News Scan for Oct 12, 2017

News brief

Florida announces its first local Zika case of the year

The Florida Department of Health (Florida Health) today reported the state's first locally acquired Zika case of the year, putting the nation's total this year at three local cases.

In a statement, Florida Health said the locally transmitted case has been confirmed in Manatee County, which wasn't one of the areas to report cases last year.

An investigation found a couple had recently traveled to Cuba, with one partner experiencing Zika symptoms shortly after returning home. Evidence suggests that the infected person was then bitten by a mosquito in or around the home, which transmitted the virus to the other partner.

Though the person who contracted Zika in Cuba wasn't tested for the virus during the symptomatic phase, a test this week found evidence of past Zika infection. The partner who was most recently symptomatic tested positive.

Florida Health said there is no evidence of ongoing local transmission, and the isolated case doesn't constitute a Zika zone. However, as part of established protocols, officials notified mosquito control, which is implementing mosquito reduction steps.

Florida has 154 travel-linked Zika cases this year, along with 32 with undetermined exposure. The state's number of local and imported cases for 2017 is much lower than the 1,122 travel-related and 296 local cases reported in 2016. Texas is the only other state to report local Zika cases this year, and both occurred in the previously affected Rio Grande Valley near the border with Mexico.
Oct 12 Florida Health statement

Study warns of possible repeat poor vaccine protection against H3N2 in seniors

Low influenza vaccine effectiveness (VE) in seniors against the H3N2 flu strain last season could show the same pattern this season, since H3N2 is still the dominant global strain and current vaccines still contain the same H3N2 component, European researchers warned today in Eurosurveillance.

After analyzing the latest report from the Influenza Monitoring Vaccine Effectiveness in Europe (I-MOVE) network, researchers provided final estimates against H3N2 hospitalizations for people age 65 and older for the previous season, which show overall VE of 17% in the group, which is lower than the early estimate of 23.4% reported in February. In people older than 80, VE was especially low, at 13%.

The scientists weren't able to measure VE against 2009 H1N1 and influenza B, because of the small number of cases. VE against those strains is usually reported to be higher.

When they compared findings in people who weren't vaccinated in the 2015-16 or 2016-17 seasons, vaccination in the earlier season seemed to have a modifying effect on effectiveness during the latter season. Though the authors said the results were too imprecise to be conclusive, the results suggest that patients vaccinated in both seasons benefited from residual protection from the earlier season, with no added effect from the 2016-17 vaccine.

Flu vaccine protection against H3N2 is known to be unpredictable, and the I-MOVE reserachers noted that most circulating H3N2 viruses last season were considered antigenically similar to the vaccine virus, though they underwent genetic diversification with the emergence of subclusters within clade 3C.2a and subclade 3C.2a1. In September, the World Health Organization (WHO) vaccine advisors recommended changing the H3N2 component of the Southern Hemisphere's vaccine for the 2018 season.

"Close monitoring of virological surveillance data will be required to prompt early promotion of complementary measures such as the use of antivirals or non-pharmaceutical interventions," the iMove team wrote.
Oct 12 Eurosurveill report

Yemen predicted to top 1 million cholera cases by year's end

Yemen's cholera epidemic will top 1 million cases, at least 600,000 of them in children, by Christmas, according to a new prediction made by Save the Children, a non-governmental organization.

The outbreak has now surpassed Haiti's 7-year cholera outbreak to become the world's largest. As of Oct 10, the WHO has reported 815,314 suspected cases and 2,156 deaths across Yemen since Apr 27. A total of 4,000 cases per day are still being reported. Haiti, in comparison, has had 815,000 cases since 2010.

Yemen's outbreak has been spurred by civil unrest that's led to a collapsed healthcare system with unpaid doctors, closed hospitals, and highly degraded public health infrastructure.

"There's no doubt this is a man-made crisis. Cholera only rears its head when there's a complete and total breakdown in sanitation," said Tamer Kirolos, Save the Children's country director for Yemen. "All parties to the conflict must take responsibility for the health emergency we find ourselves in."
Oct 11 Save the Children press release

Study identifies African areas most at risk for VHF epidemics

A mapping study to identify which parts of Africa are most at risk for epidemics from four viral hemorrhagic fever (VHD) diseases identified key differences in disease spread among countries, as well as among different regions in individual countries, an international research team reported yesterday in The Lancet.

In assessing the vulnerabilities, the investigators analyzed and mapped the emergence and likely spread of Ebola, Marburg, Lassa fever, and Crimean-Congo hemorrhagic fever. All four share similar transmission patterns between animals and people.

The potential hot spots they found include areas that have already experienced outbreaks, as well as some that haven't usually been thought of as risk areas. For example, the group found that parts of Central African Republic (CAR), Chad, Somalia, and South Sudan are highly susceptible to any of the four diseases. For Ebola and Marburg, the team predicted that areas around the Congo River in the CAR would be most at risk.

According to the analysis, parts of West Africa rank highest as sources of widespread epidemics involving any of the four viruses, including Gueckedou province in Guinea, where West Africa's recent Ebola outbreak got its start.

Simon Hay, DPhil, DSc, study coauthor and director of geospatial science at the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in Seattle, said in an IHME press release that, as seen with West Africa, it's vital to prevent or stop epidemics at the earliest possible stage. "This study's framework provides an important tool for pinpointing where local surveillance and pre-emptive countermeasures are most needed."

The authors also said national assessments can mask important subnational differences.

Peter Piot, MD, PhD, another study coauthor and director of the London School of Hygiene and Tropical Medicine, said, "By assessing pandemic potential at these different stages, we can begin to identify locations where different interventions or prevention measures could have the greatest impact. The various stages reflect important transitions in an outbreak and influence what interventions should be prioritized in which location."

In an accompanying editorial in the same issue, two infectious disease experts said gaps and bias in surveillance limit the ability to predict zoonotic spillover, but the new risk estimates combine geographical information in index cases and viral detections in animals, relating the information to environmental drivers. They noted that the nations most vulnerable to secondary transmission are also ones that have political instability. The authors are Chikwe Ihekweazu, MD, MPH, with the Nigeria Center for Disease Control, and Ibrahim Abubakar, MBBS, PhD, with University College London.

They said point out that the study authors say the work should inform investments at each epidemic stage, but they don't say where the support will come from or which institutions should receive the resources. The two said that, in the wake of the West Africa's Ebola outbreak, more emphasis has been placed on strengthening national public health institutes, rather than depending on the World Health Organization, which they said doesn't have the resources to respond to and manage all VHF threats in an area as vast as Africa.
Oct 11 Lancet study
Oct 11 Lancet editorial
Oct 11 IHME press release

Risk factors for healthcare-related infections include ICU stay, diabetes

A systematic review involving 65 studies determined that major risk factors of healthcare-associated infections (HAIs) are reoperation, intensive care unit (ICU) admission, mechanical ventilation, diabetes, longer surgery times, and cephalosporin exposure, according to a study today in the American Journal of Infection Control.

The researchers, who are from Brazil, identified 867 studies published from 2009 to 2016 and included 65 that met their criteria in the review.

They listed the following risk factor in terms of relative risk (RR), odds ratio (OR), or mean difference (MD): reoperation (RR, 7.94), ICU admission (RR, 3.76), mechanical ventilation (OR, 12.95), cephalosporin exposure (RR, 1.77), diabetes mellitus (RR, 1.76), immunosuppression (RR, 1.24), longer surgery times (MD, 34.53), days of exposure to central venous catheter (MD, 5.20), ICU stay in days (MD, 21.30), and fever of 38.5°C (101.3°F) or higher (MD, 0.62).

The authors note that, according to the European Centre for Disease Prevention and Control, about 20% to 30% of HAIs are considered preventable through intensive hygiene and control programs in hospitals.
Oct 12 Am J Infect Control study

Stewardship / Resistance Scan for Oct 12, 2017

News brief

Study shows ASP is effective, sustainable, in a long-term care hospital

An antimicrobial stewardship program (ASP) at a long-term acute care hospital in Detroit improved antimicrobial prescribing practices, reduced costs, and has proven to be sustainable, researchers report today in the American Journal of Infection Control.

The multi-part study, led by researchers from Detroit Medical Center-Wayne State University, included a survey of healthcare workers at the Kindred Hospital Detroit to assess knowledge and attitudes toward antimicrobial resistance (AMR), a retrospective review of common antibiotic prescribing practices before the ASP was implemented, and a two-phase post-implementation evaluation of the ASP's impact on antibiotic use and expenditures. Kindred's ASP, launched in November 2011, was a seven-step pyramid approach based on the Centers for Disease Control and Prevention's (CDC's) 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults.

The survey found that 65% of the 26 respondents viewed AMR as a national problem, but only 38% viewed it as a problem at their facility. And while 80% were familiar with multidrug-resistant infections like methicillin-resistant Staphylococcus aureus (MRSA), only 35% expressed confidence in caring for patients with such infections.

In the pre-ASP implementation phase, the researchers found that 43% of antibiotic courses administered to a cohort of 28 patients were inappropriate, 77% of opportunities for antibiotic de-escalation were missed, and 48% of antibiotic courses requiring early discontinuation because of misdiagnosis were not stopped. The total antibiotic cost for treating this cohort was $57,168, and the extra drug costs related to missed de-escalation opportunities and unnecessary days of therapy amounted to $23,540.

In the first post-implementation phase, there was a 42% and 58% decrease in the use daptomycin and tigecycline (the two most frequently used antibiotics in the pre-implementation phase), resulting in cost savings of $55,000. In the second post-implementation phase, the researchers demonstrated that from January through March in the years 2016 and 2017, total antibiotic costs were $26,837 and 22,397, respectively—more than $30,000 lower than the pre-ASP cost.

The authors say the findings indicate that the current ASP pilot model is effective and sustainable and can potentially be replicated at other long-term acute care hospitals.
Oct 12 Am J Infect Control study

Analysis: Ending contact precautions for MRSA, VRE doesn't increase infections

A systematic review and meta-analysis of 14 studies indicates that discontinuation of contact precautions (CPs) for MRSA and vancomycin-resistant enterococci(VRE) does not increase infection rates.

While CPs for infections caused by multidrug-resistant infections are recommended by the CDC and are considered an essential element of infection control and prevention in US hospitals, there has been little evidence to support the use of gloves and gowns in the prevention of MRSA and VRE infections in endemic settings, and questions have been raised about the impact of CP on patient care and safety. As a result, several hospitals have discontinued CPs for MRSA and VRE patients, and others are considering it.

To assess the impact of this policy, researchers from the University of Iowa reviewed 14 previously published quasi-experimental studies conducted at hospitals that had discontinued CPs for MRSA and VRE. When they pooled the results of these studies, the investigators found that discontinuation of CPs for MRSA was associated with a non-significant reduction in MRSA infection rates (pooled risk ratio [pRR], 0.84) and a statistically significant reduction in VRE infection rates (pRR, 0.82).

"We think discontinuation of CPs (as currently practiced) for MRSA and VRE can be safely accomplished, particularly in hospitals with a strong horizontal infection prevention strategy, including high levels of compliance with hand hygiene," the authors write today in the American Journal of Infection Control.

They caution, however, that the results are limited by the design of the studies included in their review, and are not applicable to outbreak situations.
Oct 12 Am J Infect Control study

Research reveals opportunities for improving antimicrobial restriction

In a third study today in the American Journal of Infection Control, researchers with the Virginia Commonwealth University Health System report that antimicrobial restriction at an academic medical center led to significant decreases in consumption of restricted agents in more than half of the medical units studied, but in none of the surgical units.

In an analysis conducted at the 865-bed academic medical center from January 2013 through May 2015, the researchers looked at the use the restricted drugs linezolid, daptomycin, and ceftaroline and the non-restricted agent vancomycin. Use was quantified by individual hospital unit and unit type (medical vs. surgical) in days of therapy per 1,000 patient-days. A total of 11 units were analyzed.

In terms of the restricted antibiotics, significant reductions in consumption were detected in 4 of 7 medical units (57%), while increases were detected in 2 of 7 medical units (29%) and 1 of 4 surgical units (25%). No significant reductions in restricted antibiotics were detected in the surgical units. In addition, no significant reductions in vancomycin use were detected in any of the units, but significant increases were detected in 1 of 7 medical units (14%) and 1 of 4 surgical units (25%).

The authors say their analysis reveals opportunities for improving the hospital's antimicrobial restriction strategy, particularly in those units that demonstrated increases in consumption of restricted agents, and they suggest that the methodology may be useful to other programs assessing their restriction policies.
Oct 12 Am J Infect Control study

CARB-X awards $3.8 million to Entasis to develop novel antibiotic class

CARB-X today awarded $3.8 million in funding to Entasis Therapeutics, Inc. to develop its penicillin-binding protein (PBP) inhibitor program, according to a company press release.

The PBP inhibitor program is a novel antibiotic class that targets PBPs—groups of proteins that are essential to bacterial cell wall synthesis. While beta-lactam antibiotics kill bacteria by binding to these proteins, many types of gram-negative bacteria have evolved to produce beta-lactamase enzymes that inactivate these antibiotics. The non-beta-lactam PBP inhibitors developed by Entasis, however, are unaffected by all four classes of beta-lactamases. The company says current leads in the program have demonstrated potent in vivo and in vitro activity against multidrug-resistant Pseudomonas aeruginosa, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant Acinetobacter baumannii.

The award is the company's second from CARB-X (the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator), a public-private partnership launched in 2016 to address gaps in new antibiotic development and funding, specifically in the pre-clinical phase. In March, Entasis received $2.1 million for development of ETX0282, an extended-spectrum beta-lactamase inhibitor.

"We are excited to extend our work with CARB-X following our initial partnership earlier this year and look forward to working together to bring these new anti-infective products through discovery into clinical trials," Entasis CEO Manos Perros, PhD, said in the release.

In addition to the $3.8 million in initial funding, Entasis could receive another $6.3 million from CARB-X if it hits certain milestones.

With today's announcement, CARB-X is now supporting 19 different projects in the pre-clinical phase of development. It aims to invest more than $450 million over 5 years, with a goal of accelerating the discovery and development of at least 20 new antibacterial products.
Oct 12 Entasis press release