News Scan for Apr 29, 2020

News brief

Ebola infects 1 more person in DRC

The Democratic Republic of Congo (DRC) reported one more Ebola infection, raising the number of recent cases in Beni to seven.

The patient is a 39-year-old woman who had been in isolation since her daughter died from Ebola on April 20, Reuters reported yesterday. Her illness raises the outbreak total to 3,462, including 2,267 deaths, according to the World Health Organization (WHO) online dashboard.

In another development, one of the patients recently diagnosed with Ebola in Beni, a 28-year-old motorbike taxi driver, escaped from a treatment center and is thought to be in an area controlled by armed militias. Boubacar Diallo, the WHO's deputy incident manager, told Reuters that the patient is believed to be in an area controlled by Mai armed groups. The incident raises the risk of further spread in the community.

In a weekly situation report on the outbreak yesterday, the WHO said the resurgence of the disease in Beni underscores the importance of heightened vigilance amid the challenges of community engagement, access to affected areas, ongoing insecurity, and limited response capacity due to other local and global health emergencies.
Apr 28 Reuters story
WHO online Ebola dashboard
Apr 28 WHO African regional office weekly report

Revised C diff guidance has quickly changed practice, study finds

Revised clinical practice guidelines for Clostridioides difficile infection (CDI) have had an immediate and significant impact on treatment, researchers reported yesterday in Clinical Infectious Diseases.

Using US antibiotic prescription data for 2006 through August 2019, researchers from the University of Pittsburgh and the VA Pittsburgh Healthcare System performed an interrupted time-series analysis to compare linear trends for monthly treatment courses of vancomycin, fidaxomicin, and metronidazole. The aim of the analysis was to determine if use of the three drugs changed after publication of revised CDI guidelines from the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) in 2018, which recommended vancomycin or fidaxomicin as preferred treatments for initial and first recurrent non-severe CDI, rather than metronidazole as previously recommended.

The analysis found that cumulative treatment courses of oral vancomycin and fidaxomicin increased by 54% and 48%, respectively, in the 18 months following the guidelines compared with the 18 months before, while those of oral metronidazole decreased by 3%. Monthly vancomycin and fidaxomicin use also significantly increased throughout the period following revised guidelines (P < 0.0001 and P = 0.0002, respectively), while monthly use of metronidazole decreased significantly (P < 0.0001).

The analysis also showed that the monthly increases in vancomycin use and decreases in metronidazole use were significantly greater following publication of the revised IDSA/SHEA guidelines than after the publication of two randomized clinical trials that established the superiority of vancomycin over metronidazole.

The authors say the fact that the data used to revise CDI treatment guidelines were available for years before changes in practice were endorsed by IDSA and SHEA suggests that guidelines for CDI and other infections should be updated more frequently.

"Taken together, our findings support a new IDSA initiative to develop, disseminate, and adopt more timely guidelines and guidance for managing antimicrobial-resistant and other difficult-to-treat infections, as set forth in the society's 2019 Strategic Plan," they wrote.
Apr 28 Clin Infect Dis abstract

Nigeria ends Lassa outbreak emergency

The Nigeria Centre for Disease Control (NCDC) yesterday announced the end of the emergency phase of its Lassa fever outbreak, now that cases have dropped below the emergency threshold.

In a statement, it said the outbreak, formally declared on Jan 24, has so far resulted in 979 confirmed cases, including 188 deaths, from 27 states and the Federal Capital Territory. Cases have declined over the past 3 weeks.

The WHO African regional office said in its weekly outbreaks and health emergencies report that Nigeria's Lassa fever outbreak has greatly improved over the last 10 weeks, with only a few sporadic cases reported. Two states—Edo and Ondo—account for 65% of all confirmed cases. So far, 37 health workers have been infected.

The WHO warned that there is little room for complacency, given that the environmental conditions for disease spread and the Mastomys natalensis rodents that carry the virus are still prevalent in the country.
Apr 28 NCDC statement
Apr 26 WHO African regional office weekly report

COVID-19 Scan for Apr 29, 2020

News brief

Study associates stroke with COVID-19 in adults younger than 50

Five COVID-19 patients in their 30s and 40s had large-vessel ischemic strokes from Mar 23 to Apr 7 in a New York City health system, more than five times what the system had been seeing every 2 weeks in the past year, according to a research letter published yesterday in the New England Journal of Medicine.

When admitted, the patients' mean National Institutes of Health Stroke Scale (NIHSS) score was 17 (scores range from 0 to 42, with higher numbers indicating more severe stroke). One patient had previously had a stroke. Over the past year, the health system had seen only 0.73 patients in that age-group with large-vessel stroke every 2 weeks.

Two patients delayed calling an ambulance after developing stroke symptoms because they were worried about hospital exposure to the novel coronavirus. One, a previously healthy 33-year-old woman who had a cough, headache, and chills for a week, waited 28 hours after she began having trouble speaking and weakness in her left arm and leg before seeking treatment.

On hospital arrival, she had an NIHSS score of 19. Computed tomography (CT) and CT angiography demonstrated a partial blockage in the right middle cerebral artery, a blood clot partially blocking the right carotid artery, and fluid buildup in the lungs characteristic of COVID-19 infection. She tested positive for the virus and was released to a rehabilitation facility after 10 days.

The authors noted that retrospective data from Wuhan, China, showed a 5% incidence of stroke among hospitalized COVID-19 patients, but with the youngest stroke patient being 55 years old.

Stroke was also associated with the SARS (severe acute respiratory syndrome) outbreak in Singapore, and abnormal clotting and damage to the lining of blood vessels are thought to be complications of COVID-19.

"Social distancing, isolation, and reluctance to present to the hospital may contribute to poor outcomes," the authors said.
Apr 28 NEJM research letter

Trump's enthusiasm for antimalarials tied to spike in Internet search

A new study published today in JAMA Internal Medicine shows that Internet search for hydroxychloroquine and chloroquine spiked after endorsements from President Donald Trump and billionaire entrepreneur Elon Musk.

The study, conducted by researchers at Oxford University, Harvard University, Johns Hopkins University, and the University of California San Diego, used Google Trends to record searches originating from the United States from Feb 1 to Mar 29 that were related to the antimalarial drugs touted as potential therapeutics for COVID-19 after some success was seen in small clinical settings in China and France.

Google searches for buying chloroquine (which included words such as "buy," "order," and "Amazon") were 442% higher, and searches for hydroxychloroquine were 1,389% higher following endorsements from Trump, the study authors found.

President Trump first endorsed the drugs on Mar 19, and even following public news reports on Mar 22 of chloroquine-related deaths and poisonings, searches to buy chloroquine or hydroxychloroquine remained substantially above expected levels at 212% (95% confidence interval [CI], 66% to 1098%) and 1,167% (95% CI, 628% to 1741%) higher, respectively, the authors said.

"The present analysis suggests that in times of public health crises, demand for unproven and potentially hazardous COVID-19 treatments is massively increased by endorsements. Public health leaders, regulatory agencies, media, and retailers must amplify accurate information," the authors concluded.
Apr 29 JAMA Intern Med study

Many US employees regularly exposed to infection at work, study finds

About 10% of US workers have jobs in which they are exposed to disease or infection at least once a week, while 18% are exposed at least monthly, making workplaces an important focus for public health interventions, a study published yesterday in PLOS One has found.

Using national employment and survey exposure data, University of Washington researchers showed that more than 90% of healthcare workers providing patient care or support are exposed more than once a month, while 75% are exposed more than once a week.

While healthcare workers are likely to have workplace infectious disease prevention plans, other sectors have high levels of exposure and may not have such plans in place, such as administrative support professionals, daycare and preschool teachers, social workers, and plumbers. For instance, 52% of police officers, airport screeners, firefighters, childcare workers, and personal attendants are exposed at least once a month.

The authors pointed out that, of the first 25 COVID-19 patients in Singapore, 17 had probable occupational exposure, including retail and casino workers, taxi drivers, domestic workers, and security guards.

The authors noted that quantifying how many people are at risk for infection can help guide the public health response to infectious disease outbreaks such as the COVID-19 pandemic as well as the risk response and communications plans of governments and individual businesses. Measures could include holding workplace infectious disease training, increasing access to paid sick leave, cross-training, ensuring flexible working conditions and temp workers to fill in when workers are ill, and offering hazard pay for workers exposed during a pandemic.

"Occupational characteristics, such as interfacing with the public and being in close quarters with other workers, not only put workers at high risk for disease, but also make them a nexus of disease transmission to the community," they wrote. "This can further be exacerbated through presenteeism, the term used to describe the act of coming to work despite being symptomatic for disease."
Apr 28 PLOS One study