News Scan for Sep 13, 2018

News brief

Kuwait probe so far finds no source of Korean man's MERS exposure

Kuwait's health ministry said yesterday that an investigation so far hasn't turned up any evidence to suggest that a South Korean business traveler who was diagnosed with MERS-CoV (Middle East respiratory syndrome coronavirus) after returning to his home country was exposed in Kuwait, the Korea Times reported today.

At a media briefing, Mustafa Redha, MD, health ministry undersecretary, said 10 people who had close contact with the South Korean man in Kuwait have tested negative for the virus and the country has taken all steps needed to protect its citizens and visitors from the virus.

Kuwaiti health officials have asked the World Health Organization (WHO) to send a team to confirm its test results, and the Korea Centers for Disease Control and Prevention (KCDC) is slated to send two experts, according to the Times.

According to reports from South Korean health officials, a few days before the man flew back to South Korea he visited a hospital in Kuwait twice for worsening diarrhea. He flew through Dubai on the way to South Korea, and the news report said the man's transfer took less than 3 hours and he had not visited any other country. The incubation period for MERS-CoV is 2 to 14 days.

Kuwait has not reported a MERS case since 2015, but the virus is known to circulate widely in dromedary camels in the Middle East and beyond.

In other developments, no other MERS-CoV cases have been found in South Korea so far following the confirmation of the man's illness on Sep 8. In its latest update today, the KCDC said it is still monitoring 21 close contacts among 431 people identified as contacts.
Sep 13 Korea Times story
Sep 13 KCDC update (in Korean)

Saudi MOH: Two new MERS cases linked to camel exposure

The Saudi Arabian Ministry of Health (MOH) recorded two new MERS-CoV cases this week, both connected to camel exposure, according to an update today.

A 44-year-old man from Riyadh and a 64-year-old man from Hofuf were both diagnosed as having MERS-CoV (Middle East respiratory syndrome coronavirus) and are hospitalized for their infections. Both cases are described as primary and linked to camel contact.

Camel contact, both direct and indirect, is one of the known risk factors for MERS transmission.

The new activity appears to have raised MERS case totals to 2,251 globally since 2012, including 798 deaths.
MOH epidemiologic week 37 update

CDC: Cyclospora investigation ends with 511 illnesses

Yesterday the US Centers for Disease Control and Prevention (CDC) released its final numbers on a Cyclospora outbreak tied to contaminated McDonald’s salads, noting that 4 more cases had been added to outbreak totals, raising the final tally to 511 illnesses.

Sixteen states reported cases, and 24 people were hospitalized. There were no deaths. Illinois reported the most cases (274), followed by Iowa (99) and Missouri (52). During the investigation into the outbreak, ill people reported buying salads from McDonald's restaurant locations in the Midwest, the CDC said.

Case-patients ranged in age from 14 to 91 years, with a median age of 52. Sixty-six percent of patients were women. "This outbreak appears to be over," the agency said.

On Jul 13, McDonald's voluntarily stopped selling salads in 14 states. On Jul 26, the Food and Drug Administration confirmed that a bagged romaine lettuce and carrot mix from a Fresh Express processor in Streamwood, Ill., was contaminated with Cyclospora.
Sep 12 CDC update

Backyard poultry connected to 334 cases of Salmonella

The CDC today also announced the end of an investigation into Salmonella illnesses caused by exposure to backyard poultry flocks.

Officials confirmed 334 illnesses, including 56 hospitalizations, in 47 states since Feb 15 of this year, the CDC said. No deaths were connected to this outbreak, which involved several strains of Salmonella: Seftenberg, Montevideo, Infantis, Enteritidis, Indiana, and Litchfield.

Twenty-one percent of illnesses were reported in children under the age of 5, and 132 (63%) of 211 ill people reported contact with chicks or ducklings in the week before their illness started.

Whole-genome sequencing conducted on 141 isolates from ill people showed that 28 contained genes that predict antibiotic resistance to at least one of the following: ampicillin, streptomycin, sulfamethoxazole, tetracycline, gentamicin, ceftriaxone, amoxicillin-clavulanic acid, cefoxitin, ciprofloxacin, or fosfomycin.

The CDC said hand washing, and supervising children are some commonsense ways to reduce the risk of Salmonella illness from backyard birds.
Sep 13 CDC update

Eye exams recommended for all children born during Zika outbreak

A study today in Pediatrics shows that 25.4% of children born to mothers with confirmed or suspected Zika infections during Brazil's 2015-16 outbreak had eye abnormalities. The authors said these findings should prompt universal eye screening for all children born after Zika outbreaks.

In the study, 224 infants born to Brazilian mothers who had symptomatic Zika infections, or infants with microcephaly or other signs of possible Zika infection or exposure, were tested with reverse transcriptase polymerase chain reaction and subsequently given eye examinations in 2016 and 2017.

According to the study, eye abnormalities were found in 57 of 224 infants (25.4%). Optic nerve (44 of 57; 77.2%) and retina abnormalities (37 of 57; 64.9%) were the most common abnormalities reported.

"CNS [central nervous system] abnormalities significantly increased the chances of eye abnormalities in our cohort by 15-fold," the authors wrote. "Nevertheless, we also examined infants who had no apparent clinical findings and were born to mothers with a diagnosis of ZIKV infection during pregnancy. Five infants had eye abnormalities identified in the absence of any CNS findings."

Thus, the authors recommend eye screenings in Zika outbreak settings regardless of the presence of microcephaly, other abnormalities, or laboratory confirmation of infection.
Sep 13 Pediatrics study

Rapid cholera spread in Zimbabwe capital triggers stepped-up response

A quickly spreading cholera outbreak in Zimbabwe's capital city of Harare has prompted the WHO to scale up its response, according to a statement today from its Regional Office for Africa.

The outbreak began on Sep 1, and as of Sep 11, 2,000 suspected cases have been reported, 58 of them confirmed and 24 fatal. Zimbabwe's health ministry has declared a state of emergency and is working with its international partners to contain the spread of the disease.

According to the WHO, the outbreak is centered in Glenview, a high-density suburb of Harare that is an active trading center with a highly mobile population. Inadequate supplies of safe water have forced residents to turn to unsafe supplies, such as wells and bore holes. Cases have been reported in 5 of the country's 10 provinces.

Matshidiso Moeti, MD, who directs the WHO's African regional office, said in the statement, "When cholera strikes a major metropolis such as Harare, we need to work fast to stop the spread of the disease before it gets out of control." The WHO is helping the health ministry form a surge team and is providing cholera kits that contain oral rehydration solution, intravenous fluid, and antibiotics to cholera treatment centers.

The government is weighing the benefits of a possible oral cholera vaccine (OCV) campaign, and the WHO is deploying an expert in OCV campaigns to Harare. Zimbabwe experiences frequent cholera outbreaks and reported its largest outbreak in 2008, an event that led to more than 4,000 deaths.

Several African countries are battling cholera outbreaks, including Niger, Cameroon, Algeria, Angola, the Democratic Republic of the Congo, Kenya, Nigeria, and Tanzania.
Sep 13 WHO Regional Office for Africa statement

Stewardship / Resistance Scan for Sep 13, 2018

News brief

Investigation provides details on Candida auris outbreak in New York

A study published yesterday in Emerging Infectious Diseases describes the outbreak of the multidrug-resistant fungal infection Candida auris in New York healthcare facilities.

Since C auris was first detected in the United States in 2016, New York has consistently reported the highest number of cases. Of the 391 confirmed and probable cases reported to the Centers for Disease Control and Prevention (CDC) in 11 states as of Aug 17, 213 are in New York. To better understand the spread of C auris in New York healthcare facilities, researchers from the New York State Department of Health, New York City Department of Health and Mental Hygiene, and the CDC conducted an epidemiologic investigation that included review of clinical cases reported by Apr 30, 2017, contract tracing and screening, and collection of environmental samples from facilities where case-patients resided.

The investigators detected 51 cases in 19 healthcare facilities, all but one of which were in New York City. Of these case-patients, 31 (61%) had lived in long-term care facilities before being admitted to the hospital where the infection was diagnosed. The 90-day mortality rate among these cases was 45% (23/51), although the number of deaths attributable to C auris is unknown. Exploration of epidemiologic links revealed a large, interconnected web of affected healthcare facilities throughout New York City.

Screening cultures performed for 572 patients in the 19 facilities where cases were identified revealed an additional 61 patients who were colonized with C auris. Environmental samples were positive for C auris at 15 of 20 facilities, with contamination of surfaces and objects in case-patient rooms and mobile equipment outside those rooms common. Assessment of infection control found that adherence to recommended practices—including hand hygiene, implementation of contact precautions, use of personal protective equipment, and environmental cleaning with proper disinfectants—varied.

The investigators say the reasons for the preponderance of C auris cases in New York City are unknown. The possibilities include a true higher prevalence from multiple introductions into the city, more detection from aggressive case finding, the presence of a large, interconnected network of healthcare facilities, or a combination of all three factors. The infection prevention and control lapses observed by investigators have since prompted intensive improvement efforts.

"The goals are delaying endemicity, preventing outbreaks within facilities, reducing transmission and geographic spread, and blunting the effect of C auris in New York and the rest of the United States," the investigators write.
Sep 12 Emerg Infect Dis article

Analysis of European data finds link between warmer temps, resistance

A team of researchers that earlier this year identified a link between antibiotic resistance and warmer temperatures across the United States is reporting similar findings in an analysis of European data.

In a study yesterday on the preprint server bioRxiv, the researchers from Harvard, Boston Children's Hospital, and Statens Serum Institut in Denmark performed an ecological analysis of country-level antibiotic resistance prevalence in three common bacterial pathogens—Escherichia coli, Klebsiella pneumoniae, and Staphylococcus aureus—across 28 European countries. They used multivariable models to evaluate associations with minimum temperature and other predictors, including antibiotic consumption and population density, over a 17-year period (2000-2016), then quantified those effects on the rate of change of antibiotic resistance across geographies.

The results of the analysis showed that countries with warmer ambient minimum temperatures were experienced faster increases in antibiotic resistance over time for most pathogens and antibiotic classes, even after accounting for rates of antibiotic consumption and population density. Specifically, a 10°C (18°F) increase in the average minimum temperature was associated with an increased rate of change in resistance to aminoglycosides, third-generation cephalosporins, and fluoroquinolones in E coli and K pneumoniae—ranging from 0.33% per year to 1.2% per year.

The researchers also found, however, that the rate of S aureus resistance to methicillin decreased by 0.4% a year as minimum temperatures increased, a finding they argue reflects widespread declines in methicillin-resistant S aureus across Europe over the study period.

As in their previous study, the researchers note that their findings do not show that increasing temperatures are causing antibiotic resistance rates to rise, but that temperature may be playing a role in modulating the rate of change of antibiotic resistance in a region and deserves further exploration. They conclude, "We hope this work will drive further avenues of research to investigate the role of climate as well as other sociodemographic factors on the distribution and transmission of antibiotic resistance."
Sep 12 bioRxiv abstract
May 23 CIDRAP News story "Study finds antibiotic resistance rise tied to hotter temps"

European Parliament representatives adopt One Health AMR action plan

Stressing the need to take into account that human, animal, and environmental health are interlinked, members of the European Parliament (MEPs) today voted to adopt a One Health action plan against antimicrobial resistance.

In the non-binding resolution, adopted with 589 votes for and 12 against, MEPs urged the European Union (EU) Commission and EU member states to restrict the sale of antibiotics by human and animal health professionals and to remove any incentives for prescribing them. The resolution also called for penalties for illegal sales, and sales without prescriptions, of antibiotics.

"We have to start looking at the whole cycle, because people's and animal health are interconnected," rapporteur Karin Kadenbach, an MEP from Austria, said in a European Parliament press release. "Diseases are transmitted to people from animals and vice versa, and that is why we support the holistic approach of the 'One Health' initiative."

MEPs also recommended that the EU Commission draft a list of priority pathogens for humans and animals that could be used to guide future antibiotic research and development efforts, and they emphasized the need for cheaper rapid diagnostic tests to determine whether infections or bacterial or viral.
Sep 13 European Parliament press release

India bans 328 combination drugs, including antibiotics

In a blow to pharmaceutical firms but with antimicrobial stewardship ramifications, the government of India has banned 328 combination drugs, Reuters reported today.

The Indian government in 2016 had banned 350 such drugs, called fixed-dose combinations (FDCs), but a scientific advisory board was reviewing the ban after industry groups mounted a legal challenge. The country's Supreme Court ordered the review.

India's health ministry said yesterday that the board of experts had found "no therapeutic justification for the ingredients contained in 328 FDCs and that these FDCs may involve risk to human beings." The ministry is immediately prohibiting the manufacture, sale, and use of the drugs in people. The Times of India reports that two of the drugs are the antibiotic Lupidiclox and the antibacterial Taxim AZ.

Health advocates have cheered the ban over concern about antibiotic resistance because of the misuse of FDCs, Reuters said.

The president of the Indian Drug Manufacturers' Association, Deepnath Roychowdhury, said the order would affect drugs worth about 16 billion rupees ($222 million) a year, but he said the industry would respect the verdict.
Sep 13 Reuters news story
Sep 13 Times of India report