News Scan for Mar 06, 2017

News brief

Zika complications in Canadian travelers higher than thought

A study today of Zika infections in Canadian travelers who visited destinations in the Americas revealed they were just as common as other mosquito-borne diseases, with complications more severe than expected. A team from Canada reported its findings in the Canadian Medical Association Journal (CMAJ).

The researchers reviewed data on 1,118 travelers who got sick after travel in the Americas and visited one of seven CanTravNet clinics, located in large cities in five provinces, from October 2015 to September 2016.

Lab-confirmed Zika infection was found in 41 (3.7%), dengue in 3.7%, and chickungunya in 2.1%. Except for one sexually transmitted case, nearly all of the Zika infections were likely transmitted by mosquitoes. About 60% of the Zika-infected patients were women, and 19 of the 24 were of child-bearing age. The most common symptoms during the acute phase were rash and fever, and about half noted muscle or joint pain or headaches. Only one in six had conjunctivitis.

As for serious complications, three pregnant women were infected, with two cases of congenital infection, and two other travelers had Guillain-Barre syndrome, putting the total of severe complications at 10% of Zika cases. Researchers said no complications were seen in any of the patients infected with dengue or chikungunya.

In a press release on the study, Andrea Boggild, MD, a tropical disease specialist with the University of Toronto and Public Health Toronto, said, "Referral bias to our centres may have contributed to the more severe clinical presentations noted for Zika, though we would have expected the same phenomenon to occur with dengue and chikungunya were this a significant contributing bias." She also noted that the clinics primarily serve adults, so kids may be under-represented in the data.

The authors urged people to take precautions, such as delaying travel for women who are pregnant or considering getting pregnant, wearing insect repellent, and using barrier protection during sexual activity.
Mar 6 CMAJ abstract
Mar 6 CMAJ press release

H7N9 sickens two more in China

Two more H7N9 avian influenza infections have been reported from China, both in Guangxi province, Hong Kong's Centre for Health Protection (CHP) said today in a statement.

Provincial health officials didn't note the genders or ages of the patients but said they are from two different cities—Baise and Wuzhou—and are both hospitalized in critical condition. Guangxi province is in south central China.

China is experiencing its fifth and biggest H7N9 wave since the outbreak began in 2013, and though overall activity has peaked, the country is still reporting smaller but steady stream of cases. So far the country has reported at least 474 cases since October, and imported cases were also reported from Hong Kong, Macao, and Taiwan.
Mar 6 CHP statement

Three new Saudi MERS cases hint at hospital outbreak

The Saudi Arabian Ministry of Health (MOH) reported three new cases of MERS-CoV yesterday and today in Wadi ad-Dawasir in south central Saudi Arabia.

Two patients were identified as having MERS-CoV (Middle East respiratory syndrome coronavirus) yesterday, a 31-year-old Saudi man in critical condition and a 32-year-old Saudi woman in stable condition. The MOH said the sources of their infections are under review.

Today a 48-year-old Saudi woman is listed in critical condition after presenting with symptoms of MERS-CoV. The MOH said she contacted her illness through a healthcare exposure. The MOH also said today that a 63-year-old Saudi man with preexisting disease has died of MERS in Mahayel-Aseer in the southwest. His case was previously reported.

The new cases bring Saudi Arabia's total since the outbreak began in 2012 to 1,572 MERS cases, including 652 deaths. Fifteen patients are still recovering from the disease.

In related news, a new study in Emerging Infectious Diseases said a robust surveillance program has helped limit the spread of MERS-CoV in Saudi Arabia. Researchers from the Saudi MOH and the US Centers for Disease Control and Prevention said that from April 2015 to February 2016, Saudi health officials tested 57,363 people who had suspected MERS-CoV infection, and only 384 (0.7%) tested positive.

Saudi Arabia has accounted for more than 80% of the world's MERS cases.
Mar 5 MOH report
Mar 6 MOH report
Mar 3 Emerg Infect Dis study

Stewardship / Resistance Scan for Mar 06, 2017

News brief

Study makes case for 'watchful waiting' approach to kids' ear infections

Appropriate use of the "watchful waiting" strategy for management of acute otitis media (AOM) in children could reduce healthcare costs and improve health outcomes, according to a new study in Pediatrics.

Under current American Academy of Pediatrics (AAP) guidelines, physicians are advised to prescribe antibiotics for children 6 months or older who have severe signs of unilateral or bilateral AOM. But based on joint decision-making with parents, the guidelines also advise that clinicians can suggest observation for 48 to 72 hours before initiating antibiotic therapy if the symptoms are unilateral and non-severe. Current practice, however, appears to favor immediate antibiotic prescription for AOM, with recent data suggesting that US physicians prescribe antibiotics for AOM 95% of the time.

In the study, investigators examined the electronic medical records of 247 randomly selected patients who had been diagnosed as having AOM in the emergency department of an urban children's hospital from April 2014 through January 2015. These data were then incorporated into a decision-analytic cost-utility model of a hypothetical cohort of 1,000 children with AOM. The primary outcome was the incremental cost-effectiveness ratio (ICER) expressed in 2015 US dollars per disability-adjusted life year (DALY) averted from a societal perspective.

Of the 247 chart-reviewed patients with AOM, 231 (93.5%) were prescribed antibiotics, while 7 (2.8%) underwent watchful waiting and 9 (3.6%) were sent home without an antibiotic prescription. When the patient's records were evaluated using AAP guidelines for AOM management, 104 (42.1%) met the conditions for immediate antibiotic therapy, and 143 (57.9%) were eligible for watchful waiting. Of the patients for whom watchful waiting was an option, it was implemented only 4.9% of the time.

In the decision-analytic model, the investigators found that for every 1,000 patients with AOM, implementing watchful waiting for those who met the criteria would yield 514 fewer immediate antibiotic prescriptions and 205 fewer antibiotic courses ultimately taken, averting 14.3 DALYs and saving $5,573.

In this model, the authors write, using watchful waiting when clinically appropriate "was thus a dominant strategy, meaning it was superior to current practice by generating fewer DALYs at a lower cost."

The authors conclude that while increasing use of the watchful waiting approach would likely require more education for parents and providers, "appropriate use of the strategy could simultaneously reduce health expenditures, improve health outcomes, and be cost-saving to society."
Mar 3 Pediatrics study

Higher risk of mortality, costs for community-onset C difficile patients

Community-onset Clostridium difficile infection (CDI) is associated with increased risk of all-cause mortality and short- and long-term economic costs, according to a new study in PLoS One.

For the study, researchers estimated the attributable mortality and costs of community-onset CDI by conducting a population-based matched cohort study in which 7, 950 community-onset CDI patients identified in Ontario from 2003 through 2010 were matched with randomly selected uninfected subjects and followed through 2011. The investigators examined 30-day, 180-day, and 1-year all-cause mortality and evaluated the costs of publicly funded healthcare services. Costs were calculated in Canadian dollars.

The researchers found that patients with community-onset CDI had considerably higher risk of all-cause mortality and higher costs compared with uninfected patients. The relative risk for 30-day, 180-day, and 1-year mortality were 7.32, 3.55, and 2.59, respectively, and the cumulative 30-day, 180-day, and 1-year costs were $10,700, $12,517, and $13,312, respectively. In the stratified analyses, hospitalizations and physician visits accounted for the largest cost components across all phases.

"Our estimates of absolute and relative mortality and costs highlight the need for interventions to prevent community-onset CDI," the authors write.
Mar 3 PLoS One study