and diabetes were associated with lower odds of receiving an antibiotic for RTI.

"The rates of observed empirical antibiotic prescribing for RTI highlights the importance of ongoing local and national initiatives to reinforce stewardship in the COVID-19 context and beyond," the study authors wrote. "Clinical review and decision making, and early use of microbiological diagnostics, are central to limit unnecessary antibiotic therapy and other antibiotic-related harm."
Jun 18 JAC-Antimicrob Resist study