H5N1

Outbreak of invasive pneumococcal disease among shipyard workers, Turku, Finland, May to November 2019

Via Eurosurveillance: Outbreak of invasive pneumococcal disease among shipyard workers, Turku, Finland, May to November 2019. The abstract:

We report an outbreak of invasive pneumococcal disease and pneumococcal pneumonia among shipyard workers, in Turku, Southwest Finland. In total, 31 confirmed and six probable cases were identified between 3 May and 28 November 2019. Streptococcus pneumoniae serotypes 12F, 4 and 8 were isolated from blood cultures of 25 cases. Occupational hygiene measures and vaccination of ca 4,000 workers are underway to control the outbreak at the shipyard.

ECDC: Surveillance of antimicrobial resistance in Europe 2018

ECDC has published Surveillance of antimicrobial resistance in Europe 2018. Excerpt from the executive summary: 

As in previous years, the AMR situation in Europe displays wide variations depending on bacterial species, antimicrobial group and geographical region. For several bacterial species–antimicrobial group combinations, a north-to-south and west-to-east gradient is evident. In general, lower resistance percentages were reported by countries in the north while higher percentages were reported in the south and east of Europe. The high variability in AMR across EU/EEA countries reinforces the scope for significant reductions through investments to strengthen current best practice.   

In 2018, more than half of the Escherichia  coli isolates reported to EARS-Net and more than a third of the Klebsiella pneumoniae isolates were resistant to at least one antimicrobial group under regular surveillance, and combined resistance to several antimicrobial groups was frequent. Resistance percentages were generally higher in K. pneumoniae than in E. coli. While carbapenem resistance remained rare in E. coli, several countries reported carbapenem resistance percentages above 10% for K. pneumoniae. 

Carbapenem resistance was also common in Pseudomonas  aeruginosa and Acinetobacter species, and at higher percentages compared with K. pneumoniae. For all four gram-negative bacteria, the countries reporting the highest carbapenem resistance percentages were also among the countries reporting the highest resistance percentages for other antimicrobial groups. For most gram-negative bacterial species–antimicrobial group combinations, changes in resistance percentages between 2015 and 2018 were moderate, and resistance remained at previously reported high levels.  

For Streptococcus pneumoniae, the resistance situation appeared stable, but with large inter-country variations. For Staphylococcus aureus, the decline in the percentage of methicillin-resistant (i.e. MRSA) isolates reported in previous years continued in 2018. Nevertheless, MRSA remains an important pathogen in the EU/EEA, as the levels of MRSA were still high in several countries, and combined resistance to other antimicrobial groups was common. 

Mandatory vaccination: Suited to enhance vaccination coverage in Europe?

An editorial in Eurosurveillance: Mandatory vaccination: suited to enhance vaccination coverage in Europe? Excerpt:

Vaccines are one of the most successful medical measures that save millions of human lives every year. With the implementation of routine immunisation programs, high and maintained vaccination coverages for many vaccine-preventable diseases—such as those against poliomyelitis or diphtheria—have been reached in most European countries and many others. Although vaccine acceptance is often high within the general population, even in countries with high vaccination coverage a significant number of children and adults are not sufficiently vaccinated because of missed opportunities or various concerns and misperceptions. 

The reasons for this ‘vaccine hesitancy’ are multifactorial, complex and vary across vaccines, time and countries/regions, and are influenced by factors such as complacency (not perceiving disease as high risk and vaccination as necessary), convenience and constraints (practical barriers), and confidence (lack of trust in safety and effectiveness). As a result, vaccination coverages against highly contagious pathogens such as measles virus are not sufficient to prevent outbreaks and infectious disease spread in many countries today.  

Despite the World Health Organization (WHO)’s goal to eliminate measles, a constant increase in measles cases has occurred in recent years. In 2018, more than 82,500 people in 47 of the 53 countries in the WHO European Region were infected with measles, leading to 72 deaths. These numbers were the highest in a decade. They were three times higher than in 2017 and 15 times higher than in 2016, when numbers were at a record low. 

In 2019, the situation seems to be even worse, indicating that current plans of action in the affected areas are insufficient to stop measles circulation. This is evidenced by the fact that the estimated coverage with the second dose of a measles-containing vaccine is far below the necessary 95% to achieve herd/population immunity in several European countries. 

In order to maintain or improve the population immunity acquired by vaccination, several countries are currently revisiting their strategies and discussing changes in vaccination policies, with a focus on either educating the population and giving individuals freedom of choice or implementing mandatory vaccination to ensure high coverage rates. 

With increasing calls to introduce mandatory vaccination programs, intense debates on their effectiveness have also started in several European countries. There are concerns that mandatory vaccination may lead to opposing attitudes and even less vaccine uptake, particularly in those with existing critical attitudes towards vaccines; nonetheless, other studies have disproved that implementation of compulsory vaccination led to opposing attitudes and/or had negative effects. 

However, it is indisputable that with any changes in vaccination policies, intensified information strategies are necessary to improve trust, rectify perceived risks and improve access and affordability of vaccines. Moreover, it is important to note that mandatory vaccination can follow different routes depending on a country’s specific social and cultural backgrounds, as well as epidemiological situations. 

Consideration of these factors can lead to implementing temporary or permanent vaccine mandates for certain vaccines (such as measles/measles-mumps-rubella (MMR) partial compulsory vaccination), for all vaccines included in a national vaccination program or for selected target groups, such as infants and children before entrance in educational settings or certain occupational groups, such as healthcare workers (HCW).  

For example, in France three mandatory vaccines (against diphtheria, tetanus and poliomyelitis (DTP)) co-existed with eight recommended vaccines (against MMR, pertussis, Streptococcus pneumoniae, hepatitis B (HepB), Neisseria meningiditis serogroup C (MenC) and Haemophilus influenza (Hib)) for routine childhood immunisation up until 2017. However, misperceptions in the population, i.e. that non-mandatory vaccines are less valuable, optional or not as safe and effective as the mandatory ones, resulted in insufficient and stagnating vaccine coverages of the recommended vaccines. This growing vaccine hesitancy, as well as large outbreaks and deaths from measles, led to a change in French policy to extend the mandates to all 11 childhood vaccines.  

Italy has had a similar situation, where four mandatory vaccines were in place already before 2017 (against poliomyelitis, tetanus, diphtheria and HepB). The coverage for vaccination against measles, mumps and rubella dropped country-wide from 90% to 87% between 2000–16. This, together with large measles outbreaks, led the government to extend the existing vaccine mandates to 10 mandatory vaccines (hexavalent vaccine against DTPert (pertussis)-poliomyelitis-Hib-HepB, as well as MMR and Varicella (V) vaccine) in 2017, whereas vaccination against Men C, S. pneumoniae and rotavirus remained recommended vaccines.  

The current issue of Eurosurveillance presents articles from France and Italy on approaches and experiences after the extension of mandatory vaccination. While an article in last week’s issue of Eurosurveillance by Mathieu et al describes the population’s general attitude towards mandatory vaccination shortly before implementation of extended vaccination mandates in France, the rapid communication by Lévy-Bruhl et al. in this issue evaluates the effects of mandatory vaccination on vaccine coverage 2 years after its implementation. D’Ancona et al., also in this issue, depict challenges in Italy in the year following the introduction of the new mandate and how these are being addressed.

Canada: Invasive Group A strep cases rising, but the reason is a medical mystery

Via CBC News: Invasive Group A strep cases rising, but the reason is a medical mystery. Excerpt:

Public concern about strep A bacteria escalated in early March, after Markham-Stouffville Hospital, just north of Toronto, confirmed there had been three cases of infection in its childbirth unit in February and that a mother had died from a severe form of it. 

Group A streptococcus is a common bacteria that exists everywhere, including inside people's noses and mouths and on skin wounds, said Dr. Isaac Bogoch, an infectious disease specialist at University Health Network in Toronto.  People often don't even know it's there.  

Strep A is transmitted through direct contact with the bacteria, including coughing, sneezing or touching a wound. When strep A makes people sick, it's usually nothing more serious than strep throat.  

But in rare cases, the bacteria becomes "invasive," entering parts of the body where it doesn't normally go, including the bloodstream, muscles and organs.  

That causes serious infections — the most severe of which are flesh-eating disease and streptococcal toxic shock syndrome. Both can be fatal. Treatment includes antibiotics and sometimes surgical removal of infected tissue.  

Number of cases doubles 

Although the invasive form of strep A is rare, the number of reported cases in Canada has been rising steadily over the last 15 years, according to data from the Public Health Agency of Canada and from provincial and territorial public health departments.  

In 2002, there were 866 reported cases across the country. By 2017, that number more than doubled to at least 2,178 cases (that total does not include Alberta, New Brunswick, Nova Scotia, Nunavut, P.E.I. or Yukon, whose numbers weren't available.)  

More than 100 people died of an invasive Group A strep infection in Canada in 2017, according to information provided by provincial and territorial public health agencies to CBC News.

Public health experts, including the Public Health Agency of Canada, say they don't know why the numbers are rising and that they continue to investigate. They also don't know exactly what makes common strep A  bacteria turn into a destructive invader of the body.      

"This is an area of active study in the research community," a spokesperson for Health Canada told CBC News in an email.   

WHO: High levels of antibiotic resistance found worldwide, new data shows

A WHO news release: High levels of antibiotic resistance found worldwide, new data shows. Excerpt:

WHO’s first release of surveillance data on antibiotic resistance reveals high levels of resistance to a number of serious bacterial infections in both high- and low-income countries. 

WHO’s new Global Antimicrobial Surveillance System (GLASS) reveals widespread occurrence of antibiotic resistance among 500 000 people with suspected bacterial infections across 22 countries. 

The most commonly reported resistant bacteria were Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, and Streptococcus pneumoniae, followed by Salmonella spp. The system does not include data on resistance of Mycobacterium tuberculosis, which causes tuberculosis (TB), as WHO has been tracking it since 1994 and providing annual updates in the Global tuberculosis report. 

Among patients with suspected bloodstream infection, the proportion that had bacteria resistant to at least one of the most commonly used antibiotics ranged tremendously between different countries – from zero to 82%. Resistance to penicillin – the medicine used for decades worldwide to treat pneumonia – ranged from zero to 51% among reporting countries. And between 8% to 65% of E. coli associated with urinary tract infections presented resistance to ciprofloxacin, an antibiotic commonly used to treat this condition. 

“The report confirms the serious situation of antibiotic resistance worldwide,” says Dr Marc Sprenger, director of WHO’s Antimicrobial Resistance Secretariat. 

“Some of the world’s most common – and potentially most dangerous – infections are proving drug-resistant,” adds Sprenger. “And most worrying of all, pathogens don’t respect national borders. That’s why WHO is encouraging all countries to set up good surveillance systems for detecting drug resistance that can provide data to this global system.” 

To date, 52 countries (25 high-income, 20 middle-income and 7 low-income countries) are enrolled in WHO’s Global Antimicrobial Surveillance System. For the first report, 40 countries provided information about their national surveillance systems and 22 countries also provided data on levels of antibiotic resistance.

Picard: Streptococcus outbreak in Canada is part of a larger story

Via The Globe and Mail, André Picard writes: Streptococcus outbreak in Canada is part of a larger story. You'd better read the whole article, and take notes. Excerpt:

The Middlesex-London Health Unit has issued an alert about a continuing outbreak of invasive group A streptococcus (iGAS). 

There have been 132 reported cases of the bacterial infection since April, 2016. 

To date, there have been nine deaths, 20 cases of necrotizing fasciitis (flesh-eating disease), 20 cases of toxic shock and 29 others have ended up in intensive care with other grave symptoms.  

Those numbers are frightening, but they are just a small part of a much larger story.  

In recent months, there have been similar outbreaks of this particularly nasty strain of strep A in Toronto, Montreal, Vancouver, Calgary and likely elsewhere.  

In every city, there have been deaths and a number of amputations caused by flesh-eating disease, but the story has stayed under the radar because this type of infection largely affects intravenous-drug users and the precariously-housed, especially those living in shelters. 

Disease and death stalk marginalized communities quite routinely, so outbreaks of infectious diseases like iGAS don't generate much attention from public-health officials and the media. That is true in London as much as anywhere else. 

But what happened in London is that strep A started harming people in the general population as well.  

"There has also been an increase in iGAS infections among people who have no connection, and are not related, to the outbreak in people who inject drugs or who are under-housed. We need a better understanding of what's happening, which is why we've issued this alert," Dr. Gayane Hovhannisyan, the associate medical officer of health, said in a statement. 

In many ways, this is maddening. 

Why don't we care about infectious diseases until they start to affect school children, university students and the suit-and-tie wearing members of society?  

The reality is that almost every infectious-disease outbreak – from annual influenza through to pandemics like AIDS – strikes the vulnerable first. That's how it gains a foothold to wend its way into the general population. 

In other words, there is a great deal of self-interest in doing better health surveillance, and providing better health care, to members of marginalized communities such as the homeless, drug users and sex workers. 

But we do the exact opposite. 

Overcrowded shelters, for example, create the ideal conditions for the spread of disease. That's why the outbreaks of iGAS were concentrated at the Salvation Army Centre for Hope in London, Seaton House in Toronto and Old Brewery Mission in Montreal.

Resurgence of scarlet fever in England, 2014–16: A population-based surveillance study

Via The Lancet Infectious Diseases: Resurgence of scarlet fever in England, 2014–16: a population-based surveillance study. The summary:

Background 

After decades of decreasing scarlet fever incidence, a dramatic increase was seen in England beginning in 2014. Investigations were launched to assess clinical and epidemiological patterns and identify potential causes. 

Methods 

In this population-based surveillance study, we analysed statutory scarlet fever notifications held by Public Health England from 1911 to 2016 in England and Wales to identify periods of sudden escalation of scarlet fever. Characteristics of cases and outbreaks in England including frequency of complications and hospital admissions were assessed and compared with the pre-upsurge period. Isolates from throat swabs were obtained and were emm typed. 

Findings 

Data were retrieved for our analysis between Jan 1, 1911, and Dec 31, 2016. Population rates of scarlet fever increased by a factor of three between 2013 and 2014 from 8·2 to 27·2 per 100 000 (rate ratio [RR] 3·34, 95% CI 3·23–3·45; p<0·0001); further increases were observed in 2015 (30·6 per 100 000) and in 2016 (33·2 per 100 000), which reached the highest number of cases (19 206) and rate of scarlet fever notification since 1967. The median age of cases in 2014 was 4 years (IQR 3–7) with an incidence of 186 per 100 000 children under age 10 years. 

All parts of England saw an increase in incidence, with 620 outbreaks reported in 2016. Hospital admissions for scarlet fever increased by 97% between 2013 and 2016; one in 40 cases were admitted for management of the condition or potential complications. Analysis of strains (n=303) identified a diversity of emm types with emm3 (43%), emm12 (15%), emm1 (11%), and emm4 (9%) being the most common. Longitudinal analysis identified 4-yearly periodicity in population incidence of scarlet fever but of consistently lower magnitude than the current escalation. 

Interpretation 

England is experiencing an unprecedented rise in scarlet fever with the highest incidence for nearly 50 years. Reasons for this escalation are unclear and identifying these remains a public health priority.

See also Helen Branswell's report on this study in STAT.

Overlooked infection kills 150,000 babies a year, mostly in Africa

Via Thompson Reuters: Overlooked infection kills 150,000 babies a year, mostly in Africa - study.

A bacterial infection passed from mothers to babies kills around 150,000 unborn children and infants a year but has been widely overlooked in developing countries, researchers said on Monday as they urged faster progress on developing a vaccine. 

Nearly one in five pregnant women worldwide is infected with Group B Streptococcus (GBS), which causes stillbirths, deaths and permanent problems such as vision and hearing loss in babies, researchers found in the first global study of the disease.  

Africa is disproportionately affected, with 65 percent of the world's stillbirths and infant deaths from GBS, though it is home to only about 13 percent of the world's population, according to the study led by the London School of Hygiene and Tropical Medicine.  

Most of these deaths could be prevented by a new vaccine that is still in clinical development, the study found. 

"The burden of Group B strep has been underappreciated, particularly in low and middle-income countries," co-author Shabir Madhi of Wits University in South Africa told the Thomson Reuters Foundation. 

In high-income countries pregnant women are typically screened for GBS and given antibiotics during labour to prevent infecting the baby, which is effective, the researchers said. 

But this is rarely done in developing countries where laboratory screening is limited and many births take place at home, they said.  

In Africa the rate of infection in pregnant women is also higher than worldwide, ranging from 25 to 35 percent, although it is not clear why, said Madhi. 

There is no vaccine currently available to prevent GBS, but one still undergoing trials was found to be 80 percent effective and could potentially prevent 231,000 infant and maternal GBS cases a year, the study found. 

"If the vaccine is developed, the place it's most needed is in Africa," Madhi said. Unfortunately, he added, it will likely not be on the market for at least five years.

Canada: BC’s serious strep A infections rates soar to record highs

Via The Vancouver Sun: B.C.’s serious infections rates soar to record highs. Excerpt:

Faced with surging numbers of severe, invasive group A streptococcus infections across B.C., mystified provincial public health officials are seeking feedback from Canadian and American counterparts and preparing to publish reports to draw attention to the problem. 

A soon-to-be-released report will show that in 2016 there were 303 confirmed cases of invasive Group A Streptococcal disease (iGAS) in B.C., or 6.4 cases per 100,000 population, the highest rate since 1997 when it became a mandatory reportable disease. Illnesses like scarlet fever, strep throat and impetigo are caused by strep A bacteria. But it can also lead to potentially deadly toxic shock syndrome and flesh-eating disease (necrotizing fasciitis). That is what an 11-year old Richmond boy contracted four months ago when he was one of two boys in the same classroom who got iGAS.  

John Chen has been in hospital since March. A classmate was hospitalized a week earlier with different complications from the infection.  

It is the first time a cluster of cases has ever been reported to public health officials in Canada so B.C. experts are now reviewing policies and consulting colleagues to determine whether notifications to parents should go out earlier than they did in this situation when families got letters only after the second case. 

Dr. Monika Naus, a medical director at the B.C. Centre for Disease Control, said experts are unsure how to turn iGAS incidence trends around. In the Vancouver Coastal Health region, there were 47 cases of iGAS, according to the most recent (April) year-to-date report. That compares to 34 the year before. In 2016, there were 114 cases in VCH or 9.8 cases per 100,000 population. That is more than double the average of 47 cases for each of the preceding four years, when the rate per 100,000 population was 4.2 per 100,000. 

 The highest number of cases (84) was in Vancouver; those affected  ranged in age from five to 83.

Canada: Father calls for prompt notification of school infections after son diagnosed with flesh-eating disease

Via CBC News British Columbia: Father calls for prompt notification of school infections after son diagnosed with flesh-eating disease. Excerpt:

The father of a boy battling flesh-eating disease wants a review of parental notification procedures when there's been an infection at their child's school. 

Sam Chen says his 11-year-old son, John, was diagnosed with invasive Group A streptococcus on Sunday, March 26. 

Chen says he notified the school the next day and, later that afternoon, Vancouver Coastal Health sent a letter to parents telling them another student had also been infected.  

The letter warns parents to watch for symptoms of the infection — fever, sore throat and feeling unwell — and asks them to take their child to a doctor immediately if any of the symptoms develop.  

Chen says they should have been notified about the first infection.

"If we had [gotten] the letter [sooner] everything would be different. Because now, nothing can change my son's situation," Chen said.  

Symptoms exhibited days earlier 

John's symptoms had developed a few days prior to his diagnosis. A first visit to a doctor had him sent home with Advil.  

It wasn't until his parents took him to B.C. Children's Hospital that he was diagnosed, prompting 18 surgeries to save his life and limbs. He has remained in the hospital ever since.  

Dr. Althea Hayden, a medical health officer with the regional health authority, says the disease is extremely rare and those at most risk of transmission are close family members — but even that risk is very low. 

Hayden said there haven't been any documented cases of the infection being transmitted in a classroom setting.