Archive for January, 2017
Eleven more H7N9 infections have been reported from four Chinese provinces
Wednesday, January 18th, 2017CHP alerts public to high avian influenza A(H7N9) activity in Guangdong
The Centre for Health Protection (CHP) of the Department of Health today (January 17) drew the public’s special attention to the high activity of avian influenza A(H7N9) in Guangdong. Travellers should be on full alert and maintain strict personal, hand, food and environmental hygiene particularly in the upcoming Lunar New Year holidays.
The Health and Family Planning Commission of Guangdong Province reported that 11 human cases of avian influenza A(H7N9), with two deaths, have been recorded so far in 2017 including three from Foshan, two from Guangzhou and one each in Zhongshan, Zhaoqing, Meizhou, Dongguan, Qingyuan and Shunde.
Of note, in the first week of January, 60 out of 637 environmental samples from 21 live poultry markets in 15 cities in Guangdong tested positive for H7 virus. The positive percentage is 9.42 per cent.
The CHP is also closely monitoring an additional human H7N9 case in Hunan. According to the Hunan Provincial Center for Disease Control and Prevention the female patient, aged 36 from Hengyang and in a critical condition, had poultry exposure.
“As human H7N9 cases continue to occur in Guangdong and the positive percentage of environmental samples is substantial, we again urge the public to pay special attention to health risks of the places of visit,” a spokesman for the CHP said.
“We strongly urge the public to avoid touching birds, poultry or their droppings and visiting poultry markets or farms during travel. If feeling unwell, such as having a fever or cough, wear a mask and seek medical advice at once. Travellers returning from affected areas should consult doctors promptly if symptoms develop, and actively inform the doctors of their travel history for prompt diagnosis and treatment,” the spokesman said.
Adults and parents should also look after children with extra care in personal, hand, food and environmental hygiene against infections during travel.
“While local surveillance, prevention and control measures are in place, we will remain vigilant and work closely with the World Health Organization and relevant health authorities to monitor the latest developments,” the spokesman said.
As the H7N9 virus continues to be detected in animals and environments in the Mainland, additional human cases are expected in affected and possibly neighbouring areas. In view of the heavy trade and travel between the Mainland and Hong Kong, further sporadic imported human cases in Hong Kong every now and then are expected, especially in the coming few months.
The CHP’s Port Health Office conducts health surveillance measures at all boundary control points. Thermal imaging systems are in place for body temperature checks on inbound travellers. Suspected cases will be immediately referred to public hospitals for follow-up.
The display of posters and broadcasting of health messages in departure and arrival halls as health education for travellers is under way. The travel industry and other stakeholders are regularly updated on the latest information.
The public should maintain strict personal, hand, food and environmental hygiene and take heed of the advice below while handling poultry:
- Avoid touching poultry, birds, animals or their droppings;
- When buying live chickens, do not touch them and their droppings. Do not blow at their bottoms. Wash eggs with detergent if soiled with faecal matter and cook and consume them immediately. Always wash hands thoroughly with soap and water after handling chickens and eggs;
- Eggs should be cooked well until the white and yolk become firm. Do not eat raw eggs or dip cooked food into any sauce with raw eggs. Poultry should be cooked thoroughly. If there is pinkish juice running from the cooked poultry or the middle part of its bone is still red, the poultry should be cooked again until fully done;
- Wash hands frequently, especially before touching the mouth, nose or eyes, before handling food or eating, and after going to the toilet, touching public installations or equipment such as escalator handrails, elevator control panels or door knobs, or when hands are dirtied by respiratory secretions after coughing or sneezing; and
- Wear a mask if fever or respiratory symptoms develop, when going to a hospital or clinic, or while taking care of patients with fever or respiratory symptoms.
The public may visit the CHP’s pages for more information: the avian influenza page, the weekly Avian Influenza Report, global statistics and affected areas of avian influenza, the Facebook Page and the YouTube Channel.
Issued at HKT 18:34
Pan-Resistant New Delhi Metallo-Beta-Lactamase-Producing Klebsiella pneumoniae — Washoe County, Nevada, 2016
Wednesday, January 18th, 2017On August 25, 2016, the Washoe County Health District in Reno, Nevada, was notified of a patient at an acute care hospital with carbapenem-resistant Enterobacteriaceae (CRE) that was resistant to all available antimicrobial drugs. The specific CRE, Klebsiella pneumoniae, was isolated from a wound specimen collected on August 19, 2016. After CRE was identified, the patient was placed in a single room under contact precautions. The patient had a history of recent hospitalization outside the United States. Therefore, based on CDC guidance (1), the isolate was sent to CDC for testing to determine the mechanism of antimicrobial resistance, which confirmed the presence of New Delhi metallo-beta-lactamase (NDM).
The patient was a female Washoe County resident in her 70s who arrived in the United States in early August 2016 after an extended visit to India. She was admitted to the acute care hospital on August 18 with a primary diagnosis of systemic inflammatory response syndrome, likely resulting from an infected right hip seroma. The patient developed septic shock and died in early September. During the 2 years preceding this U.S. hospitalization, the patient had multiple hospitalizations in India related to a right femur fracture and subsequent osteomyelitis of the right femur and hip; the most recent hospitalization in India had been in June 2016.
Antimicrobial susceptibility testing in the United States indicated that the isolate was resistant to 26 antibiotics, including all aminoglycosides and polymyxins tested, and intermediately resistant to tigecycline (a tetracycline derivative developed in response to emerging antibiotic resistance). Because of a high minimum inhibitory concentration (MIC) to colistin, the isolate was tested at CDC for the mcr-1 gene, which confers plasma-mediated resistance to colistin; the results were negative. The isolate had a relatively low fosfomycin MIC of 16 μg/mL by ETEST.* However, fosfomycin is approved in the United States only as an oral treatment of uncomplicated cystitis; an intravenous formulation is available in other countries.
A point prevalence survey, using rectal swab specimens and conducted among patients currently admitted to the same unit as the patient, did not identify additional CRE. Active surveillance for multidrug-resistant bacilli including CRE has been conducted in Washoe County since 2010 and is ongoing; no additional NDM CRE have been identified.
This report highlights three important issues in the control of CRE. First, although CRE are commonly sent to CDC as part of surveillance programs or for reference testing, isolates that are resistant to all antimicrobials are very uncommon. Among >250 CRE isolate reports collected as part of the Emerging Infections Program, approximately 80% remained susceptible to at least one aminoglycoside and nearly 90% were susceptible to tigecycline (2). Second, to slow the spread of bacteria with resistance mechanisms of greatest concern (e.g., gene encoding NDM or mcr-1) or with pan-resistance to all drug classes, CDC recommends that when these bacteria are identified, facilities ensure that appropriate infection control contact precautions are instituted to prevent transmission and that health care contacts are evaluated for evidence of transmission (3). Third, the patient in this report had inpatient health care exposure in India before receiving care in the United States. Health care facilities should obtain a history of health care exposures outside their region upon admission and consider screening for CRE when patients report recent exposure outside the United States or in regions of the United States known to have a higher incidence of CRE (1).
References
- CDC. New carbapenem-resistant Enterobacteriaceae warrant additional action by healthcare providers. Atlanta, GA: US Department of Health and Human Services, CDC; 2013. https://emergency.cdc.gov/han/han00341.asp
- Guh AY, Bulens SN, Mu Y, et al. Epidemiology of carbapenem-resistant Enterobacteriaceae in seven U.S. communities, 2012–2013. JAMA 2015;314:1479–87. CrossRef PubMed
- CDC. CRE toolkit: facility guidance for control of carbapenem-resistant Enterobacteriaceae (CRE). Atlanta, GA: US Department of Health and Human Services, CDC; 2015. https://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf
Suggested citation for this article: Chen L, Todd R, Kiehlbauch J, Walters M, Kallen A. Notes from the Field: Pan-Resistant New Delhi Metallo-Beta-Lactamase-Producing Klebsiella pneumoniae — Washoe County, Nevada, 2016. MMWR Morb Mortal Wkly Rep 2017;66:33. DOI: http://dx.doi.org/10.15585/mmwr.mm6601a7.
A family of highly drug-resistant and potentially deadly bacteria may be spreading more widely–and more stealthily — than previously thought
Wednesday, January 18th, 2017Janelle SJ, Kallen A, de Man T, et al. Notes from the Field: New Delhi Metallo-β-Lactamase–Producing Carbapenem-Resistant Enterobacteriaceae Identified in Patients Without Known Health Care Risk Factors — Colorado, 2014–2016. MMWR Morb Mortal Wkly Rep 2016;65:1414–1415. DOI: http://dx.doi.org/10.15585/mmwr.mm6549a6.
New Delhi Metallo-β-Lactamase–Producing Carbapenem-Resistant Enterobacteriaceae Identified in Patients Without Known Health Care Risk Factors — Colorado, 2014–2016
Weekly / December 16, 2016 / 65(49);1414–1415
Sarah J. Janelle, MPH1; Alexander Kallen, MD2; Tom de Man, MS2; Brandi Limbago, PhD2; Maroya Walters, PhD2; Alison Halpin, PhD2; Karen Xavier1; Joyce Knutsen1; Elizabeth Badolato1; Wendy M. Bamberg, MD1 (View author affiliations)
Carbapenem-resistant Enterobacteriaceae (CRE) are considered an urgent threat in the United States because they are associated with high morbidity and mortality, limited treatment options, and potential for rapid spread among patients (1). Carbapenemases, enzymes that confer resistance to the carbapenem class of antibiotics, are believed to contribute to increasing transmission and regional spread of CRE because the genes encoding these enzymes can reside on mobile plasmids and can be transferred among bacterial species. Klebsiella pneumoniae carbapenemase (KPC) is the most common carbapenemase seen in the United States, but isolates with the New Delhi metallo-β-lactamase (NDM) are emerging. Known risk factors for carbapenemase-producing CRE, including NDM, include health care exposures such as hospitalization outside the United States, recent overnight admissions to short-stay and long-term acute care hospitals, residence in long-term care facilities, surgical procedures, and having indwelling devices. Community-associated CRE lack these health care exposures and are rare in the United States (2). During 2014–2016, NDM-producing CRE were isolated from patients in Colorado without known health care risk factors.
The Colorado Department of Public Health and Environment (CDPHE) has conducted statewide laboratory-based surveillance of CRE since November 2012. CRE isolates that are resistant to two or more carbapenems are tested for the KPC and NDM genes by polymerase-chain reaction at the CDPHE laboratory. As of April 2016, Colorado had reported the second highest number of NDM-producing CRE in the United States (3). NDM was first detected in Colorado in 2012 in eight patients during a hospital outbreak (4). Ten additional patients with NDM-producing CRE were identified in Colorado during 2014–2016. Among these 10 patients, the mean age was 64 years (range = 20–85 years); isolates from nine patients were from urine, and in one patient, from bile. Five patients had traveled internationally in the 2 months before specimen collection (two of whom had known hospitalizations during international travel) (Figure). In six patients, the isolate was detected from cultures collected in outpatient settings and lacked the known CRE risk factors of overnight stays in health care settings, dialysis, or surgery in the preceding 12 months, and had no invasive devices in the preceding 2 days (i.e., the isolates were community-associated).
Among the six patients identified with community-associated, NDM-producing CRE, two patients traveled internationally: one to an unknown country in Africa and one to the Bahamas. Mean age was 61 years (range = 20–85 years). All patients received diagnoses of urinary tract infections. Medical record review indicated that three of these six patients had antibiotic exposure, two within 1 month and the other within 10 months prior to the positive culture. Three of the six patients with community-associated, NDM-producing CRE had no underlying comorbidities; one patient was pregnant at the time of her positive culture, and two patients had underlying medical conditions. One patient with underlying medical conditions reported caring for a family member in multiple health care facilities before the positive NDM culture, including an acute care hospital, a long-term acute care hospital, and an assisted living facility.
There were no known epidemiologic links among the 10 most recent patients, and no known epidemiologic links between recent patients and patients from the 2012 outbreak. Whole genome sequencing (WGS) performed at CDC on isolates from 15 patients* confirmed that the recent isolates did not share common strains or plasmids with the 2012 outbreak. Among the seven recent isolates that underwent WGS, only two E. coli ST167 isolates appeared to be related. These isolates were separated by only 10 single nucleotide polymorphism differences and share a common NDM allele (blaNDM7) and other genetic signatures; the two patients associated with these isolates resided in the same large metropolitan area but had no known epidemiologic links. The source for the community-associated strains is unknown, but might represent transmission of multiple NDM strains outside inpatient health care settings.
The vast majority of CRE isolates previously identified in Colorado were reported from patients with recent health care exposures or indwelling devices and with underlying comorbidities. Approximately 8% of the patients with CRE reported to CDC’s Emerging Infections Program, which includes the Denver metropolitan area, did not have health care risk factors documented in their medical records; 9% did not have any underlying comorbidities (2). Of note, identification of carbapenemase-producing CRE from healthy international travelers without health care exposure has been reported (5); however, only two of the six patients with community-associated, NDM-producing CRE in Colorado had this exposure. The finding that six of 10 recent NDM-producing CRE are community-associated suggests that the epidemiology of CRE could be changing. Further surveillance is required to determine whether this pattern continues.
Testing for common carbapenemases at clinical or state health laboratories can inform CRE epidemiology and guide health care facilities to implement additional infection prevention and control interventions, such as screening contacts of patients with a CRE infection or colonization (6). As a result of this investigation, CDPHE has now implemented patient interviews as a routine part of NDM-producing CRE case investigations to assist in determining possible risk factors and epidemiologic links.
There has been a rise in the number of human plague cases globally resulting in the categorisation of Yersinia pestis, the aetiological agent of the highly fatal pneumonic plague, as a re-emerging pathogen by the WHO.
Wednesday, January 18th, 2017“….The progression of pneumonic plague is very rapid after first appearance of the symptoms in humans, and the case fatality rate approaches 100%, if the antimicrobial treatment is delayed. Unfortunately, antibiotic-resistant Y. pestis strains have been isolated from plague patients and/or engineered for bioweaponization, which is concerning as Y. pestis is classified by the Centers for Disease Control and Prevention (CDC) as a Tier-1 select agent. The optimal strategy for protection against this deadly disease would be through vaccination; however, there are currently no Food and Drug Administration (FDA)-licensed plague vaccines available in the United States.…”
A Nigerian air force jet has mistakenly bombed a camp for displaced people near Rann, killing up to 100 people and injuring dozens more.
Tuesday, January 17th, 2017https://www.youtube.com/watch?v=qsWLMT4otpk
Tens of thousands of people seeking better lives are expected to trek across deserts and board unseaworthy boats in war-torn Libya this year in a desperate effort to reach European shores by way of Italy.
Tuesday, January 17th, 2017“….More than 181,000 people, most so-called “economic migrants” with little chance of being allowed to stay in Europe, attempted to cross the central Mediterranean last year from Libya, Africa’s nearest stretch of coast to Italy. About 4,500 died or disappeared…..”
Question to out-going CDC chief: “What scares you the most? What keeps you awake at night?”
Tuesday, January 17th, 2017His answer:
Frieden: The biggest concern is always for an influenza pandemic. Even in a moderate flu year, [influenza] kills tens of thousands of Americans and sends hundreds of thousands to the hospital. That increase in mortality last year may have been driven in significant part by a worse flu season compared to a mild flu season the prior year. So flu, even in an average year, really causes a huge problem. And a pandemic really is the worst-case scenario. If you have something that spreads to a third of the population and can kill a significant proportion of those it affects, you have the makings of a major disaster.
A Turkish cargo plane flying from Hong Kong has crashed in Kyrgyzstan, killing at least 37 people, most of them on the ground
Monday, January 16th, 20171/15/1919: After a tank bursts at the United States Industrial Alcohol Company, fiery hot molasses floods the streets of Boston, killing 21 people and injuring scores of others.
Monday, January 16th, 2017HiRO: Health Integrated Rescue Operations & Disaster Drones
Sunday, January 15th, 2017“….One HiRO (Health Integrated Rescue Operations) package is designed to provide help for a severely injured victim, another is intended for up to 100 people with significant to minor injuries……Drone experts from…Hinds Community College, with advice from the researchers, designed and built the disaster drones, which are equipped to fly in bad weather. “These drones have impressive lift and distance capability, and can carry a variety of sensors, including infrared devices, to help locate victims in the dark,” says Dennis Lott, director of Hinds CC’s unmanned aerial vehicle program.
Lott notes that any progress toward EMS response drone technology remains limited by Federal Aviation Administration ‘Part 107’ regulations that currently restrict most privately owned drones to a maximum weight of 55 pounds, an altitude ceiling of 400 feet, and line-of-sight operations, that is, within visible range………”