H5N1

Saudi Arabia: Not only MERS but also Klebsiella

Via Doctor KSA.com, an English-language Saudi website: Coronavirus Kills 3 More. Meanwhile, a nosocomial Klebsiella outbreak has also been going on in Al-Ahsa:

The novel coronavirus has claimed another three lives, with a new case having been reported. 

The three patients had been suffering from chronic diseases. Two of them had reached End Stage Renal Disease (ESRD). 

The latest victim, diagnosed yesterday, was a woman who was suffering from chronic cardiac disease, said Dr. Khalid Al-Mirghalani, spokesman for the Health Ministry. 

Authorities tested 51 suspected samples in the past 24 hours and found them negative. Laboratories in the Eastern Province also tested 155 samples prior to the latest deaths and found the results negative. 

Al-Mirghalani said that the Ministry of Health has intensified its precautionary measures to combat the spread of the virus.

 “We have increased surveillance and deployed additional health officials in vulnerable places to monitor the disease,” he said, adding that the ministry had also launched an awareness campaign in the Eastern region highlighting precautionary measures to fight the virus. 

Meanwhile, a ministry spokesman said the Klebsiella bacteria cases at Al-Ahsa Obstetrics and Children Hospital are limited. 

He said the majority of the cases are for premature newborns, but most of them recovered already. Residents and citizens at Al-Ahsa have been circulating the news on social networking sites that the Klebsiella virus is spreading and has already killed four children.

US: Experts debate plan to speed antibiotic development

Via The New York Times: Experts Debate Plan to Speed Antibiotic Development. Excerpt:

Government officials, drug companies and medical experts, faced with outbreaks of antibiotic-resistant “superbugs,” are pushing to speed up the approval of new antibiotics, a move that is raising safety concerns among some critics. 

The need for new antibiotics is so urgent, supporters of an overhaul say, that lengthy studies involving hundreds or thousands of patients should be waived in favor of directly testing such drugs in very sick patients. Influential lawmakers have said they are prepared to support legislation that allows for faster testing. 

The Health and Human Services Department last month announced an agreement under which it will pay $40 million to a major drug maker, GlaxoSmithKline, to help it develop medications to combat antibiotic resistance and biological agents that terrorists might use. Under the plan, the federal government could give the drug company as much as $200 million over the next five years. 

“We are facing a huge crisis worldwide not having an antibiotics pipeline,” said Dr. Janet Woodcock, director of the Center for Drug Evaluation and Research at the Food and Drug Administration. “It is bad now, and the infectious disease docs are frantic. But what is worse is the thought of where we will be five to 10 years from now.” 

Annually, tens of thousands of Americans die from infections, largely acquired in hospitals, that are resistant to antibiotics, experts say. 

Doctors, faced with dwindling options and little time to decide, are often left with agonizing choices over how to save a patient’s life. For example, some doctors, in extreme cases, are again using Colistin, an older antibiotic that was largely abandoned years ago because of the damage it can cause the kidneys.

Saudi Arabia: Questions about the latest MERS death

Via Arab News: Elderly woman is 18th MERS-CoV fatality in KSA. Excerpt, and then some questions:

The octogenarian woman in Al-Ahsa who had contracted the SARS-like coronavirus has died, raising the death toll in the Kingdom to 18 and the world total at 23, a Ministry of Health statement said on Sunday. 

"An 81-year-old woman who was suffering from kidney failure as well as other chronic illnesses has died" in the eastern Al-Ahsa region after contracting the virus, the statement said. 

Now called by the MERS-CoV by the World Health Organization, short for Middle East Respiratory Virus - corona virus, the new virus is from the same family as those that cause common colds and the one that caused the deadly outbreak of Severe Acute Respiratory Syndrome (SARS) that emerged in Asia in 2003. 

On May 18, the WHO included the 81-year-old woman in Al-Ahsa as case number 41 in its list of MERS-CoV victims worldwide. It cited a report of the Saudi MOH saying the woman became ill on April 28, 2013, and was "currently in critical but stable condition." 

"She was in the same health care facility previously identified as the focus of this outbreak, from 8 to 28 April 2013," it added. 

The facility referred to had earlier been identified by health officials as a hospital in Hofuf town in Al-Ahsa. 

In its latest update on May 23, the WHO placed the worldwide total of laboratory-confirmed cases of MERS-CoV infection at 44 since the virus was discovered by scientists in September 2012. 

Saudi Arabia counts by far the most cases, with 30 confirmed infections and 18 fatalities, while cases have also been detected in Jordan, Qatar, Tunisia, UAE, Germany, Britain and France. 

Most cases have been registered in the east, with the ministry saying that most of those who died were "elderly people with chronic illnesses." 

The 17th fatality was a 63-year-old Syrian man in the central province of Qassim, the first non-Saudi in the kingdom to catch MERS-CoV. 

Of those infected in Saudi Arabia, two were health workers who caught the virus from patients in their care — the first evidence of such transmission within a hospital, the WHO earlier said.

I don't know how the Saudis run their hospitals. But I understand that Saudi male nurses care for male patients and females for females; female Saudi nurses in Hofuf recently protested over the possibility of having to care for males because they might see the males' "private parts."

So how did a disease that predominantly afflicts males get into a female ward? Was it in the air? Was the 81-year-old woman a family member of a male case? Did the hospital in Hofuf have generally poor standards of cleanliness, so that the disease moved from, say, a male nurse's hand to a hallway door to a female nurse's hand touching the same door?

I have no idea. But I hope the Saudi Ministry of Health is conducting a ferocious forensic examination of that hospital, and reporting everything it finds to WHO.

Scientists look to Saudi Arabia for coronavirus clues

Via Nature News & Comment: Scientists look to Saudi Arabia for coronavirus clues. Excerpt:

The latest outbreak in Saudi Arabia provides further evidence of limited human-to-human transmission. In all clusters so far, any human-to-human spread has required close contact, and there remains no evidence of sustained spread in the community. 

One focus of attention was a haemodialysis unit at the hospital that may have been related to the latest cluster. Peter Horby, an epidemiologist at the Oxford University Clinical Research Unit in Hanoi, thinks that a more likely scenario is that transmission is occurring through various medical procedures, such as tracheal intubations or bronchoscopies, both of which are performed on people with respiratory distress. 

More data 

But researchers are still waiting for information that could help them to understand the virus, such as genetic sequences from a large number of cases. Five sequences have been posted and have been crucial in identifying the receptor that the virus uses to infect human cells. But to the frustration of researchers, only one of those sequences came from Saudi Arabia — even though the country accounts for more than half of reported cases. 

More might be coming soon.“We are working on sequencing of the virus from the recent cluster,” says Ziad A Memish, Deputy Minister for Public Health and Director WHO Collaborating Center for Mass Gathering Medicine. “We expect this work will be completed in the next 2-3 weeks.” 

Asked whether the sequences would be shared with researchers, Memish said: “Investigation is ongoing and the [health ministry] will summarize findings and possibilities soon.” 

“It is of the utmost importance to obtain further detailed sequence data of the viruses that caused the recent outbreak,” says Bart Haagmans, a virologist at the Erasmus Medical Center in Rotterdam, the Netherlands. 

Such data would help researchers not only to further understand the epidemiology of this virus, but also to investigate whether antivirals and any candidate vaccines will also work against it, he adds.

Thinking about H7N9, MERS, and ignorance

We are now six weeks into the publicly announced H7N9 outbreak. March 31 seems like a long time ago. We've assimilated an extraordinary amount of information about a seemingly mild-mannered poultry virus that sometimes kills people. But the experience reminds me of a 1958 morning in Mr. Kennedy's Grade 12 philosophy course at Santa Monica High.

Mr. Kennedy drew a small circle on the chalkboard: "When you don't know very much," he explained, "you're not aware of much that you don't know." Then he drew a much larger circle around the first one: "When you know more, you also realize how much more you're ignorant of."

Despite this discouraging analysis of the value of learning (which presaged Donald Rumsfeld's "unknown unknowns"), I carried on with my own education. Now, at the age of 72, my ignorance has approached oceanic proportions—and especially about both H7N9 and MERS. This has been a very frustrating time.

I certainly pick up a similar note of frustration in the official statements about the two outbreaks. Three long months after the first Mr. Li fell ill in Shanghai, our ignorance about H7N9 seems to expand by the day. We've learned that H7N9 in poultry extends at least from Tianjin (where Mr. Yao, the onetime poultry dealer, picked up the chickens that infected his 7-year-old daughter and the 4-year-old boy across the street) to Dongguan, just north of Shenzhen and the Hong Kong border. That's far enough to suggest that it's probably all over the People's Republic, a recently mutated virus carried far on the tide of Chinese enterprise.

But it's so new and so rare that we almost never find it except when someone falls ill. Even then, the victim may have no recollection of any contact with poultry. The current pause in new cases may be thanks to the shutdown of the Shanghai live-poultry market, or to some seasonal quirk that will drive H7N9 underground until cooler weather in the fall. We don't know.

The answers to our questions about H7N9 lie somewhere beyond that recently expanded circle of our knowledge. But we're still most comfortable inside the inner circle of our old knowledge, where we know about other avian influenzas and their behaviour and the means of fighting them. 

We're similarly inside our inner circle of knowledge about SARS, trying to figure out why its cousin MERS is taunting us from somewhere beyond our newly expanded outer circle. And here we've been dealing with it since April 2012, without even determining who the index case was in Zarqa Hospital back then, or how that case contracted the virus.

Still less do we know how it then moved well south of Jordan into the Persian Gulf states and Saudi Arabia, where it has established itself very comfortably in at least one hospital in Al-Ahsa province. Why this fondness for medical settings? We don't know. And why did the first French case show such innocuous symptoms that he was given a roommate in Valenciennes hospital? We don't know.

As frustrating as life may be on the outer frontiers of our ignorance, we should recall that we've been here before. It was months before Guan Yi got the test results proving SARS was being transmitted from wild animals, especially civet cats, fed to patrons of "wild flavour" restaurants. With that, shutting off the supply (if only temporarily) broke the chain of infection, and SARS was finally caught inside the circle of our knowledge. In hindsight, the period of our SARS ignorance seems brief; at the time, it seemed to go on forever while hundreds died.

So we're going to need patience. It may take months more to bring these new viruses into the circle where we can deal effectively with them. And once we've managed that, we'll be aware of still more we're ignorant of.

Unfortunately, we can't withdraw inside a nice safe zone of known knowns and known unknowns. As Mr. Kennedy observed over half a century ago, our ignorance will always be greater than our knowledge. But awareness of ignorance is also a kind of knowledge, and without it we can never ask the right questions—the only questions where the right answers really matter.

Saudi Arabia: A new nCoV note from Dr. Memish

Via ProMED-mail, a very interesting note:

Date: Sunday, May 5, 2013, 11:18 PM 

From: Ziad Memish 

Subject: Urgent follow up re nCOV cluster in Alhassa KSA 

Dear colleagues, 

As a follow up to the most recently reported 10 case cluster of nCOV in Alhasa in the Eastern Province of KSA. Our investigation is still ongoing and we picked up 3 more cases: 

Case 11: 62 year old female with multiple comorbidities. Start of symptoms [19 Apr 2013] and deceased [3 May 2013] 

Case 12: 71 year old male with multiple comorbidities. Start of symptoms [15 Apr 2013], deceased [3 May 2013] 

Case 13: 58 year old female with comorbidities. Start of symptoms [1 May 2013] and currently ventilated in critical but stable condition. 

So far there is no apparent community transmission and transmission seem linked to one HCF [health care facility]. 

We will keep you posted on progress.

By all means click through to read the moderator's response, which sums up what we can now call the Alhasa cluster. The moderator suggests this is a nosocomial outbreak, and perhaps that shouldn't surprise us: it started as just such an outbreak in a Jordanian hospital a year ago.

Dr. Memish's use of ProMED-mail to provide news is a welcome development.

Mike Coston at Avian Flu Diary has the story with some useful links.

Picard retracts on HAI-related column

Earlier today I posted an excerpt from a column by André Picard, the excellent health reporter for The Globe and Mail: Picard: Rita MacNeil’s death should make us angry. This evening, an addendum to another report on healthcare-associated and nosocomial infections says this:

Correction: Rita MacNeil was admitted to hospital for abdominal surgery. Among other things, she suffered an infection before her death. She did not acquire the infection in the hospital, according to senior medical officials of the Cape Breton District Health Authority. A Friday news column incorrectly said she contracted an infection in hospital after surgery. 

Picard: Rita MacNeil’s death should make us angry

Via The Globe and Mail, André Picard writes a remarkable column about the death of Rita MacNeil, a singer whose death last week saddened Canada. Instead, he says, Rita MacNeil’s death should make us angry.

The death of Ms. MacNeil, a remarkable woman who overcame poverty, sexual and physical abuse, depression, addiction and obesity to become a star, should not only make us sad – it should make us angry. 

Angry because it underscores the scourge of hospital-acquired infections; angrier still because we have missed a glorious opportunity to take a larger lesson from her death, one that is a fitting tribute to a singer who was a social activist. 

Hospital-acquired infections sicken 250,000 patients annually and kill between 8,000 and 12,000 Canadians. The bugs patients catch while in care are one of the leading causes of death in this country; they kill twice as many people as breast cancer. 

Many, but not all, of the deaths are preventable. After all, people who are in hospital are often gravely ill; they are susceptible to infections. Sometimes, an infection can even bring about a merciful death: For a long time, physicians called pneumonia the “old man’s friend” because it is a relatively painless death. 

But people dying of hospital-acquired infections are not all frail seniors and not all are dying painlessly. They are suffering – and suffering horribly – from increasingly difficult-to-treat bugs like Clostridium difficile (where you essentially defecate to death) and methicillin-resistant Staphylococcus aureus (MRSA), which causes painful boils and can lead to the shutdown of your organs. These pathogens are increasingly resistant to treatment. 

We need to be careful not to point fingers of blame but, at the same time, we cannot simply ignore some damning facts. 

One of the greatest dangers after surgery is infection. The surgical wound can be a point of entry for a lot of nasty bugs. This is particularly true for patients with cellulitis. Their wounds must be cared for meticulously because, paradoxically, when you are being treated with antibiotics, you become more susceptible to infection. 

During Ms. MacNeil’s stay, part of the hospital was closed because of an outbreak of Norwalk virus. In that same period, several patients contracted MRSA. 

These are not airborne infections. There are two principal routes of spread of hospital-acquired infections: shared toilets combined with inadequate housekeeping and health professionals who don’t adequately wash their hands. 

The Cape Breton Regional Hospital, where Ms. MacNeil was treated and died, has a troubling patient safety record. 

When the Canadian Institute for Health Information published the first hospital standardized mortality rates (a comparison of expected deaths and actual deaths), the CBRH had the worst record in the country – with a mortality rate 37 per cent above average. (And let’s not forget that the average rate in Canada is pretty poor to begin with.)

Taiwan: More on the hospital staff with H7N9 symptoms

It's still only 5:30 Thursday morning in Taiwan, so we can't expect an update about the hospital staffers yet. But this CNA report on Focus Taiwan is said to be currently "most read": 3 hospital staff show symptoms after H7N9 contact. Excerpt:

Three hospital personnel have developed respiratory symptoms after coming into contact with Taiwan's first confirmed case of H7N9 avian flu, the Central Epidemic Command Center said Wednesday. 

All three had taken proper protective measures when providing medical care for the patient, a 53-year-old man who fell ill three days after retuning from China's Jiangsu Province, one of the H7N9-affected areas, the center said. 

A survey of the epidemic situation showed that 139 local people had come into contact with the man, a Taiwanese businessman based in Jiangsu's Suzhou area, the center said. 

Three of them had close contact, 26 had contact more than seven days ago (putting them past the infectious period) and 110 are hospital personnel, the center said. 

Four of the hospital personnel have also passed the infectious period and have not developed symptoms, the center said. 

A further three of the hospital personnel did not take proper protective measures when treating or caring for the patient, but none of them have so far shown any symptoms, the center said, adding that they will be strictly monitored until April 27. 

The epidemic control center said that all those who have had contact with the patient have been served notice urging them to engage in self-health management. 

They will also be subject to close monitoring until their respective infectious periods expire, the center said, adding that public health officials will help people on the watch list to get medical treatment should they develop flu-like symptoms such as fever or coughing. 

The quasi-official Straits Exchange Foundation said Wednesday it has posted information about the imported H7N9 case in Taiwan on its website and urged the Taiwanese trade association in Suzhou to help push Taiwanese residents in the region to step up epidemic prevention measures and provide them with news updates.

H7N9: Taiwan CDC's first report

An April 24 news release from the Centers for Disease Control,R.O.C.(Taiwan). Excerpt:

In the late afternoon of April 24, 2013, the Central Epidemic Command Center (CECC) confirmed the first imported case of H7N9 avian influenza in a 53-year-old male Taiwanese citizen who worked in Suzhou, Jiangsu Province, China prior to illness onset.  

He developed his illness three days after returning to Taiwan. Infection with avian influenza A (H7N9) was confirmed on April 24, 2013.  

The patient is currently in a severe condition and being treated in a negative-pressure isolation room. 

Minister of Health, Dr. Wen-Ta Chiu, and Commander of CECC, Dr. Feng-Yee Chang, have full knowledge of the situation and have instructed implementation of subsequent prevention and control measures.  

In addition, CECC has reported the case to the World Health Organization through the IHR Focal Point.  

Furthermore, according to the Cross-strait Cooperation Agreement on Medicine and Public Health Affairs, CECC has also reported the case to the contact point in China CECC indicated that the case is a hepatitis B carrier with history of hypertension.  

Due to the fact that he worked in Suzhou, Jiangsu Province before his illness, he had been traveling back and forth regularly between Suzhou and Taiwan for a long time.  

During March 28 and April 9, 2013, the patient traveled to Suzhou. On April 9, he returned to Taiwan from Shanghai. According to the case, he had not been exposed to birds and poultry during his stay in Suzhou and had not consumed undercooked poultry or eggs.  

On April 12, he developed fever, sweating, and fatigue, but no respiratory or gastrointestinal symptoms. On April 16, he sought medical attention at a clinic when he developed high fever and was transferred to a hospital by the physician. He was then hospitalized in a single-patient room for further treatment. 

On April 16, he was administered Tamiflu. On April 18, his chest x-ray showed interstitial infiltrate in the right lower lung.  On the night of April 19, his conditions worsened.  

On April 20, he was transferred to a medical center for further treatment. He was then intubated due to respiratory failure and placed in the negative-pressure isolation room in the intensive care unit. 

During his stay in the hospitals, two throat swab specimens were collected and both tested negative for avian influenza A (H7N9) virus by real-time RT-PCR. On April 22, the medical center collected a sputum specimen from the patient and the specimen was tested positive for influenza A.  

In the morning of April 24, avian influenza A (H7N9) virus was detected in the sputum specimen using real-time RT-PCR.  In the later afternoon of April 24, the National Influenza Center in Taiwan confirmed the identification and completed the genome sequencing of the virus.  

At the time of writing, CECC has obtained the list of 139 people who have come into contact with the confirmed case, including 3 close contacts, 26 regular contacts (past the 7-day incubation period), and 110 healthcare workers, for investigation and follow-up activities. 

Of the 110 healthcare workers, 4 have passed the 7-day incubation period and shown no symptoms. Only three contacts failed to put on appropriate personal protective equipment when the contact occurred.  Thus far, the three have not developed symptoms, but they will be followed up until April 27, 2013.  

On the other hand, while delivering healthcare services, three healthcare workers who were geared with appropriate personal protective equipment developed symptoms of upper respiratory infection.  

The public health authority have conducted thorough health education activities for all contacts, issued them with “Self-Health Management Advice for H7N9 Influenza”, and will be following up with them closely until the period of voluntary contact tracing is lifted.