H5N1

BC’s top doctor wrote a book about fighting viruses in 2009

The Tyee has published my article: BC’s Top Doctor Wrote a Book about Fighting Viruses in 2009. Excerpt:

Soap and Water & Common Sense: The Definitive Guide to Viruses, Bacteria, Parasites, and Disease By Dr. Bonnie Henry House of Anansi, 2009. 

Dr. Bonnie Henry’s news conferences have become a part of daily life in B.C. When they attend her briefings, Premier John Horgan, Health Minister Adrian Dix, and Public Safety Minister Mike Farnworth fade into the background, at a safe distance from her and one another. They speak chiefly to endorse what their chief medical officer says. The contrast with Trump’s press conferences is impossible to miss. 

It certainly helps that Dr. Henry can deliver alarming news in a calm tone of voice, without relying on technical jargon; we pay attention, we absorb the news, but we don’t freak out. Treated like adults, we respond like adults.  

Those same communication skills are evident throughout her 2009 book Soap and Water & Common Sense, written years before she became B.C.’s provincial health officer. The book is now available with a new introduction, written in March, and the content itself is still very timely: while our healthcare system is fighting COVID-19, other diseases are going to exploit their opportunity.

Culture of secrecy shields hospitals with outbreaks of drug-resistant infections

Via The New York Times: Culture of Secrecy Shields Hospitals With Outbreaks of Drug-Resistant Infections. Excerpt from a disturbing report:

In January, the Centers for Disease Control and Prevention sent out an urgent public alert about a deadly bacteria, resistant to virtually every known antibiotic, that sickened more than a dozen Americans who had elective surgery at Grand View Hospital in Tijuana, Mexico. 

But when similar outbreaks take place at hospitals on American soil, the C.D.C. makes no such public announcement. That is because under its agreement with states, the C.D.C. is barred from publicly identifying hospitals that are battling to contain the spread of dangerous pathogens.  

The rise of a deadly drug-resistant fungus called Candida auris, a focus of a New York Times report last weekend, has raised fresh questions about the secrecy enveloping infectious outbreaks at American medical institutions.

Patient advocates say hospitals and health authorities are often slow to alert the public about drug-resistant germs, potentially endangering patients. 

“They might not get up and go to another hospital, but patients and their families have the right to know when they are at a hospital where an outbreak is occurring,” said Lisa McGiffert of the Patient Safety Action Network. “That said, if you’re going to have hip replacement surgery, you may chose to go elsewhere.” 

Kevin Kavanagh, board chairman of the advocacy group Health Watch USA, contrasted the C.D.C.’s handling of the infections in Tijuana with a 2016 outbreak of a different drug-resistant pathogen, known as carbapenem-resistant Enterobacteriaceae, or CRE, at a rural hospital in Kentucky. It was not until early 2018 that the C.D.C. issued a report on that outbreak — and even then, the agency did not name the hospital where it occurred.  

CRE sometimes kills up to half of people infected. No deaths were reported in the Kentucky outbreak, but at least two dozen patients at the hospital were colonized with the bug, meaning they were not sick but could have spread it to others.

The report identified a cleaning cart as a possible source for the spread of the pathogen, which had traveled between the hospital’s emergency room and its surgical ward. 

The C.D.C. declined to comment, but in the past officials have said their approach to confidentiality is necessary to encourage the cooperation of hospitals and nursing homes, which might otherwise seek to conceal infectious outbreaks.  

Those pushing for increased transparency say they are up against powerful medical institutions eager to protect their reputations, as well as state health officials who also shield hospitals from public scrutiny.

New Year's Eve, 2008

Just out of curiosity, I've checked what I'd been blogging about here on December 31, 2008...ten short years ago.

It was mostly bird flu; the H1N1 "swine flu" pandemic was almost six months in the future, and I hadn't yet realized that bird flu could not be considered apart from an enormous range of global-health issue. (Also in the future: Haiti's cholera, MERS, H7N9, Zika, and urban Ebola.)

So I was reporting on a two-month-old baby in Shenzhen who was recovering from H9N2. The case provoked authorities in Guangdong to tighten inspection of poultry markets.

Indian doctors in Manipur were working "round the clock" to prevent the spread of H5N1 to their city after an outbreak in Assam state.   

In Nigeria, the Bauchi state ministry of health was on the alert for H5N1 as well; it was about that time, I seem to recall, that Nigeria had one human case of H5N1, which had been fatal.

Here in Canada, Ontario was finally making public the rates of hospital-acquired infections from superbugs like C. diff and MRSA.

On New Year's Day, I was reporting a health scare about possible H5N1 in an Indonesian village. And I posted links to the old Flu Wiki Forum (no longer online) and Mike Coston at Avian Flu Diary (still very much online).

Ten years later we're watching a slightly different mix of bacteria and viruses, but the war goes on. It has been my good fortune to follow the war from a safe vantage point, while gaining ever deeper respect for the men and women fighting it from the villages of Asia and Africa and Latin America to the hospitals of Europe and North America. I hope my posts have accurately reported their extraordinary efforts.

Comparative efficacy of treatments for Clostridium difficile infection

Via The Lancet Infectious Diseases: Comparative efficacy of treatments for Clostridium difficile infection: a systematic review and network meta-analysis. The abstract:

Background 

Several new treatments for Clostridium difficile infections have been investigated. We aimed to compare and rank treatments for non-multiply recurrent infections with C difficile in adults. 

Methods 

We did a random effects network meta-analysis within a frequentist setting to obtain direct and indirect comparisons of trials. We searched MEDLINE, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov for published and unpublished trials from the creation of these databases until June 30, 2017. We included randomised controlled trials of treatments for non-multiply recurrent infections with confirmed C difficile in adults (at least 18 years) that reported both primary cure and recurrence rates, and we used the Cochrane Risk of Bias tool to appraise trial methods. 

For our analysis, we extracted the total numbers of patients with primary cure and recurrence from published and unpublished reports. The primary outcome was sustained symptomatic cure, defined as the number of patients with resolution of diarrhoea minus the number with recurrence or death. 

Findings 

Of 23 004 studies screened, 24 trials, which comprised 5361 patients and 13 different treatments, were included in the analysis. The overall quality of evidence was rated as moderate to low. For sustained symptomatic cure, fidaxomicin (odds ratio 0·67, 95% CI 0·55–0·82) and teicoplanin (0·37, 0·14–0·94) were significantly better than vancomycin. Teicoplanin (0·27, 0·10–0·70), ridinilazole (0·41, 0·19–0·88), fidaxomicin (0·49, 0·35–0·68), surotomycin (0·66, 0·45–0·97), and vancomycin (0·73, 0·56–0·95) were better than metronidazole. Bacitracin was inferior to teicoplanin (0·22, 0·06–0·77) and fidaxomicin (0·40, 0·17–0·94), and tolevamer was inferior to all drugs except for LFF571 (0·50, 0·18–1·39) and bacitracin (0·67, 0·28–1·58). Global heterogeneity of the entire network was low (Cochran's Q=15·70; p=0·47).  

Interpretation 

Among the treatments for non-multiply recurrent infections by C difficile, the highest quality evidence indicates that fidaxomicin provides a sustained symptomatic cure most frequently. Fidaxomicin is a better treatment option than vancomycin for all patients except those with severe infections with C difficile and could be considered as a first-line therapy. Metronidazole should not be recommended for treatment of C difficile.

The evolving epidemiology of Clostridium difficile infection in Canadian hospitals during a postepidemic period (2009–2015)

Via CMAJ: The evolving epidemiology of Clostridium difficile infection in Canadian hospitals during a postepidemic period (2009–2015). The abstract:

Background: The clinical and molecular epidemiology of health care–associated Clostridium difficile infection in nonepidemic settings across Canada has evolved since the first report of the virulent North American pulsed-field gel electrophoresis type 1 (NAP1) strain more than 15 years ago. The objective of this national, multicentre study was to describe the evolving epidemiology and molecular characteristics of health care–associated C. difficile infection in Canada during a post-NAP1-epidemic period, particularly patient outcomes associated with the NAP1 strain.  

Methods: Adult inpatients with C. difficile infection were prospectively identified, using a standard definition, between 2009 and 2015 through the Canadian Nosocomial Infection Surveillance Program (CNISP), a network of 64 acute care hospitals. Patient demographic characteristics, severity of infection and outcomes were reviewed. Molecular testing was performed on isolates, and strain types were analyzed against outcomes and epidemiologic trends. 

Results: Over a 7-year period, 20 623 adult patients admitted to hospital with health care–associated C. difficile infection were reported to CNISP, and microbiological data were available for 2690 patients. 

From 2009 to 2015, the national rate of health care–associated C. difficile infection decreased from 5.9 to 4.3 per 10 000 patient-days. NAP1 remained the dominant strain type, but infection with this strain has significantly decreased over time, followed by an increasing trend of infection with NAP4 and NAP11 strains. The NAP1 strain was significantly associated with a higher rate of death attributable to C. difficile infection compared with non-NAP1 strains (odds ratio 1.91, 95% confidence interval [CI] 1.29–2.82). 

Isolates were universally susceptible to metronidazole; one was nonsusceptible to vancomycin. The proportion of NAP1 strains within individual centres predicted their rates of health care–associated C. difficile infection; for every 10% increase in the proportion of NAP1 strains, the rate of health care–associated C. difficile infection increased by 3.3% (95% CI 1.7%–4.9%). 

Interpretation: Rates of health care–associated C. difficile infection have decreased across Canada. In nonepidemic settings, NAP4 has emerged as a common strain type, but NAP1, although decreasing, continues to be the predominant circulating strain and remains significantly associated with higher attributable mortality.

See also this CBC News report on the study.

WHO: The world is running out of antibiotics

A WHO news release: The world is running out of antibiotics, WHO report confirms.

A report, Antibacterial agents in clinical development – an analysis of the antibacterial clinical development pipeline, including tuberculosis, launched today by WHO shows a serious lack of new antibiotics under development to combat the growing threat of antimicrobial resistance. 

Most of the drugs currently in the clinical pipeline are modifications of existing classes of antibiotics and are only short-term solutions. The report found very few potential treatment options for those antibiotic-resistant infections identified by WHO as posing the greatest threat to health, including drug-resistant tuberculosis which kills around 250 000 people each year.  

"Antimicrobial resistance is a global health emergency that will seriously jeopardize progress in modern medicine," says Dr Tedros Adhanom Ghebreyesus, Director-General of WHO. "There is an urgent need for more investment in research and development for antibiotic-resistant infections including TB, otherwise we will be forced back to a time when people feared common infections and risked their lives from minor surgery."  

In addition to multidrug-resistant tuberculosis, WHO has identified 12 classes of priority pathogens – some of them causing common infections such as pneumonia or urinary tract infections – that are increasingly resistant to existing antibiotics and urgently in need of new treatments. 

The report identifies 51 new antibiotics and biologicals in clinical development to treat priority antibiotic-resistant pathogens, as well as tuberculosis and the sometimes deadly diarrhoeal infection Clostridium difficile. 

Among all these candidate medicines, however, only 8 are classed by WHO as innovative treatments that will add value to the current antibiotic treatment arsenal. 

There is a serious lack of treatment options for multidrug- and extensively drug-resistant M. tuberculosis and gram-negative pathogens, including Acinetobacter and Enterobacteriaceae (such as Klebsiella and E.coli) which can cause severe and often deadly infections that pose a particular threat in hospitals and nursing homes. 

There are also very few oral antibiotics in the pipeline, yet these are essential formulations for treating infections outside hospitals or in resource-limited settings. 

"Pharmaceutical companies and researchers must urgently focus on new antibiotics against certain types of extremely serious infections that can kill patients in a matter of days because we have no line of defence," says Dr Suzanne Hill, Director of the Department of Essential Medicines at WHO.  

To counter this threat, WHO and the Drugs for Neglected Diseases Initiative (DNDi) set up the Global Antibiotic Research and Development Partnership (known as GARDP). On 4 September 2017, Germany, Luxembourg, the Netherlands, South Africa, Switzerland and the United Kingdom of Great Britain and Northern Ireland and the Wellcome Trust pledged more than €56 million for this work.  

"Research for tuberculosis is seriously underfunded, with only two new antibiotics for treatment of drug-resistant tuberculosis having reached the market in over 70 years," says Dr Mario Raviglione, Director of the WHO Global Tuberculosis Programme. "If we are to end tuberculosis, more than US$ 800 million per year is urgently needed to fund research for new antituberculosis medicines". 

New treatments alone, however, will not be sufficient to combat the threat of antimicrobial resistance. WHO works with countries and partners to improve infection prevention and control and to foster appropriate use of existing and future antibiotics. WHO is also developing guidance for the responsible use of antibiotics in the human, animal and agricultural sectors.

Hong Kong: Cluster of Clostridium difficile toxin cases in Tung Wah Group of Hospitals Wong Tai Sin Hospital

Via the Centre for Health Protection: Cluster of Clostridium Difficile toxin cases in Tung Wah Group of Hospitals Wong Tai Sin Hospital.

The following is issued on behalf of the Hospital Authority:        

The spokesperson for Tung Wah Group of Hospitals Wong Tai Sin Hospital made the following announcement today (June 19):        

Four patients (two males and two females, aged 80 to 88) of a Rehabilitation and Extended Care ward had presented with diarrhoea symptoms since June 6. Appropriate tests were arranged for the patients and their test results were positive for Clostridium Difficile toxin. The patients are being treated under isolation in stable condition.        

Infection control measures in the ward have already been stepped up according to established guidelines. All other patients in the ward concerned are under close surveillance.

The cases have been reported to the Hospital Authority Head Office and the Centre for Health Protection for necessary follow-up.

US: Serious bacterial infections acquired during treatment of patients given a diagnosis of chronic Lyme disease

Via MMWR: Serious Bacterial Infections Acquired During Treatment of Patients Given a Diagnosis of Chronic Lyme Disease. The summary:

What is already known about this topic?  

“Chronic Lyme disease” is a nonspecific diagnosis without a consistent definition that has been given to patients with various symptoms. Treatments offered for chronic Lyme disease, such as prolonged antibiotic or immunoglobulin therapy, lack data supporting effectiveness and are not recommended.  

What is added by this report?  

Clinicians, health departments, and patients have contacted CDC with reports of serious bacterial infections resulting from treatment of persons who have received a diagnosis of chronic Lyme disease. Five of these cases are described to illustrate complications resulting from unproven treatments, including septic shock, Clostridium difficile colitis, osteodiscitis, abscess, and death.  

What are the implications for public health practice? 

Clinicians, public health practitioners, and patients should be aware that treatments for chronic Lyme disease lack proof of effectiveness and can result in serious complications. Systematic investigation into the scope and effects of these complications, including the rate and extent of infections and the pathogens associated with these infections, would be helpful to inform clinical practice and fully characterize the risks associated with treatments for chronic Lyme disease.

Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile

Via The Lancet: Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study. The summary:

Background 

Patients admitted to hospital can acquire multidrug-resistant organisms and Clostridium difficile from inadequately disinfected environmental surfaces. We determined the effect of three enhanced strategies for terminal room disinfection (disinfection of a room between occupying patients) on acquisition and infection due to meticillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, C difficile, and multidrug-resistant Acinetobacter. 

Methods 

We did a pragmatic, cluster-randomised, crossover trial at nine hospitals in the southeastern USA. Rooms from which a patient with infection or colonisation with a target organism was discharged were terminally disinfected with one of four strategies: reference (quaternary ammonium disinfectant except for C difficile, for which bleach was used); UV (quaternary ammonium disinfectant and disinfecting ultraviolet [UV-C] light except for C difficile, for which bleach and UV-C were used); bleach; and bleach and UV-C. The next patient admitted to the targeted room was considered exposed. 

Every strategy was used at each hospital in four consecutive 7-month periods. We randomly assigned the sequence of strategies for each hospital (1:1:1:1). The primary outcomes were the incidence of infection or colonisation with all target organisms among exposed patients and the incidence of C difficile infection among exposed patients in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT01579370.  

Findings 

31 226 patients were exposed; 21 395 (69%) met all inclusion criteria, including 4916 in the reference group, 5178 in the UV group, 5438 in the bleach group, and 5863 in the bleach and UV group. 115 patients had the primary outcome during 22 426 exposure days in the reference group (51·3 per 10 000 exposure days). 

The incidence of target organisms among exposed patients was significantly lower after adding UV to standard cleaning strategies (n=76; 33·9 cases per 10 000 exposure days; relative risk [RR] 0·70, 95% CI 0·50–0·98; p=0·036). The primary outcome was not statistically lower with bleach (n=101; 41·6 cases per 10 000 exposure days; RR 0·85, 95% CI 0·69–1·04; p=0·116), or bleach and UV (n=131; 45·6 cases per 10 000 exposure days; RR 0·91, 95% CI 0·76–1·09; p=0·303) among exposed patients. 

Similarly, the incidence of C difficile infection among exposed patients was not changed after adding UV to cleaning with bleach (n=38 vs 36; 30·4 cases vs 31·6 cases per 10 000 exposure days; RR 1·0, 95% CI 0·57–1·75; p=0·997). 

Interpretation 

A contaminated health-care environment is an important source for acquisition of pathogens; enhanced terminal room disinfection decreases this risk.

Man's best friend, bacteria's worst enemy: Dog sniffs out superbug in Canada hospital

Credit: Vancouver Coastal Health

Via The Guardian: Man's best friend, bacteria's worst enemy: dog sniffs out superbug in Canada hospital. Excerpt:

Hospital ID badge dangling from his neck, Angus considered the empty bed in front of him. After a few strong sniffs, he moved on. 

Nearing the next bed, his floppy ears perked up before he stopped dead in his tracks, tapping his paw and eyeing his handler expectantly. 

The two-year-old English springer spaniel is believed to be the only canine hospital employee in the world trained to sniff out the notorious superbug Clostridium difficile, or C difficile. 

The seeds of Angus’ unlikely career were planted three years ago, after Teresa Zurberg, a Vancouver resident, suffered a C difficile infection. Her bout with the bacteria – which attacks people whose immune systems have been weakened by antibiotics – left her in the hospital for five days and she lost 20 pounds.  

“It was awful. I almost died,” Zurberg said.  

Her husband, Markus, a nurse who works in patient safety and quality care, stumbled across an article on a beagle in the Netherlands who had been specially trained to check patients for C difficile.  

Could Zurberg – a canine handler who trains bomb- and drug-detecting dogs – do the same thing in Vancouver? he wondered. “I told him, ‘If it’s got a smell, I can teach a dog to find it,’” Zurberg said. Their new English springer spaniel pup might be perfect for the job, she suggested.  

The pair approached Vancouver Coastal Health, the health authority that oversees the city’s general hospital – and were surprised by the enthusiastic reaction they received. “I was expecting them to laugh at us but they were like: ‘Hey, that’s really cool.’” 

Working with the health authority, Zurberg and Angus became part of a one-of-a-kind pilot program. The hope, said Nancy Desrosiers of Vancouver Coastal Health, was to find an innovative approach to address what has become a global concern.

“It really is one of those vicious cycles,” she said, pointing to a steadily rising number of infections that result in longer hospital stays and increase the likelihood of further infections. “In Canada, 64% of all of our C difficile cases are hospital-acquired.” 

Unlike the patient-sniffing beagle in the Netherlands – who is now retired – Angus, it was decided, would focus exclusively on searching for C difficile in the hospital environment. 

Hospitals normally use ultraviolet light to find the bacteria, but Angus can move much more quickly and efficiently through rooms. Once he detects the bacteria, the area is cleaned with a robot that uses ultraviolet light to disinfect 99.9% of the C difficile spores.