Study: More than 5 million kids have lost a parent or caregiver to COVID-19

More than 5 million children have lost a parent or caregiver during the COVID-19 pandemic, according to a modeling study published yesterday in The Lancet Child & Adolescent Health.

The study by an international team used updated excess mortality and fertility data to model increases in minimum estimates of COVID-19 orphanhood and caregiver deaths in 20 countries from Mar 1, 2020 to Oct 31, 2021. Orphanhood was defined as the death of one or both parents, and caregiver death included parental death or death of a custodial or co-residing grandparent. The team's original study had estimated that, from Mar 1, 2020, to Apr 30, 2021, 2,737,300 children had experienced a COVID death of a parent or caregiver.

The updated estimate found that, from Apr 30 to Oct 31, 2021, the number of children affected by COVID-19-associated orphanhood or caregiver death increased 90%, from 2,737,300 children to 5,200,300 children. Over the entire 20-month period, 491,300 children aged 0 to 4 years, 736,800 children aged 5 to 9 years, and 2,146,700 children aged 10 to 17 years were estimated to have experienced COVID-19-associated orphanhood. Globally, 76.5% of those children lost a father, and 23.5% lost a mother.

The total number of orphaned children ranged widely across the 20 countries, from 2,400 children in Germany to 1,917,000 children in India. Per capita, the highest rates of orphanhood were in Peru (8.28 per 1,000 children) and South Africa (7.22).

The study authors say the data suggest the surge of parent and caregiver deaths "must be urgently addressed with sustainable and scalable solutions, and integrated into coordinated and collaborative global, regional, and national strategies."

"Such support should focus on three core components: preventing caregiver death through equitable COVID-19 vaccine coverage, containment, and treatment; preparing families that are safe and nurturing to support affected children (such as through kinship care, foster care, and adoption); and protecting children using evidence-based strategies to reduce risks of poverty, childhood adversity, and violence," coauthor Susan Hillis, PhD, of the Centers for Disease Control and Prevention, said in a Lancet press release.

"These strategies will help save lives now and put the programmatic and financial infrastructure in place on a global scale to secure a better future for children and families around the world."
Feb 24 Lancet Child Adolesc Health study
Feb 24 Lancet press release

Workforce in nursing homes, other healthcare areas shrank amid COVID

US skilled nursing facilities (SNFs) faced sharp employment losses during the pandemic—particularly in counties with a large infection burden—and did not rebound like other healthcare sectors, finds a study today in JAMA Health Forum.

In the study, a team led by RAND Corp. researchers examined the effect of COVID-19 on the US healthcare workforce in 2020 and the first half of 2021, a time of elevated health risks, burnout, and childcare disruptions.

"While federal programs have provided financial assistance to hospitals and institutions, the net effect of these forces on health care employment levels and wages has not been examined," the researchers wrote.

The team analyzed industry- and county-level data from the US Bureau of Labor Statistics Quarterly Census of Employment and Wages to measure changes in employment and average wages among employees of physician and dentist offices, home healthcare, hospitals, SNFs, and combined other facilities.

Healthcare employment fell from 22.2 million in 2019 to 21.1 million in the second quarter of 2020, a 5.2% drop (compared with a 9.0% decline in all industries) but rebounded to 21.8 million in the same period in 2021. Average healthcare wages rose at a lower rate than other industries (5.0% vs 6.7% in 2020 and 1.5% vs 6.9% in 2021).

The largest declines in employment in 2020 were in dentists' offices (10.0%) and SNFs (8.4%), while the smallest declines occurred in hospitals (2.5%) and physicians' offices (4.6%). Other healthcare sectors rebounded to prepandemic employment levels in 2021, but SNFs saw even more declines (13.6% relative to 2019) despite having the largest wage increases (9.5% in 2020 and 6.3% in 2021).

The adjusted 2020 SNF employment level relative to 2019 was 105.2% among counties with the lowest quintile of COVID-19 infections and 90.4% among those in the top 20%.

Counties with the lowest physician-to-population ratios tended to have higher adjusted employment levels in physicians' offices (107.8% vs 97.9%) and dentists' offices (110.1% vs 98.4%).

"Future research is needed to understand if organizations are demanding fewer workers or fewer workers are willing to work at health care positions," the authors wrote. "Overall, our results imply that intensified early efforts are needed to protect the health care workforce in future pandemics."
Feb 25 JAMA Health Forum research letter

Four nations report new polio cases as 8 Afghan polio vaccinators slain

Four countries have confirmed new polio cases, with the Democratic Republic of the Congo (DRC), Nigeria, and Yemen reporting circulating vaccine-derived poliovirus type 2 (cVDPV2)  and Madagascar noting circulating vaccine-derived poliovirus type 1 (cVDPV1), according to an update yesterday from the Global Polio Eradication Initiative (GPEI).

The cases come as United Nations (UN) and World Health Organization (WHO) officials decry the murder of eight polio vaccination workers in Afghanistan.

The DRC reported 2 cVDPV2 cases in Maniema province, with 1 being the first of 2022 and the other from 2021. The number of 2021 cases now stands at 26. Nigeria confirmed 3 cVDPV2 cases, 2 in Borno state and 1 in Kano, which is the first of 2022. Nigeria's 2021 case count has reached 415. Yemen reported 3 new cVDPV2 cases, 1 each in Abyan, Ad Dali, and Al Hudaydah governorates. Yemen has had 13 cVDPV2 cases and 3 cVDPV1 cases in 2021.

Madagascar officials confirmed 1 cVDPV1 case each in Diana and Sofia regions, with 1 being the first of 2022 and the other from 2021, bringing the number of 2021 cases to 12.
Feb 24 GPEI update

The slaying of the eight polio vaccination workers happened yesterday in four separate incidents in northern Afghanistan, according to a UN news release. They are the first such attacks since nationwide immunization campaigns resumed in November 2021 and come after nine polio immunization workers were killed in the country last year. 

One member of a vaccination transit team was killed in Taloqan district in Takhar province, while four members of house-to-house teams were murdered in two separate incidents in Kunduz city. And two vaccinators and a social mobilizer were slain in the Emamsaheb district of Kunduz province. 

In the wake of the killings, the UN immediately suspended the national polio vaccination campaign, which began on Feb 21, in Takhar and Kunduz provinces.

"WHO condemns all attacks on health workers in the strongest terms and appeal to the Taliban Authorities to immediately identify and bring the perpetrators to justice," said Ahmed Al-Mandhari, MD, WHO regional director for the Eastern Mediterranean, in a WHO statement.

"The polio programme supported by WHO, UNICEF, and other partners has made extensive progress in controlling transmission of wild poliovirus in Afghanistan…. In 2021, Afghanistan reported 4 cases of wild poliovirus, and only one case has been reported to date in 2022."

The immunization campaign had planned to target nearly 10 million preschoolers across the country. Four additional campaigns are planned for 2022.
Feb 24 UN news release
Feb 24 WHO statement

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

Study: Increased flu vaccination could cut flu-linked antibiotics

A study of influenza-associated antibiotic prescribing in California suggests that increasing influenza vaccination coverage could have a modest benefit for reducing antibiotic prescribing, researchers reported today in Epidemiology & Infection.

For the study, researchers from Harvard T.H. Chan School of Public Health and Kaiser Permanente estimated age/diagnosis-specific proportions of antibiotic prescriptions for the Kaiser Permanente Northern California population from 2010 through 2018, looking at prescriptions for all diagnoses, ear infections, and respiratory diagnoses without indication of a bacterial infection.

They estimated antibiotic prescribing associated with influenza, which can lead to bacterial complications such as streptococcal pharyngitis and otitis media (ear infection), by calculating the proportion of all antibiotic prescribing that could be explained statistically by weekly variation in influenza incidence.

The proportion of influenza-associated antibiotic prescribing among all antibiotic prescribing was higher in children aged 5 to 17 years than in children under 5 years old, ranging from 1.4% in children younger than 1 year to 2.7% in children ages 15 to 17 years.

For adults over 20 years of age, the proportion of influenza-associated prescribing among all prescribing was lower, ranging from 0.7% for ages 25 to 29 to 1.6% for ages 60 to 64. Most influenza-associated prescribing in children under 10 was for ear infections, while for age-groups over 25, 45% to 84% of influenza-associated antibiotic prescribing was for respiratory diagnoses without a bacterial infection.

"Our results suggest an overall modest benefit of increasing influenza vaccination coverage for reducing antibiotic prescribing, with that benefit being greatest for school-age children, as well as the benefit of reducing unnecessary antibiotic prescribing for respiratory diagnoses with no bacterial indication in persons aged over 25y, both of which may further contribute to the mitigation of antimicrobial resistance," the study authors write.
Feb 24 Epidemiol Infect abstract

Study finds increased risk of C difficile from contaminated hospital rooms

Originally published by CIDRAP News Feb 23

A study conducted at five acute care hospitals adds further evidence of the role the hospital environment plays in Clostridioides difficile infection (CDI), researchers reported today in the American Journal of Infection Control.

An estimated 236,000 healthcare-associated CDI cases occur each year in the United States, and even with thorough cleaning efforts, C difficile spores can persist in hospital rooms for months, posing colonization and infection risks to patients. To examine the risk posed by a previous room occupant with CDI on subsequent room occupants, a team led by researchers from Johns Hopkins University examined all adult inpatients admitted to five acute care hospitals in Maryland and Washington, DC, from July 2016 through December 2018

A room was considered contaminated for each day it was occupied by a patient who was actively infectious, and for 30 days after. Patients were considered exposed to a contaminated room if they had occupied a contaminated room in the preceding 90 or 365 days. The researchers used logistic regression to assess the association of exposure to a contaminated room with CDI diagnosis.

During the study period, 2,128 CDI cases were reported among 218,731 hospital admissions. After controlling for the number of previous admissions and length of stay, patients admitted to a room previously occupied by a patient with CDI had 27% increased odds of subsequently being diagnosed as having CDI if they were exposed within the past 90 days (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.12 to 1.44) and 40% increased odds if they were exposed within 365 days (OR, 1.40; 95% CI, 1.25 to 1.57).

Similarly, cumulative patient-day exposure to previously CDI-positive occupied rooms within both 90 and 365 days was found to be independently significant, with a 4.5% (OR 1.045; 95% CI, 1.03 to 1.06) and 4.2% (OR 1.042; 95% CI, 1.03 to 1.06) increase in odds of CDI with each day of exposure, respectively.

"Our results contribute to the evolving literature on the impact of the hospital environment on the risk of transmission of pathogenic organisms," the authors write. "More studies are needed to better define transmission risks and mitigation strategies."
Feb 23 Am J Infect Control abstract

ECDC reports increase in extensively drug-resistant Shigella in UK, Europe

Originally published by CIDRAP News Feb 23

The European Centre for Disease Prevention and Control (ECDC) is reporting an increase in extensively drug-resistant (XDR) Shigella sonnei infections in the United Kingdom and elsewhere in Europe.

In a rapid risk assessment published today, the ECDC said the increase was first noted by the UK Health Security Agency in late January, when it reported 47 cases of XDR S sonnei from September 2021 through Jan 10, 2022—up from 16 in the previous 4-month period. The UK outbreak strain showed non-susceptibility to penicillins, third-generation cephalosporins, aminoglycosides, tetracyclines, sulfonamide, quinolones, and azithromycin.

On Feb 10, nine European Union/European Economic Activity (EU/EEA) countries (Austria, Belgium, Denmark, France, Germany, Italy, Ireland, Norway, and Spain) reported at least 146 confirmed cases of shigellosis related to the UK cluster. In individual countries, at least 29 isolates have been reported to be genetically linked through whole-genome sequencing, and Austria, Belgium, Denmark, Germany, Norway, and Spain report that all or at least some of the isolates appear to be genetically close to the UK representative sequences.

Shigella transmission occurs via the fecal-oral route, and symptoms of infection include diarrhea, high fever, and stomach cramps. Antibiotics are typically needed only in patients with severe disease or who require hospitalization. Seven of the UK patients and one Italian patient have been hospitalized.

Most of the reported cases are adult men who have sex with men (MSM), some of whom have been infected through sexual transmission. The ECDC says that, because sexual contact networks among some MSM in Europe are highly connected and sometimes involve high-risk sexual practices, the risk of spread among MSM in EU/EEA countries in the coming months is high, particularly with COVID-19 restrictions being lifted.

The agency also notes that while the risk to the non-MSM population is low, opportunities for infection could increase when transmission among MSM is high.
Feb 23 ECDC rapid risk assessment

ECDC warns that Italian Candida auris outbreak could spread

Originally published by CIDRAP News Feb 22

The ECDC yesterday issued a warning about an ongoing outbreak of the multidrug-resistant yeast Candida auris in Italy.

The outbreak began with a single case detected in a hospital in Liguria in July 2019. In February 2020, a case was detected in the same hospital's intensive care unit for COVID-19 patients, and C auris case numbers continued to increase at the facility through 2020 and 2021. Whole-genome sequencing of isolates from 10 of the early cases showed that the isolates belonged to the South Asian clade and that all except one were part of the same cluster originating from the index case.

To date at least 277 cases have been detected at eight hospitals in Liguria, 210 of them at the initial hospital. An additional 11 cases have been detected in facilities in the neighboring region of Emilia-Romagna.

C auris was first identified in Japan in 2009 and since then has been detected in 40 countries on six continents. It can cause severe invasive infections in patients who have underlying disease or immunosuppression, and clinicians have limited treatment options. Nearly all C auris isolates described worldwide have been reported as resistant to fluconazole, with varying levels of resistance to other azoles, echinocandins, and amphotericin B.

The ECDC says that, given the high number of cases and the inter-regional spread, the risk of further spread within Italy is considered high. 
Feb 21 ECDC rapid risk assessment

VA study finds most dental antibiotic prophylaxis prescriptions improper

Originally published by CIDRAP News Feb 22

Another study of antibiotic prescribing by Veterans' Affairs (VA) dentists found that five of every six prescriptions for antibiotic prophylaxis were inconsistent with guidelines, researchers reported today in Infection Control & Hospital Epidemiology.

The cross-sectional study of visits to VA dentists from 2015 through 2019 examined all antibiotics prescribed within 7 days of a visit in the absence of an oral infection. In the primary analysis, antibiotic prophylaxis was considered appropriate only if it was associated with a visit that involved manipulation of gingival tissue and if the patient had a cardiac condition at the highest risk of an adverse outcome from infective endocarditis according to guidelines.

In the secondary analysis, antibiotic prophylaxis was considered appropriate if it was associated with tooth extractions or implants and the patients had a cardiac condition or was immunocompromised.

The investigators analyzed data on 369,102 prophylaxis prescriptions for 358,078 visits. Over 90% of the visits were categorized as gingival manipulation. The median prescription duration was 7 days; only 6.5% were prescribed for 1 day.

In the primary analysis, using a narrow definition of appropriate, 15% of prophylaxis prescriptions were considered appropriate. In the secondary analysis, with a broader definition, 72% of prophylaxis prescriptions were considered appropriate. Prophylaxis inconsistent with guidelines increased over time.

For the narrow definition, multivariable analysis found that Black (vs White) race, Latino (vs non-Latino) ethnicity, and visits located in the West census region were associated with unnecessary prophylaxis. Variables associated with a lower risk for inappropriate prophylaxis were older age, prosthetic joints, immunocompromising condition, and rural location. Similar predictors were identified on multivariable analysis for the broad definition, although Latino ethnicity was less likely to be associated with inappropriate prophylaxis and dental visits in the Northeast more likely.

The study authors say pressure for dentists to prescribe antibiotics by medical clinicians may play a role in the lack of guideline concordance.

"Other factors that may be associated with potentially unnecessary prescribing by dentists include time constraints, an aging population, dental implant placements, underinsurance, and procedural skills during emergencies," they write.
Feb 22 Infect Control Hosp Epidemiol abstract

WHO survey finds gaps in global infection prevention and control

Originally published by CIDRAP News Feb 22

A World Health Organization (WHO) survey of infection prevention and control (IPC) professionals found significant gaps in IPC implementation, WHO researchers reported yesterday in The Lancet Infectious Diseases.

From Jan 16 to Dec 31, 2019, 4,440 IPC professionals from 81 countries completed the WHO online IPC assessment framework (IPCAF), a questionnaire that scores responses to questions about eight WHO IPC core components: (1) IPC program; (2) IPC guidelines; (3) IPC education and training; (4) healthcare-associated infection (HAI) surveillance; (5) multimodal strategies; (6) monitoring and audit of IPC practices and feedback; (7) workload, staffing, and bed occupancy; and (8) materials and equipment for IPC. Each section generates a score from 0 to 100.

The overall weighted IPCAF median score indicated an advanced level of IPC implementation (605), but significantly lower scores were found in low-income (385) and lower-middle-income (500) countries, as well as in public healthcare facilities (515). Core component 8 (90) and core component 2 (87.5) scored the highest, and core component 7 (70) and core component 3 (70) scored the lowest.

Overall, only 15.2% (588 of 3,873) of facilities met all IPCAF minimum requirements, ranging from 0% (0 of 417) in low-income countries to 25.6% (278 of 1,087) in primary facilities, 9% (24 of 268) in secondary facilities, and 19% (18 of 95) in tertiary facilities in high-income countries.

The authors of the paper say the findings identify key opportunities to inform ongoing global IPC improvement efforts, particularly in low-income and lower-middle-income countries, and note that improvements will be needed to reduce the global burden of HAIs and antimicrobial resistance (AMR).

"The endemic burden of HAIs and AMR continues to affect patient safety, hamper high standards of quality of care, and impede the achievement of universal health coverage," they wrote.

"To address these challenges and make substantial durable progress in IPC, a greater emphasis must be placed on developing and enforcing stronger policies and regulations, supported by leadership and accountability mechanisms at the highest levels, as well as by an appropriately trained IPC workforce at the facility level."
Feb 21 Lancet Infect Dis study

Guideline-discordant dental antibiotics linked to increased C diff risk

Originally published by CIDRAP News Feb 21

A study of US veterans who developed CDI within 30 days of a dental antibiotic prescription found that nearly 80% received guideline-discordant antibiotics, researchers reported today in Infection Control & Hospital Epidemiology.

Using data on VA patients with dental antibiotic prescriptions, a team of VA researchers found that 212,763 patients had an antibiotic prescribed by a VA dentist within 7 days of a dental encounter from 2015 through 2019, and 108 (0.05%) had a positive C difficile diagnostic test within 30 days.

Of the patients with CDI, 79.7% received antibiotics that were discordant with guidelines from the American Dental Association and the American Heart Association (AHA), which recommend antibiotic prophylaxis only for patients with a pre-existing cardiac condition who are undergoing gingival manipulation or being treated for acute apical abscess.

Of those with discordant prescriptions, only 19.4% had a pre-existing cardiac condition. In addition, 24.4% had prosthetic joints and 4.6% were immunocompromised. Furthermore, 59.3% had a chronic gastrointestinal issue, 34.3% had gastroesophageal reflux disease, and 50.0% had been prescribed either a proton pump inhibitor or H2 receptor antagonist for gastric conditions; all three factors have been associated with increased CDI risk.

The analysis also found that 89% with a documented penicillin allergy receive clindamycin, which the AHA recommends against because of the documented increased risk of CDI and other adverse events.

"Although our current results do not causally link the dental antibiotics to the subsequent CDI event, the antibiotics prescribed by a dentist represent an additional exposure," the authors write. "We recommend increased vigilance by dentists to antimicrobial stewardship, awareness of identified risk factors, and an increased adherence to guidelines."
Feb 21 Infect Control Hosp Epidemiol abstract

Canadian proposal aims to boost access to new antibiotics

Originally published by CIDRAP News Feb 21

The Canadian Antimicrobial Innovation Coalition (CAIC) and McMaster University last week released a proposal to boost access to new and innovative antibiotics in Canada.

The proposal contains 30 recommendations that aim to rectify the lack of access in Canada to several new antibiotics that have been approved and marketed in the United States and Europe in recent years. A July 2021 study published in Clinical Infectious Diseases found that, of 18 novel antibiotics approved and commercially launched in 14 high-income countries over the past decade, only 2 have been introduced in Canada.

In addition, the proposal also notes that several new antibiotics already approved in Canada are rarely used owing to costs and administrative barriers, resulting in overuse of first-line drugs in Canada.

Among the recommendations made in the proposal are guaranteed minimum revenue agreements for manufacturers of novel antibiotics that would delink sales volume from return on investment; expedited and streamlined marketing approval of select priority antibiotics that have already been approved by the US Food and Drug Administration or the European Medicines Agency; specific funding envelopes to help Canadian hospitals buy new antibiotics; national forecasts for the antibiotics that will be needed by Canadian patients; and investments in antibiotic stewardship.

"Part of the reason we're seeing drugs approved elsewhere but not here in Canada is because approval costs are high, our population is relatively small, and physicians try to use new antibiotics only as a last resort to reduce the chance of resistance to them developing," project chair Lori Burrows, PhD, of McMaster University, said in a press release. "We believe that this can be rectified through incentivization and regulatory improvements, as other G7 countries are doing."

The authors of the proposal suggest piloting it in a select region of the country using a limited number of novel antibiotics that have already been approved in Canada.
Feb 15 McMaster press release
Dec 2021 McMaster/CAIC antibiotic access and capacity proposal