COVID-19 Scan for Aug 19, 2022

News brief

Public transportation workers see high COVID-19 incidence, death rates

A study of California public transportation workers published today in Morbidity and Mortality Weekly Report (MMWR) shows public transportation workers have higher rates of both COVID-19 incidence and mortality compared to other industries.

The study was based on confirmed COVID-19 outbreaks in California workplaces documented from Jan 1, 2020, to May 26, 2022, that were reported to the California Department of Public Health. An outbreak was defined as three or more COVID-19 cases (confirmed or probable) within 2 weeks.

According to the authors, 340 COVID-19 outbreaks, 5,641 outbreak-associated cases, and 537 COVID-19–associated deaths occurred in public transportation industries in California.

Outbreak incidence was 5.2 times higher, and mortality was 1.8 times higher in bus and urban transit industries than in all other industries. The cumulative outbreak incidence for all public transportation industries (35.3 outbreaks per 1,000 establishments) was 1.4 times higher than the average for all industries.

"The elevated outbreak incidence identified in public transportation industries suggests higher risk for SARS-CoV-2 workplace exposure among public transportation workers, and elevated mortality rates suggest increased risk for dying from COVID-19," the authors said. "Regardless of whether exposures occur from interactions with the public, coworkers, or other sources, these observations indicate that public transportation workers represent a vulnerable group who should be prioritized for COVID-19 prevention strategies."
Aug 19 MMWR
study

 

New GAO report reviews hospital struggles during COVID patient surges

US hospitals included in a new US Government Accountability Office (GAO) public health preparedness report recounted struggling to care for patients amid staffing, supply, and space shortages and a lack of information during COVID-19 surges.

The GAO, or "congressional watchdog," is an independent, apolitical agency that tracks how tax money is spent and reports its findings to Congress and federal agencies.

In preparing the report, released this week, the GAO reviewed Department of Health and Human Services (HHS) and hospital documentation and interviewed agency officials and representatives from eight hospitals and eight associated coalitions in three states chosen for their involvement in government regional preparedness and response efforts.

"All eight hospitals reported staffing challenges, such as a lack of staff to care for the increase in sick patients or staff becoming ill and unable to work, affecting hospital services," the report stated.

The hospitals worked to adapt operations by bringing in more staff, when possible, and training staff on appropriate use of personal protective equipment (PPE).

"Health care coalitions—groups of health care and response organizations in a defined geographic location supported by HHS funding—aided hospitals," the report said. "For example, they helped coordinate patient transfers to balance hospital loads, obtain and distribute needed medical supplies, and communicate hospital needs to their states."

HHS is working to support medical surge preparedness for hospitals and other healthcare organizations, but the report said it is too early to know if the efforts have been effective.

"For example, HHS implemented a new medical surge exercise for coalitions in 2021 to test readiness, and plans to establish targets to measure performance," it said. "It is also considering how to use the findings and lessons learned from its 2021 assessment of coalitions during the pandemic to improve its support of coalitions and their communities."

HHS is also funding the creation of a regional health disaster-response system, the report said, including better data sharing on resource and capacity issues; forming specialized teams to respond to crises; and writing regional guidelines on caring for patients and boosting hospital surge capacity.
Aug 17 GAO report

ASP Scan (Weekly) for Aug 19, 2022

News brief

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

Danish study supports shorter antibiotics course for pneumonia

A study of hospitalized pneumonia patients in Denmark found similar outcomes between short-course and prolonged-course antibiotic therapy, Danish researchers reported yesterday in Clinical Microbiology and Infection.

For the study, researchers with University of Copenhagen Hospital prospectively followed patients admitted to four hospitals with community-acquired pneumonia (CAP) from November 2017 through February 2019. They included patients who had achieved clinical stability within 3 days of treatment and measured outcomes among those treated—as decided by the attending physician—with 8 to 14 days of antibiotic therapy (prolonged-course) and those treated with 4 to 7 days of therapy (short-course). The primary outcome was post-treatment mortality within 30 days, and secondary outcomes included readmissions or new antibiotics.

The study cohort included 1,151 patients with a median age of 74, with an equal distribution of men and women. The median treatment duration was 6 days in the short-course group and 9 days in the prolonged-course group.

The 30-day post-treatment mortality was 3.36% (11/327) in the short-course group and 3.40% (28/824) in the prolonged-course group (adjusted odds ratio [aOR], 1.05; 95% confidence interval [CI], 0.38 to 1.88). Readmission occurred in 15.6% (42/269) of short-course patient vs 14.0% (102/727) of prolonged-course patients (aOR, 1.07; 95% CI, 0.75 to 1.69) and new prescription of antibiotics in 11.9% (32/269) vs 12.1% (88/727) (aOR, 0.99; 95% CI, 0.61 to 1.49).

"Our findings support the increasing evidence on the effectiveness of short-course therapy in patients hospitalised with CAP," the study authors wrote, citing recent randomized controlled trials (RCTs) that have found short antibiotic courses for CAP to be non-inferior to longer courses. "These results could serve as an important adjunct to RCTs by enabling their findings to be more applicable in routine clinical settings."
Aug 18 Clin Microbiol Infect study

 

Long antibiotic durations noted for kids with pneumonia, urinary infections

Originally published by CIDRAP News Aug 17

Prescribing data from a children's hospital network in Chicago showed considerable variation in antibiotic durations for children treated for CAP and urinary tract infections (UTIs) in ambulatory settings, with the variability largely unrelated to the severity of symptoms, researchers reported late last week in the Journal of the Pediatric Infectious Diseases Society.

The retrospective study used outpatient prescribing data from 2016 through 2019 to determine antibiotic durations for CAP and UTIs in pediatric populations and the influence of non-clinical predictors of long antibiotic duration. While some medical society guidelines suggest 10 days of antibiotics for pediatric CAP, and 7 to 14 days of antibiotics for UTIs in children ages 2 to 24 months, recent studies have suggested shorter antibiotic durations for both conditions may be just as effective in children. Guidelines at the hospital and its 14 outpatient centers recommend 7 days of antibiotics for treatment of both CAP and UTIs in children.

Overall, 2,124 prescriptions for CAP and 1,116 prescriptions for UTI were included in the study. Prescriptions were longer than 10 days in 59.9% and 47.6% of children treated for CAP and UTI, respectively. Long durations were more common in the emergency department (ED) than in clinics for UTIs, and more common in convenient care for CAP. Younger children had greater odds of long antibiotic duration for both diagnoses, with children younger than 1 year old having much higher odds of a longer antibiotic duration for CAP (odds ratio [OR], 8.64; 95% CI, 5.01 to 14.89) and for UTIs (OR, 4.24; 95% CI, 2.33 to 7.72) compared with older children.

Medicaid insurance was also associated with long therapy for UTI (OR, 1.66; 95% CI, 1.17 to 2.35) and CAP (OR, 1.43; 95% CI, 1.o9 to 1.86). Residents and fellows were less likely to give long durations than attending physicians, while advanced practice nurses were more likely to administer long therapies in CAP. Subsequent hospitalizations were uncommon for UTI (n = 10) and CAP (n = 20).

"Future stewardship interventions should address non-clinical predictors of antibiotic duration including addressing potential provider biases that can influence the decision-making process," the study authors concluded. "Reducing the unnecessarily long duration of therapy is an important quality intervention to reduce the risk of antimicrobial resistance and adverse events."
Aug 14 J Pediatric Infect Dis Soc abstract

 

Higher antibiotic use found in young, White, rural children in Kentucky

Originally published by CIDRAP News Aug 17

In another study published late last week in the same journal, an analysis of statewide Medicaid data in Kentucky showed that antibiotic fills were higher among young, White children in rural areas and those with chronic conditions.

To evaluate patient-level antibiotic use among children in Kentucky, which consistently ranks as one of the highest prescribing states for antibiotic use in adults and children, researchers from the University of Tennessee, the University of Louisville, and Duke University examined pharmacy data from a cohort of children enrolled in Medicaid from 2012 through 2017. The cohort followed the same children, who were ages 0 to 14 in 2012, over the 6-year study period, looking at outpatient antibiotic prescriptions, age, sex, race, zip code, and chronic conditions.

A total of 169,724 children were included in the study, and they received 1,478,484 antibiotic prescriptions over the study period. Of these children, there were 10,804 (6.4%) children with no antibiotic prescription claims during the study period; 43, 473 (25.6%) had 1 to 3 antibiotic prescriptions; 34,318 (20.2%) had 4 to 6 antibiotic prescriptions; 30, 994 (18.3%) had 7 to 10; 35, 018 (20.6%) had 11 to 20; and 15, 117 (8.9%) children had more than 20 antibiotic prescriptions. 

Overall, the population had a median total of six antibiotic prescriptions during the study period, but use was higher in children ages 0 to 5 (median of 8 antibiotic fills, compared with 5 for older children), White children (median of 7 antibiotic fills, compared with 3 for Black children), children in rural settings (median of 9 antibiotic fills, compared with 7 for suburban children and 4 for urban children), and children with chronic conditions (median of 8 antibiotic fills, compared with 6 for children without chronic conditions).

The study authors say the findings support studies in other states that have found racial and urban-rural disparities in antibiotic prescribing for children, and that further research is needed to better understand whether these disparities reflect variations in family expectations, care-seeking behavior, and/or clinician bias.

"Eliminating racial and rural differences in antibiotic prescribing should be a priority for outpatient antibiotic stewardship," they wrote.
Aug 14 J Pediatric Infect Dis Soc study

 

BD, Accelerate announce collaboration on rapid ID, susceptibility tests

Originally published by CIDRAP News Aug 16

Becton, Dickinson and Company (BD) and Accelerate Diagnostics yesterday announced a commercial collaboration agreement to bring rapid identification and antibiotic susceptibility tests to more clinicians and patients worldwide.

Under the agreement, BD will market and sell through its global sales network the Food and Drug Administration–approved Accelerate Pheno system, which delivers rapid pathogen identification and antibiotic susceptibility test results from blood cultures 1 to 2 days faster than traditional laboratory methods. The agreement also covers the Accelerate Arc module.

The companies say the two testing systems will help clinicians determine faster whether a patient needs an antibiotic, and if so, which one they need. 

"When a patient is very sick, every minute matters," Brooke Story, MBA, president of Integrated Diagnostic Solutions for BD, said in a press release. "Through our collaboration with Accelerate Diagnostics, we can help clinicians more quickly, efficiently and effectively treat patients, which may lead to a reduction in health care costs and help slow the spread of antimicrobial resistance."
Aug 15 Accelerate Diagnostics press release

 

Survey reveals low antibiotic knowledge, improper antibiotic use in China

Originally published by CIDRAP News Aug 16

The overall level of antibiotic knowledge in China is low, and inappropriate use of antibiotics is high, according to the results of a survey published last week in BMC Infectious Diseases.

The online survey, conducted from July through September 2018, was used to collect data from respondents in China on antibiotic use and related knowledge. While non-prescription antibiotic sales are illegal in China, the practice is common, and inappropriate antibiotic use has long been widespread. The survey focused on three aspects of inappropriate antibiotic use: self-medication with antibiotics (SMA), self-storage with antibiotics (SSA), and non-adherence to antibiotic treatment (NAAT). Logistic regression was used to determine factors associated with these inappropriate behaviors.

Of the 15,526 respondents, more than 55% could not correctly identify whether antibiotics were used to treat bacterial or viral infections, and 57.6% could not distinguish antibiotics from anti-inflammatory agents. Overall, 26.0%, 46.6% and 27.4% of the participants had high, medium, and low levels of antibiotic knowledge, respectively.

Regarding inappropriate use, 37.1% reported SMA, 67.9% reported SSA, and 53.3% reported NAAT in the past 6 months. A breakdown of the four types of non-adherence behaviors showed that 48.3%, 15.2%, 25.5%, and 78.0% of respondents said that they had missed antibiotics, increased antibiotic dosage, decreased antibiotic dosage, and discontinued antibiotics once symptoms disappeared, respectively.

After adjusting for other variables, multivariate logistic regression analyses showed that respondents aged 30 to 44 years (aOR, 1.36; 95% CI, 1.26 to 1.47), with higher levels of education (aOR, 1.16; 95% CI, 1.05 to 1.29), poor status of self-perceived health (aOR, 1.57; 95% CI, 1.38 to 1.80), and medium (aOR, 1.08; 95% CI, 1.02 to 1.15) or low (aOR, 1.40; 95% CI, 1.28 to 1.54) levels of antibiotic knowledge were more likely to report SMA, SSA, and NAAT.

The study authors say the results indicate an urgent need for a national action plan and effective public health strategies to address the widespread inappropriate use of antibiotics in China. 
Aug 13 BMC Infect Dis study

 

VHA program tied to improved antibiotic use for respiratory infections

Originally published by CIDRAP News Aug 15

A clinician-directed intervention implemented at facilities in the Veterans' Healthcare Administration (VHA) was associated with better management of, and reduced antibiotic prescribing for, acute respiratory infections (ARIs), researchers reported today in Infection Control & Hospital Epidemiology.

The ARI Campaign, implemented in 2017 by the VHA's Antimicrobial Stewardship Taskforce to reduce unnecessary antibiotic prescribing for ARIs, encourages Veterans' Affairs (VA) hospitals to engage high-prescribing physicians with two strategies: audit and feedback with peer comparison of ARI antibiotic prescribing rates, and individualized academic detailing of ARI management. To evaluate the effectiveness of the ARI Campaign, researchers with the VA and the Centers for Disease Control and Prevention (CDC) calculated the probability of receiving antibiotics for an ARI before and after implementation (October 2012 through March 2019). Secondary outcomes included probability of a return clinic visit or infection-related hospitalization.

Comparing 1,003,509 and 323,023 uncomplicated ARI visits before and after implementation, respectively, the researchers found the probability of receiving antibiotics for ARI decreased 18% after implementation (OR, 0.82; 95% CI, 0.78 to 0.86). Facilities with the highest quartile of intervention intensity demonstrated larger reductions in antibiotic prescribing (OR, 0.69; 95% CI, 0.59 to 0.80) compared to nonparticipating facilities (OR, 0.89; 95% CI, 0.73 to 1.09).

Return visits (OR, 1.00; 95% CI, 0.94 to 1.07) and infection-related hospitalizations (OR, 1.21; 95% CI, 0.92 to 1.59) were not different before and after implementation within facilities that performed intensive implementation.

"The findings suggest that implementation of the clinician-directed intervention was associated with improvements in guideline-concordant ARI management," the study authors concluded.
Aug 15 Infect Control Hosp Epidemiol abstract

 

Antibiotic stewardship education linked to improved dental antibiotic use

Originally published by CIDRAP News Aug 15

The first US antibiotic stewardship intervention for private practice dentists was associated with fewer antibiotic prescriptions and significant improvements in appropriate antibiotic prescribing, researchers reported last month in Open Forum Infectious Diseases.

In a prospective multipractice cohort study, a team led by Ohio State pharmacists and clinicians recruited private practice dentists for a four-phase dental antibiotic stewardship initiative. The four phases included collection of baseline antibiotic use data and a pre-education survey to establish the level of knowledge about antibiotic stewardship, three interactive education sessions conducted by infectious disease and antibiotic stewardship program (ID ASP) experts, 3 months of audit and weekly feedback with 1-on-1 consults for dentists who prescribed antibiotics inappropriately, and a post-education survey.

Outcomes assessed included overall antibiotic prescribing, antibiotic appropriateness, and antibiotic duration before and after education.

Fifteen dentists participated, 10 of whom had practiced for more than 20 years. The pre-education survey found 14 were unfamiliar with dental antibiotic stewardship. While procedures over the study period increased from 8,526 to 9,203, the number of antibiotic prescriptions pre/post-education decreased 14.5%, from 2,124 to 1,816. Overall, the proportion of appropriate antibiotic use (both for treatment and prevention) increased from 19% to 87.9% pre/post-education, with appropriate prophylactic antibiotic use improving from 46.6% to 76.6% and appropriate use of treatment antibiotics improving from 15% to 90.2%.

In addition, antibiotic duration pre/post-education decreased from 7.7 days to 5.1 days, and use of clindamycin declined 90%. The post-education survey responses recommended making antibiotic stewardship a required annual continuing education component.

"Similar to antibiotic stewardship in hospitals, simply asking physicians or dentists to do a better job at prescribing antibiotics does not work," the study authors wrote. "After learning dental antibiotic stewardship from ID ASP experts, dentists rapidly optimized antibiotic use."

The authors also note that they have since been invited to speak about dental antibiotic stewardship at local and national study clubs and dental societies.
Jul 25 Open Forum Infect Dis study

Danish study supports shorter antibiotics course for pneumonia

A study of hospitalized pneumonia patients in Denmark found similar outcomes between short-course and prolonged-course antibiotic therapy, Danish researchers reported yesterday in Clinical Microbiology and Infection.

For the study, researchers with University of Copenhagen Hospital prospectively followed patients admitted to four hospitals with community-acquired pneumonia (CAP) from November 2017 through February 2019. They included patients who had achieved clinical stability within 3 days of treatment and measured outcomes among those treated—as decided by the attending physician—with 8 to 14 days of antibiotic therapy (prolonged-course) and those treated with 4 to 7 days of therapy (short-course). The primary outcome was post-treatment mortality within 30 days, and secondary outcomes included readmissions or new antibiotics.

The study cohort included 1,151 patients with a median age of 74, with an equal distribution of men and women. The median treatment duration was 6 days in the short-course group and 9 days in the prolonged-course group.

The 30-day post-treatment mortality was 3.36% (11/327) in the short-course group and 3.40% (28/824) in the prolonged-course group (adjusted odds ratio [aOR], 1.05; 95% confidence interval [CI], 0.38 to 1.88). Readmission occurred in 15.6% (42/269) of short-course patient vs 14.0% (102/727) of prolonged-course patients (aOR, 1.07; 95% CI, 0.75 to 1.69) and new prescription of antibiotics in 11.9% (32/269) vs 12.1% (88/727) (aOR, 0.99; 95% CI, 0.61 to 1.49).

"Our findings support the increasing evidence on the effectiveness of short-course therapy in patients hospitalised with CAP," the study authors wrote, citing recent randomized controlled trials (RCTs) that have found short antibiotic courses for CAP to be non-inferior to longer courses. "These results could serve as an important adjunct to RCTs by enabling their findings to be more applicable in routine clinical settings."
Aug 18 Clin Microbiol Infect
study

 

WHO releases first Ebola therapy guidance

The World Health Organization (WHO) today issued its first guideline for Ebola therapeutics, which has a strong recommendation for using two monoclonal antibodies, mAb114 (Ebanga) and REGN-EB3 (Inmazeb).

In a statement, the WHO said clinical trials on the two drugs were conducted during outbreaks in the Democratic Republic of the Congo. It said the medication guidance complements earlier clinical advice on supportive care, which consists of fluid replacement and symptom treatment, and is known to significantly improve survival.

The WHO said the new guidance covers a range of issues, including tests to administer, pain management, nutrition, and coinfections.

Richard Kojan, MD, who cochairs the guideline development group and is president of the Alliance for International Medical Action, said in the statement that the therapeutic guide is a critical tool to fight Ebola. "It will help reassure the communities, health care workers and patients, that this life-threatening disease can be treated thanks to effective drugs," he said. "From now on, people infected with the Ebola virus will have a greater chance of recovering if they seek care as early as possible."

In clinical trials evaluating various treatments, the two drugs stood out as more effective than others that were evaluated. The WHO said it does not recommend ZMapp or remdesivir.

In 2020, the US Food and Drug Administration (FDA) approved both drugs for treating Zaire ebolavirus infection. mAb114 is made by Ridgeback Biotherapeutics, based in Miami, and REGN-EB3 is made by Regeneron, based in New York. Both drugs are given by intravenous infusion.
Aug 19 WHO statement

 

UNICEF to buy malaria vaccine; Valneva starts chikungunya vax approval

In developments regarding vaccine against mosquito-borne diseases, UNICEF this week announced a contract with GSK worth up to $170 million to produce malaria vaccine, and Valneva announced that it has started the rolling submission process for its candidate vaccine that targets chikungunya.

UNICEF said the contract with GSK is its first to supply malaria vaccine and will lead to the production of 18 million doses of RTS,S/AS01 (RTS,S) over the next 3 years. It said the vaccine has the potential to save thousands of lives every year. It added that in 2020, nearly 500,000 children died from malaria in Africa alone, translating to a rate of one child death per minute.

RTS,S took 35 years to develop, and in 2019, a pilot routine vaccination program was launched in three hard-hit countries: Ghana, Kenya, and Malawi. Information from the programs guided WHO recommendations in 2021 for widespread use. A few months later, Gavi, the Vaccine Alliance, provided malaria vaccine funding for eligible countries, which broadened use of the vaccine.
Aug 16 UNICEF statement

Valneva, a vaccine company based in France, yesterday said it started the rolling submission process in applying for FDA approval of its vaccine against chikungunya.

The company is applying for approval of the use of the vaccine in adults ages 18 and older. Clinical trials are under way in adolescents in Brazil that, if successful, could support expanding use in younger people in the future. It hopes to complete the licensing submission by the end of the year. The FDA had earlier granted the vaccine accelerated approval and breakthrough therapy designations.

The vaccine, called VLA1553, is a live attenuated single-dose vaccine. The chikungunya virus, spread by Aedes mosquitoes, has spread to 120 countries, where it has been known to fuel large outbreaks.
Aug 18 Valneva press release

 

More polio cases in Niger, Nigeria, and Yemen

Three countries reported more polio cases this week, two in Africa and one in the Middle East, the Global Polio Eradication Initiative (GPEI) said in its latest weekly update. All involved circulating vaccine-derived poliovirus type 2 (cVDPV2).

In Africa, Niger reported two more cases, both from Dosso, raising its total for the year to 10. Also, Nigeria reported three more cases, all from Zamfara, bringing its 2022 total to 33.

Elsewhere, Yemen reported two cases, including one from Abyan and one from Ibb. So far this year, the country has reported 82 cases, well above the 66 it reported for all of 2021.
Aug 18 GPEI update

 

H1N2v flu case detected in Oregon

The Centers for Disease Control and Prevention (CDC) today reported a variant H1N2 (H1N2v) case in a patient from Oregon who is younger than 18, according to its latest FluView update.

Investigators did not find that the patient had any contact with swine or had attended agricultural fairs. No other respiratory illnesses were found in the individual's household contacts. The patient was not hospitalized and has recovered from his or her illness.

The case marks the nation's fourth variant flu case of the season. A few weeks ago, three H3N2v cases were found in people who attended the same agricultural fair in West Virginia, which involved contact with pigs or pig environments.
Aug 19 CDC FluView update

 

Sporadic high-path avian flu outbreaks persist in US poultry

Four states—Pennsylvania, Florida, California, and Washington—reported more highly pathogenic avian influenza outbreaks in poultry over the past week, according to the latest update from the US Department of Agriculture (USDA) Animal and Plant Health Inspection Service (APHIS).

Pennsylvania's outbreak occurred at a location housing 90 backyard birds in Northampton County. Also in the east, Florida reported its second outbreak, which involved a sentinel flock of 10 birds in Osceola County.

In the west, California reported an outbreak at a backyard facility in Butte County that had 1,700 birds. And Washington reported an event, also involving backyard birds, in a flock of 2 poultry in Walla Walla County.

The outbreaks are part of a small but steady stream of avian flu activity that has continued in poultry over the summer. Since the outbreaks began earlier this year, poultry losses have totaled 40.1 million birds across 39 states.

In related developments, APHIS recently reported 60 more H5N1 detections in wild birds, raising the total to 2,104. Many of the new outbreaks involved black vultures found dead in Florida. Other states reporting more detections include California, Alaska, Washington, and New Jersey.
USDA APHIS poultry outbreak page
USDA APHIS wild bird detection page

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