News Scan for Sep 21, 2021

News brief

CDC alerts providers about infectious diseases in Afghan evacuees

The US Centers for Disease Control and Prevention (CDC) yesterday sent a Health Alert Network notice to health providers warning that cases of measles and mumps have been detected in people recently evacuated from Afghanistan.

So far, 16 cases of measles and 4 cases of mumps have been reported among Afghan refugees and US citizens who were recently airlifted from Afghanistan. The CDC said continued vigilance is needed, and evacuees who are in the United States are required to receive the measles, mumps, and rubella (MMR) vaccine and complete a 21-day quarantine after vaccination at designated locations. Evacuation flights into the United States from other countries have been halted to allow for MMR vaccination and quarantine.

The CDC said it expects more measles spread among evacuees, given the low MMR vaccine coverage in Afghanistan and the close living quarters inherent in the evacuation process. It urged public health departments to continue to look for people with communicable diseases, isolate those with symptoms, and identify and monitor contacts.

The notice also urged health officials to monitor for other diseases. Besides measles and mumps, other infections have been found in evacuees, including chicken pox, tuberculosis, malaria, leishmaniasis, hepatitis A, and COVID-19.
Sep 20 CDC HAN notice

Antivirals underused in Canadian kids with flu, study says

About 41% of children 16 years or younger admitted to 12 Canadian hospitals for the flu received antivirals from the 2010-11 season to 2018-19 season, according to a study in Pediatrics today. Almost 73% received antibiotics even though lab-confirmed bacterial infections were only found in 6.7% patients.

The researchers looked at data from 7,545 patients (median age, 3 years) and found that antiviral use varied from 10.2% to 81.1% across sites and 19.9% to 59.6% across flu season. Increased likelihood factors included more recent flu season (highest adjusted odds ratio [aOR], 9.18 for 2018-19), presence of chronic health conditions (highest aOR, 4.81 for cancer), intensive care unit admission (aOR, 3.62), lab confirmation timing (highest aOR, 2.67 for pre-admission results), needed respiratory support (aOR, 1.57), or antibiotic treatment (aoR, 1.51).

Of the 41.3% patients who received antiviral agents, 99.9% received oseltamivir. About 81.7% received antivirals within 2 days of hospital admission, but initiation decreased in proportion as time lengthened from symptom onset to admission (e.g., less than 2 days was 48.3%, while greater than 4 days was 35%).

Seventy-two percent of patients received antibiotics during hospitalization, but only 6.7% of patients had lab-confirmed bacterial infections. The researchers say that 93% of patients had influenza test results available within 48 hours of admission.

"In this study, only a quarter of children presented within [the recommended antiviral] time interval; delayed presentation (ie, >48 hours) may have led some clinicians not to use antiviral agents," write the researchers. "However, antiviral agents are recommended for all patients hospitalized for influenza, even if treatment is started >48 hours after onset of illness."

"These findings suggest that integrating novel rapid and accurate molecular assays to emergency department diagnostic algorithms, especially for at-risk children being hospitalized, would facilitate early diagnosis and treatment."
Sep 21 Pediatr study

Meningitis cases and deaths rise in DRC outbreak

A meningitis outbreak in the Democratic Republic of Congo (DRC), first reported earlier this month, has grown to 608 suspected cases and 161 deaths, the World Health Organization (WHO) said yesterday in an update. The latest report reflects a steady increase from the 269 cases and 129 deaths that were initially reported on Sep 8.

The area where the outbreak is occurring is in the northeastern DRC province of Tshopo, which is part of Africa's "meningitis belt." The epicenter is the province's Banalia health zone.

So far, 12 cases are lab confirmed. Only a small portion of meningitis cases are confirmed each year. Further testing on samples reveals that the Neisseria meningitidis bacteria involved in the outbreak belongs to serogroup W. Antibiotic susceptibility testing revealed that it is susceptible to ceftriaxone.

Investigations so far have found that the outbreak began in early June in two mining areas in Banalia health zone, north of the provincial capital city of Kisangani. Local health officials have stepped up response actions, and an immunization campaign with a vaccine that contains the serogroup W antigen is being planned.

Tshopo province battled its last meningitis outbreak in 2009, which resulted in 214 cases and 18 deaths. The WHO said the risk of spread to other health zones and the provincial capital is high, with the regional risk moderate and the international threat low.
Sep 20 WHO outbreak update

Non-COVID excess deaths affected minorities, men more, study says

Since the COVID-19 pandemic began, minorities and men have accounted for 58% and 34% of the excess life years lost to non-COVID related deaths, according to a study published yesterday in the Proceedings of the National Academy of Science.

The researchers looked at US data from Mar 8 to Dec 31, 2020, and found that deaths were 17.3% higher than age-population-weighted mortality in the same interval from 2017 to 2019—an excess death count of 413,592. Of the life years lost due to excess mortality, 34.2% of men's loss was not due to COVID-19 versus women's 19.0%. About 32.3% of life years lost among Black or Hispanic people was not due to COVID-19 versus the 24.2% of White people's life years lost. Overall, minorities represented 70% of non-COVID excess deaths and 58% of non-COVID excess life years lost in 2020.

People who were 45 to 75 years old and Black had greater non-COVID excess death rates. Compared with White people, Black men had a 4.7 ratio and women had an 8.5 ratio, and against Hispanic people, Black men and women had a 2.8 and 3.4 non-COVID excess death rate ratio, respectively. White people over the age of 75, on the other hand, had "substantial negative excess mortality" from non-COVID causes.

Age did not create a consistent gradient in non-COVID excess mortality except for minority women and Hispanic men.

"There is little doubt that some of the excess death we label 'non–COVID-19' are truly mismeasured COVID-19 deaths," the researchers write. "However, the evidence above suggests that measurement error represents a small share of these excess deaths and, more importantly, does not explain the large racial/ethnic disparity in non–COVID-19 excess death rates."
Sep 20 Proc Natl Acad Sci study

Stewardship / Resistance Scan for Sep 21, 2021

News brief

Canadian study finds high antimicrobial use in preterm infants

A study of preterm newborns in Canada found high rates of antimicrobial use in the first 7 days after birth, researchers reported last week in Infection Control & Hospital Epidemiology.

Using data from the Canadian Neonatal Network, which covers 90% of neonatal intensive care unit (NICU) admissions in Canada, the researchers analyzed antimicrobial use in infants born earlier than 33 weeks gestational age (GA) to determine the proportion of preterm infants without culture-proven early-onset sepsis (EOS) or necrotizing enterocolitis (NEC) who received one or more antimicrobials during the first 7 days after birth. They also explored the variability in antimicrobial use between sites in different GA subgroups.

Out of 31,295 infants from 30 sites, 27,163 (85%) did not develop EOS or NEC ≥ stage 2 during their hospitalization and were included in the analysis. Among those infants, 44% born at 26 weeks or earlier, 21% born from 27 to 29 weeks, and 10% born from 30 to 32 weeks GA received an antimicrobial on day 7 of life. Those proportions dropped to 29%, 10%, and 4%, respectively, by day 14.

The site-level median antibiotic use rate values for those without EOS and/or NEC ≥ stage 2 were 0.15 for infants born at 26 weeks or earlier, 0.11 for infants born from 27 to 29 weeks, and 0.12 for infants born from 30 to 32 weeks GA, with significant variability across the individual sites in each GA group. This intersite variability persisted for infants in all three GA groups after adjusting for confounding variables.

The study authors note that although antimicrobials are the most commonly prescribed medication in NICUs and are administered shortly after birth to most preterm infants due to increased risk of infection, excessive antimicrobial exposure in newborns without EOS is associated with increased morbidity, mortality, and/or neurodevelopmental impairment. They say the findings suggest that decreasing antimicrobial exposure in preterm infants without infections could be an important antimicrobial stewardship program (ASP) target.

"Reduction of high rates of antimicrobial use at early postnatal age, particularly among lower GA infants at very low risk of developing EOS by applying 36- or 48-hour automatic stop order and regular audit and feedback can be important ASP strategies," they wrote. "Standardizing and auditing the practice by developing nationwide NICU-specific ASP may help reduce interfacility variability in the long run."
Sep 17 Infect Control Hosp Epidemiol abstract

Trial: Probiotic doesn't prevent ventilator-associated pneumonia

A randomized trial conducted among critically ill patients found that the probiotic Lactobacillus rhamnosus GG did not prevent ventilator-associated pneumonia (VAP) or other infections, researchers reported today in JAMA.

Conducted in 44 intensive care units (ICUs) in the United States, Canada, and Saudi Arabia, the trial enrolled critically ill adults predicted to require mechanical ventilation and randomly assigned them to receive L rhamnosus GG or a placebo twice daily.

Previous randomized trials have indicated that probiotics can reduce infection rates in critically ill patients by 20% and may decrease the risk of VAP by 25% to 30%, perhaps through enhanced gut barrier function, competitive inhibition of pathogenic bacteria, and modulation of the host inflammatory response. Investigators wanted to see if this particular strain might have a similar benefit.

The primary outcome was VAP. Secondary outcomes included other ICU-acquired infections (including Clostridioides difficile infection), diarrhea, antimicrobial use, ICU and hospital length of stay, and mortality.

Of the patients included in the analysis, 1,318 received L rhamnosus GG, and 1,332 received a placebo for a median of 9 days. VAP developed in 289 of the 1,318 patients (21.9%) who received probiotics, compared with 284 of 1,332 (21.3%) in the placebo group (hazard ratio, 1.03; 95% confidence interval [CI], 0.87 to 1.22; absolute difference, 0.6%).

No significant differences were found between the two groups for any of the secondary outcomes. Fifteen patients who received probiotics (1.1%) experienced an adverse event, compared with only 1 (0.1%) in the placebo group (odds ratio, 14.02; 95% CI, 1.79 to 109.6).

"These findings do not support the use of L rhamnosus GG for prevention of ventilator-associated pneumonia or other clinically important outcomes in critically ill patients," the study authors concluded.
Sep 21 JAMA abstract