US flu activity still rising, nearing earlier peak, with 14 more kids' deaths

US flu levels rose for the fourth straight week and are now approaching earlier peak levels, while 14 new flu-related pediatric deaths raised the fatalities in kids to 92 for the season, the Centers for Disease Control and Prevention (CDC) said today in its weekly FluView report.

The rise comes as the 2009 H1N1 strain has risen to predominance across the country in a season noted for early influenza B predominance and now a two-peak epidemiologic curve. The CDC estimates that flu has sickened at least 26 million Americans this season and led to 250,000 hospitalizations and 14,000 deaths.

The percentage of clinic visits for influenza-like illness (ILI) rose to 6.8% last week, up from 6.6% the week before, while the share of respiratory samples at clinical labs that tested positive for flu rose from 30.1% to 30.8%.

The number of jurisdictions reporting high ILI activity—another clinic-visit marker—dropped a bit, from 47 to 46. The number of jurisdictions reporting regional or widespread flu remained at 51 for the third week in a row.

Among specimens tested at public health labs, 66.2% were influenza A and 33.8% influenza B for the week. Until recent weeks, flu B had predominated the entire season. Of the A strains subtyped, 95.5% were the H1N1 strain and 4.5% the H3N2 strain.

The hospitalization rate rose to 41.9 per 100,000 population, which the CDC says is similar to levels usually seen at this time of the year. The previous week saw a hospitalization rate of 35.5 per 100,000 population. As in previous weeks, the elderly have the highest hospitalization rates.

The 14 deaths in children occurred from the end of December 2019 to last week. Ten were tied to influenza B and 4 to influenza A. Of the latter, 2 were subtyped, with 1 being the H1N1 strain and one H3N2.
Feb 14 CDC FluView update

Six African and Asian countries report new polio cases

Six countries in Africa and Asia—Pakistan, Nigeria, the Democratic Republic of the Congo (DRC), Angola, Ethiopia, and the Philippines—have reported a total of 21 new polio cases in the past week, according to the latest update from the Global Polio Eradication Initiative (GPEI).

Ethiopia led the list with 7 cases of circulating vaccine-derived poliovirus type 2 (cVDPV2): 4 in Oromiya province and 3 in the Southern Nations Nationalities and Peoples' Regional State (SNNPR). Only one case had onset of paralysis this year. Of 12 cVDPV2 cases reported in Ethiopia so far, 4 cases are linked to an outbreak in neighbouring Somalia, the GPEI said.

The DRC reported 2 cases of cVDPV2 in Kwilu province and 2 in Sankuru, according to the DRC country update in the report. With onsets last year, these raised the number of 2019 cVDPV cases to 84. (A summary of new cases in the same report mentioned only 2 cases in the DRC; further information about the DRC case count could not be immediately obtained.)

The DRC reported 2 cases of cVDPV2 in Kwilu province and 2 in Sankuru. With onsets last year, these raised the number of 2019 cVDPV cases to 84.

In Angola, 3 cases of cVDPV2 were reported this week, 1 each in Bié, Huambo, and Namibe provinces. None of the cases had onset this year. The country had 114 vaccine-derived cases in seven outbreaks last year.

Nigeria reported its first cVDPV2 case with onset this year, in Anambra province. The government reported 18 cVDPV2 cases in the country last year.

The Philippines also noted its first cVDPV2 case with onset this year, in Central Luzon province. The count of vaccine-derived cases for 2019 remains at 15.

So far this year, 18 new polio cases (12 WPV and 6 cVDPV) have been reported globally, compared with 15 (9 WPV and 6 cVDPV) at this time last year.
Feb 13 GPEI report

Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans

UK partners with Nigeria to battle antimicrobial resistance

The United Kingdom yesterday announced the launch of a partnership with Nigeria, worth £10.7 million, to fight antimicrobial resistance (AMR) by improving public health surveillance, upgrading laboratory equipment, and training technicians.

The program will be operated by the Fleming Fund, a UK Aid program that helps low- and middle-income countries battle AMR, the fund said in a news release. The fund is managed by the UK Department of Health and Social Care in partnership with Mott McDonald, the fund's grant management agent.

The Fleming Fund has appointed Development Alternatives Incorporation (DAI) to support Nigeria's AMR surveillance system, in collaboration with the Nigerian AMR coordination committee and other partners.

Project activities in Nigeria to date include investment in 18 laboratories across the country and the appointment of 10 professional fellows who are being trained in data management, microbiology, epidemiology, and biosafety to help fight AMR, according to the release.
Feb 13 Fleming Fund press release

BD announces contract to help fight AMR in developing countries

In a related development, the medical technology company BD (Becton, Dickinson and Co.) yesterday announced a $6 million contract with the Fleming Fund, the British aid program that helps low- and middle-income countries fight antimicrobial resistance.

Under the contract, BD said it will provide diagnostic equipment and informatics systems to help diagnose infections and guide physicians to prescribe and use antibiotics appropriately. The company is based in Franklin Lakes, New Jersey.

More than 70 labs in 19 countries will be provided with equipment to quickly detect bacteria and fungi in clinical specimens and blood and to test antimicrobial susceptibility, along with products for microbiology data management, the company said in its press release.

The program is funded by the United Kingdom Department of Health and Social Care.

"The Fleming Fund works to support 24 countries in the development of AMR surveillance systems, using the World Health Organization's 'One Health' approach," the BD release said. "One of the core activities for the Fleming Fund country grant program is to strengthen clinical bacteriology laboratories in order to identify and perform antimicrobial susceptibility testing (AST) on priority pathogens."
Feb 13 BD press release

MCR-1 colistin resistance gene identified in Wyoming hospital patient

Originally published by CIDRAP News Feb 13

A urinary tract infection (UTI) caused by multidrug-resistant bacteria carrying the MCR-1 colistin resistance gene was identified in a Wyoming hospital patient in early 2019, researchers from the Centers for Disease Control and Prevention (CDC) and the Wyoming Department of Health (WDH) reported today in Morbidity and Mortality Weekly Report (MMWR). It's the first MCR-1-carrying isolate identified in Wyoming or surrounding states.

The patient, who had a history of recurrent UTIs, was admitted to the hospital in mid-December 2018, and admission urine culture and antimicrobial susceptibility testing identified the infecting pathogen as carbapenem-resistant Klebsiella pneumoniae with extended-spectrum beta-lactamase production. Further testing identified resistance to 16 antibiotics. In early January 2019, the Texas Antimicrobial Resistance Laboratory Network found additional resistance to colistin and identified a plasmid-mediated MCR-1 gene.

WDH subsequently began in investigation to determine where the patient might have acquired the organism, but was not able to identify the route of acquisition. The patient had not traveled internationally or been exposed to livestock, but had experience repeated UTIs caused by K pneumoniae and Escherichia coli in the previous 2 years and had been treated with antibiotics. The authors of the case report suggest this could have increased the risk for acquiring antibiotic-resistant bacteria.

A point-prevalence survey conducted to identify possible transmission of the MCR-1 gene to other patients found six patients who were in the same hospital unit at the same time as the index patient; rectal screening of four of those patients was negative. The patient recovered after receiving appropriate antibiotics and was discharged from the hospital in January 2019.

The first US patient carrying MCR-1 was identified in Pennsylvania in July 2016, and since then MCR-1-carrying isolates have been identified in 20 more states. Colistin is considered a last-resort antibiotic.
Feb 14 MMWR case report

EPA registers first Candida auris disinfectants for hospitals

Originally published by CIDRAP News Feb 12

The US Environmental Protection Agency (EPA) today announced the availability of 11 products that can be used to disinfect surfaces against the multidrug-resistant fungus Candida auris, an emerging pathogen that has proven difficult for healthcare facilities to eradicate.

Agency officials say they hope that the products registered today, which include sporicidal and germicidal sprays and wipes, will help hospitals and nursing homes reduce the spread of the pathogen, which can cause severe and deadly invasive infections, persists on healthcare surfaces, and spreads easily between patients.

"Disinfecting surfaces is one of the best ways to stop the spread of C. auris infections, and EPA's efforts are helping to ensure that healthcare providers have products that can effectively reduce the spread of the dangerous fungus," Alexandra Dapolito Dunn, JD, assistant administrator of the EPA's Office of Chemical Safety and Pollution Prevention, said in an agency press release.

The EPA says it's been working with the CDC to ensure the products are effective. Prior to these 11 products being registered, there were no antimicrobial pesticides registered specifically for use against C auris. But the CDC says testing has confirmed that some disinfectants with an EPA claim for Clostridioides difficile are also effective against the fungus.

Since it was first detected in the United States in July 2016, C auris has spread to hospitals in 16 states. According to the CDC's most recent case count, there were 988 confirmed C auris cases as of Dec 31, 2019, and 30 probable cases. An additional 2,051 patients have been found to be colonized.

The CDC says research into disinfection methods that are effective against C auris is ongoing.
Feb 12 EPA press release
Feb 12 CDC case count page

New initiative aims to reduce antibiotic residue in pharma manufacturing

Originally published by CIDRAP News Feb 12

The Stockholm International Water Institute (SIWI) launched a new initiative this week that aims to reduce emissions of antibiotic residue from pharmaceutical manufacturing.

The Responsible Antibiotics Manufacturing Platform (RAMP) will bring together governments, civil society, and the pharmaceutical industry to improve responsible manufacturing and the supply of antibiotics.

"Reducing emissions of antibiotics from manufacturing is a shared responsibility," Nicolai Schaaf, program manager of SIWI’s Pharma Team, said in a SIWI press release. "This requires changes both in industry practices and when it comes to market demand and regulation. Acknowledging this as a shared objective in the fight against antimicrobial resistance is the starting point for our collaboration platform."

The platform was launched in New Delhi, India. India is one of the world's largest manufacturers of antibiotics, and studies of wastewater from Indian pharmaceutical manufacturing facilities have found high concentrations of antibiotic residues. Experts believe that when this water is released into the environment, the antibiotic residues can promote the development and spread of antibiotic resistance.

The launch comes on the heels of legislation introduced by the Indian Ministry of Environment, Forest and Climate Change that would make India the first country to limit the concentration of antibiotics in wastewater discharged by the pharmaceutical manufacturing facilities. 
Feb 10 SIWI press release 

Electronic medical record intervention linked to fewer C diff test orders

Originally published by CIDRAP News Feb 10

An electronic medical record (EMR) "nudge" implemented at four hospitals in an academic medical network was associated with a reduction in inappropriate and total hospital-onset C difficile infection (HO-CDI) orders, researchers from Emory University School of Medicine reported today in Infection Control and Hospital Epidemiology.

The retrospective study analyzed a 2-year period before and 2 years after the four hospitals implemented a popup notification in the EMR that was triggered when providers entered a C difficile test order for patients who had received a laxative or stool softener within the previous 24 hours—an order defined as inappropriate. No other system interventions to reduce HO-CDI testing were implemented during the study period. The primary outcome was the change in the rates of total and inappropriate HO-CDI orders per 1,000 patient days between the pre- and post-intervention periods.

Of the 17,694 HO-CDI test orders assessed in the study, 7% were inappropriate, and the intervention was associated with a decrease in the proportion of inappropriate orders (8% in the pre-intervention period vs. 6% in the post-intervention period). In addition, monthly HO-CDI orders decreased by 21% post-intervention (rate ratio [RR], 0.79; 95% confidence interval [CI], 0.73 to 0.86), and there was a modest continuing decline in order rate (trend change after RR, 0.99; 95% CI, 0.98 to 1.0).

In the interrupted time series analysis, the intervention was not significantly associated with an immediate decrease in the inappropriate HO-CDI order rate (level change RR, 0.80; 95% CI, 0.61 to 1.05). However, after the intervention, the order rate significantly decreased with time (trend change after intervention RR, 0.95; 95% CI, 0.93 to 0.97).

"Implementing an EMR nudge is a relatively simple method that can help healthcare systems improve diagnostic efficiency and limit the number of C. difficile tests ordered," the authors write. "However, depending on individual hospital practices, this intervention alone may not be sufficient to reduce HO-CDI rates."
Feb 10 Infect Control Hosp Epidem abstract