Swine Flu Seen as Cresting

NOVEMBER 23, 2009

The current wave of swine flu may have peaked in most of the U.S., but the illness remains widespread and the threat of another wave remains, officials said Friday.

The news came as officials in Norway reported a mutation of the flu virus in two patients who died and one who became severely ill. The mutation, while seen before, appeared to make the H1N1 virus cause infection deeper in the respiratory system than the regular swine-flu virus, a possible explanation for the more-severe cases, Norwegian scientists said.

Swine-flu cases appear to be declining in most of the U.S., the Centers for Disease Control and Prevention said Friday. Flu activity is widespread in 43 states now, down from 46 last week and 48 two weeks ago. Flu cases also appear to have peaked in the U.K. and parts of Western Europe, but are on the rise in Eastern Europe and parts of Asia, the World Health Organization said. But pandemics occur in waves. In the 1957-58 flu pandemic, one wave peaked in the fall and was followed by a second wave in January.

Anne Schuchat, director of the CDC's National Center for Immunization and Respiratory Diseases, warned that more flu is circulating now than at the height of many flu seasons, and holiday travel could bring more infections. "It is so early in the year to have this much disease," she said at a news conference. "We don't know if these declines will persist, what the slope will be, whether we'll have a long decline or it will start to go up again."

The CDC estimates at least 22 million Americans have been infected with H1N1 flu, with 3,900 deaths. Dr. Schuchat said 21 U.S. children had died from influenza in the past week, with 15 confirmed to have had H1N1. A total of 171 pediatric deaths have been confirmed since April, although the CDC estimates that more than 500 children have died of the disease.

The Norwegian Institute of Public Health reported on its Web site that it found the change in only three of 70 virus samples from Norwegian cases that they examined, and said it didn't appear to be circulating widely. The mutated virus "might be a result of spontaneous changes which have occurred in these three patients," said Geir Stene-Larsen, the institute's director general.

The WHO and CDC said the mutation has been seen since April in six other countries, doesn't always cause severe disease, isn't widespread, and responds to vaccine and the antiviral medications. "This mutation has been seen sporadically here and around the world," Dr. Schuchat said. Some of the cases were mild, and the H1N1 virus has caused severe lower-respiratory infections without the mutation, she said.

"To date, no links between the small number of patients infected with the mutated virus have been found and the mutation does not appear to spread," the WHO said in a statement. "Although further investigation is under way, no evidence currently suggests that these mutations are leading to an unusual increase in the number of H1N1 infections or a greater number of severe or fatal cases."

U.S. vaccine deliveries picked up after a slowdown last week, with more than 11 million new doses shipped this week to warehouses where they are available for ordering. To date, 54.1 million doses have been shipped to warehouses since early October -- still well behind the government's prediction in August of a delivery of 45 million to 52 million doses by mid-October and 20 million doses weekly for the next several weeks after that.

Health officials are also investigating reports of a growing number of patients with H1N1 viruses that are resistant to oseltamivir, an antiviral drug marketed by Roche AG as Tamiflu. Seasonal H1N1 viruses are widely resistant to the drug, and the WHO has reported 57 cases of oseltamivir resistance in the new H1N1 flu.

The U.K.'s Health Protection Agency said it is investigating likely person-to-person transmission of oseltamivir-resistant swine flu on a hospital ward in Wales. Nine case were reported, and five have been confirmed as resistant to the drug, the agency said in a statement. The cases occurred in people with immunosuppression, which can cause Tamiflu resistance, the agency said. It said the drug-resistant virus wasn't any more virulent than the regular virus. "At present we believe the risk to the general healthy population is low," the agency said.

The CDC and North Carolina officials are investigating four cases of tamiflu-resistant H1N1 flu that occurred over the past six weeks at Duke University Hospital in Durham, N.C. All four patients were in an isolated unit on one floor of the hospital, and were seriously ill with severely compromised immune systems and other medical conditions, officials said.

Write to Betsy McKay at betsy.mckay@wsj.com
Printed in The Wall Street Journal, page A7

Cases of Tamiflu-resistant H1N1 causing new concern

By Steve Sternberg, USA TODAY

The momentum of the H1N1 flu outbreak has fallen off, but flu activity is still high and Tamiflu-resistant virus may have begun to spread. USA TODAY'S Steve Sternberg asks experts for their perspective.

Q: How bad is H1N1 now?
A: Forty-three states are reporting widespread cases, down from 46 last week, says Anne Schuchat, director of the Centers for Disease Control and Prevention's National Center for Immunization and Respiratory Diseases. "We are beginning to see some declines in influenza activity, but there's still a lot of influenza everywhere."

Q: Has the flu peaked?
A: "I wish I knew," Schuchat says. "Influenza is unpredictable, and it's so early in the year to have this much disease."

Q: Is the vaccine supply improving?
A: Yes, she says. As of Friday, 54.1 million doses of H1N1 vaccine were available for states to order, 11 million more than a week ago. By Wednesday, states had ordered 93% of the amount that was available to them. About 94.5 million doses of seasonal flu vaccine also have been distributed nationwide.

Q: What is the latest about Tamiflu-resistant cases?
A: Four patients at Duke University Medical Center in Durham, N.C., and at least five in an unidentified hospital in Wales have become infected with H1N1, or swine flu, viruses that no longer respond to treatment with Tamiflu. Flu viruses swap genes as part of their normal evolution; that means resistant viruses could quickly spread worldwide, says Duke's Daniel Sexton.

Q: Why should I worry about Tamiflu-resistant cases of flu?
A: Tamiflu and Relenza are the most effective antiviral drugs for treating flu. H1N1 is still largely vulnerable to both drugs, unlike many seasonal flu viruses, which are now broadly resistant and more difficult to treat. Most people will get well with rest and fluids. A hard-to-treat virus can be deadly for some patients, such as pregnant women or children with asthma or cerebral palsy, who need effective treatment because they account for a disproportionate number of deaths caused by swine flu.

Q: Does that mean H1N1 will become as deadly as the 1918 virus?
A: There's no evidence to suggest the virus is getting more virulent, Schuchat says. But it may become harder to treat.

Q: Will Thanksgiving have any impact on the epidemic?
A: "We've seen with a lot of respiratory infections that there are increases in January right after the Christmas holiday," Schuchat says. "All the kids get together with their grandparents. There's an exchange of a lot of warmth and love, but there's a little exchange of viruses, too. We think its critical that if you're sick, stay home. And if your child is sick, to keep them away from others."

Hand Washing Not a Priority for Docs

According to the Centers for Disease Control, an estimated 2 million patients get a hospital-related infection every year and 90,000 die from their infection. With only only 40 percent of doctors reportedly washing their hands after patient contact, it is evident that hand hygiene needs to be more of a priority in hospitals.

In December 2008, the Joint Commission Center for Transforming Healthcare began work on its first improvement project: addressing failures in hand hygiene. in the latest edition of the Medical Journal of Australia states that only 60 percent of doctors are washing their hands after patient contact. This does not seem to be an issue just in one country, but worldwide. In the United States, the number is only slightly higher, with about 50% of doctors washing their hands after examining a patient.

According to the World Health Organization, poor hand hygiene in hospitals and other health care settings is a major contributor to patients contracting infections while in the hospital. In the United States alone, the annual cost of taking care of these patients is over $6.5 billion dollars and contributes to over 90,000 deaths each year.

Hand hygiene compliance takes a great deal of sustained work and resources at all levels in the medical field. By January 2010, the Joint Commission Center for Transforming Healthcare will have the data to demonstrate whether the solutions can be sustained to achieve a 90+ percent compliance rate.

The commission has targeted several areas that are major causes of doctors not cleaning their hands:

*Ineffective placement of dispensers or sinks
*Hand hygiene compliance data are not collected or reported accurately or frequently
*Lack of accountability and just-in-time coaching
*Safety culture does not stress hand hygiene at all levels
*Ineffective or insufficient education
*Hands full
*Wearing gloves interferes with process
*Perception that hand hygiene is not needed if wearing gloves
*Health care workers forget

Hand hygiene is critically important to safe, high quality patient care. Unfortunately, many infections are transmitted by doctors and other health care personnel. Hopefully a comprehensive system will be established to to make hand washing a priority for medical professionals around the world. With the rate of hospital-related infections rising, hand washing needs to be a priority.

Cheryl Phillips
Exclusive to HULIQ.com

sources: ABC Australia, World Health Organization, JCCTH

Who’s most likely to spread infection in the hospital?

NOVEMBER 2, 2009
Originally published in MedPage Today

by Michael Smith, MedPage Today North American Correspondent

Good hand hygiene among healthcare workers is an important factor in preventing the spread of disease, but exactly how important depends on an individual’s job, researchers said.

In a mathematical model, so-called “peripatetic” workers — such as therapists or radiologists — were most likely to spread pathogens if they neglected hand hygiene, according to Laura Temime, PhD, of the Conservatoire des Arts et M├ętiers in Paris, and colleagues.

In contrast, so-called “assigned” workers — typically nurses and doctors — were less likely to spread pathogens, Temime and colleagues said online in Proceedings of the National Academy of Sciences.

In many nosocomial disease outbreaks, a single individual transmits the pathogen to a large number of patients — so-called “superspreading events,” Temime and colleagues said.

Using modeling techniques, they tried to pin down which types of healthcare workers were most likely to contribute to such events. They modeled the effects of neglecting hand hygiene by three different types of healthcare workers:

* Those who had frequent contact with a few patients, such as nurses
* Those with less frequent contact, but who saw more patients, such as doctors
* Those who typically saw all patients once a day, such as therapists

The first two types were classified as “assigned” in that they had responsibility for a specific set of patients; those in the last category were “peripatetic” and saw all patients.

The model tracked what would happen over a month if a single colonized patient were introduced into an 18-bed ward, under various assumptions about noncompliance with hand hygiene rules.

When all healthcare workers were compliant, the researchers said, the model predicted between 1.5 and 5.8 new cases over the month, depending on how transmissible the pathogen was.

The size of the outbreak increased from 13 to 17% if a single worker neglected hand hygiene — to between 1.7 and 6.8 cases on average over the month.

But the results were highly dependent on which workers neglected their hygiene, Temime and colleagues found.

For a worker such as a doctor, who saw many patients but infrequently, the increase ranged from 2% to 7%. But for a noncompliant peripatetic worker, the increase ranged from 73% to 238%.

Indeed, a completely noncompliant peripatetic worker produced disease spread similar to what was predicted if all staff neglected hand hygiene after 23% of patient contacts, the model showed.

One implication of the finding, Temime and colleagues said, is that measuring average compliance with hand hygiene rules, such as by overall use of hand rub products, may not be a good indicator of the real risk of spreading disease.

Peripatetic workers, they said, can play a “disproportionate role in disseminating pathogens in a hospital ward,” making them “potential superspreaders.”

USA 600 Strain

(HealthDay News) -- New research holds bad news for health officials worried about a potentially lethal infection called MRSA that haunts hospitals: A strain that infects the bloodstream is five times more deadly than other strains.

To make matters worse, the USA600 strain appears to be at least partially immune to an antibiotic that's used to treat the condition, the researchers have found.

A full half of patients infected with the strain died within a month, according to a study scheduled to be presented at the annual meeting of the Infectious Diseases Society of America, held Oct. 29 to Nov. 1 in Philadelphia. That's nearly five times the death rate of other people infected with MRSA, and 10 to 30 percent of those who acquire MRSA infections in the bloodstream die within a month, the study found.

MRSA, or methicillin-resistant Staphylococcus aureus, causes infections in the skin and bloodstream. It can also infect surgical wounds and cause pneumonia. In most cases, it sickens people in the hospital, but cases are becoming more common outside the health-care community, according to information in a news release from the Henry Ford Health System.

Researchers think it's possible that the USA600 strain is unique. But they don't know if other factors -- such as the age of patients -- could be at play.

Those who developed the USA600 strain tended to be older than those who acquired other MRSA strains, averaging 64 compared with 52 years old, the study noted.

"While many MRSA strains are associated with poor outcomes, the USA600 strain has shown to be more lethal and cause high mortality rates," Dr. Carol Moore, the study's lead author and a research investigator at the Henry Ford Hospital's division of infectious diseases, said in the news release.

"In light of the potential for the spread of this virulent and resistant strain and its associated mortality," she said, "it is essential that more effort be directed to better understanding this strain to develop measures for managing it."

MRSA is challenging to treat because strains can be immune to many medications. The USA600 strain appears to be more immune than other strains to the drug vancomycin, which often still has the power to vanquish MRSA.

More information

The U.S. Centers for Disease Control and Prevention has more about MRSA.