By ELIANE ENGELER (AP) – August 29, 2009
GENEVA — The World Health Organization said Friday that swine flu infections are declining in the Southern Hemisphere as its seasonal flu period comes to an end and the pandemic shifts back north.
Countries in the Northern Hemisphere that have already had one wave of swine flu should prepare for a second wave, which may be worse, the agency said.
"The H1N1 pandemic virus has rapidly established itself and is now the dominant influenza strain in most parts of the world," WHO said in a statement. "The pandemic will persist in the coming months as the virus continues to move through susceptible populations."
Clinicians from around the world are reporting a very severe form of the disease in young and otherwise healthy people.
"In these patients, the virus directly infects the lung, causing severe respiratory failure," WHO said.
Therefore, countries should anticipate a growing demand for treatment in intensive care units as they prepare for a second wave of the pandemic, it said.
Flu levels remain elevated in South Africa and Bolivia and many of these cases are probably swine flu, it said. But in most of the Southern Hemisphere, flu levels have returned to normal, said WHO spokesman Gregory Hartl.
At least 209,438 people worldwide have caught swine flu and at least 2,185 died of it, according to WHO. The real caseload is much higher because countries are no longer reporting individual cases.
Hartl said the agency was watching flu rates in Japan, where it believes that the high season for infections is starting earlier than normal.
Experts fear that the swine flu virus might mutate into a more deadly strain. A recent outbreak in turkeys in Chile has sparked concern that it might combine with the deadlier H5N1 strain of bird flu and re-infect humans.
WHO said there are no indications that the swine flu virus has so far mutated to a more virulent or deadly form.
Most people who catch swine flu still have a mild case, it said. But "even if the current pattern of usually mild illness continues, the impact of the pandemic during the second wave could worsen as larger numbers of people become infected," it said.
Copyright © 2009 The Associated Press.
By ELIANE ENGELER (AP) – August 29, 2009
The World Health Organization warned Friday that doctors around the world are now reporting a severe form of swine flu that goes straight to the lungs of otherwise healthy young people -- but some infectious disease experts said the alarm could be unwarranted.
The WHO update comes in the wake of reports from some countries that as many as 15 percent of patients infected with the new H1N1 pandemic virus require extensive -- and expensive -- hospital care.
"During the winter season in the southern hemisphere, several countries have viewed the need for intensive care as the greatest burden on health services," the report said. "Preparedness measures need to anticipate this increased demand on intensive care units, which could be overwhelmed by a sudden surge in the number of severe cases."
WHO Warns of Severe Form of Swine FluSwine Flu Vaccine: Enough to Spare?Swine Flu Vaccine Could Roll-Out Early
But infectious disease experts from both inside and outside the government say that the phrasing used by WHO raises some questions -- particularly because the existence of such a form of the disease is not a new development.
"WHO is certainly putting the fear of [God] in people with this type of release," said William Muraskin, a professor of urban studies at Queens College in New York, who is a specialist in international health. "The description by the WHO is similar to lung infections that claimed so many young people during the 1918 pandemic."
Dr. Julie Gerberding, former director of the U.S. Centers for Disease Control and Prevention, noted, "Severe pneumonia occurred in 1918 too, but we cannot confirm the pathophysiology is the exactly the same."
And Dr. Anthony Fauci of the National Institutes of Health, one of the government's preeminent figures on swine flu, told ABC News' Brian Hartman, "The severity should not be anything near what we saw in 1918 -- again, underscoring that things can change.
"But if what we're seeing now is predictive of what we'll be seeing in the fall and the winter this looks like a mild to moderate, not a very severe, pandemic."
Indeed, many believe that the ultimate impact of the swine flu will not be as disastrous as that of pandemics of times past.
"The total mortality remains extremely low," said John Barry, author of "The Great Influenza." "And as far as the cases go, it's important to remember that while such [severe] cases have been seen, they are extremely rare."
But rare or not, the severe form of the illness is a deadly emergency. Dr. Jeffrey Boscamp, chair in pediatrics at the Children's Hospital at Hackensack University Medical Center in New Jersey, said that the lung infection triggers a syndrome called acute respiratory distress syndrome.
"The lung becomes a battleground: the virus versus all of the immunologic components that are recruited to the lung to fight the infection," Boscamp said. "The inflammation is so severe that it becomes impossible for the lung to put oxygen back into the blood.
"When oxygenation becomes impossible, other organs -- kidneys, heart, et cetera -- fail, and death can be the outcome."
And Dr. Greg Poland, director of the Vaccine Research Group at the Mayo Clinic, noted that the intensive care doctors he works with are in contact with other intensivists around the world who describe a bleeding, or hemorrhagic, lung infection. Poland said these doctors "are indeed seeing high viral, overwhelming viral, pneumonia, which then leads to hemorrhagic pneumonitis and severe respiratory distress syndrome; this has been requiring extraordinarily intensive therapy."
A spike in such severe cases could have big implications for hospitals, some fear.
"I have seen a number of these cases, with a number of deaths," said Dr. Christian Sandrock, medical director of the Intensive Care Unit at the University of California Davis Medical Center.
He added that while doctors can treat patients with much more specialized medical care now, if these very sick patients increase in numbers at hospitals, "These are the patients that are going to crush us."
Wire reports contributed to this story.
By LAURAN NEERGAARD (AP) – August 30, 2009
WASHINGTON — The alarm sounded with two sneezy children in California in April. Just five months later, the never-before-seen swine flu has become the world's dominant strain of influenza, and it's putting a shockingly younger face on flu.
So get ready. With flu's favorite chilly weather fast approaching, we're going to be a sick nation this fall. The big unknown is how sick. One in five people infected or a worst case — half the population? The usual 36,000 deaths from flu or tens of thousands more?
The World Health Organization predicts that within two years, nearly one-third of the world's population will have caught it.
"What we know is, it's brand new and no one really has an immunity to this disease," Health and Human Services Secretary Kathleen Sebelius says.
A lot depends on whether the swine flu that simmered all summer erupts immediately as students crowd back into schools and colleges — or holds off until millions of vaccine doses start arriving in mid-October.
Only this week do U.S. researchers start blood tests to answer a critical question: How many doses of swine flu vaccine does it take to protect? The answer will determine whether many people need to line up for two flu shots — one against swine flu and one against the regular flu — or three.
The hopeful news: Even with no vaccine, winter is ending in the Southern Hemisphere without as much havoc as doctors had feared, a heavy season that started early but not an overwhelming one. The strain that doctors call the 2009 H1N1 flu isn't any deadlier than typical winter flu so far. Most people recover without treatment; many become only mildly ill.
Importantly, careful genetic tracking shows no sign yet that the virus is mutating into a harsher strain.
We're used to regular flu that, sadly, kills mostly grandparents. But the real shock of swine flu is that infections are 20 times more common in the 5- to 24-year-old age group than in people over 65. That older generation appears to have some resistance, probably because of exposure decades ago to viruses similar to the new one.
Worldwide, swine flu is killing mostly people in their 20s, 30s and 40s, ages when influenza usually is shrugged off as a nuisance.
Especially at risk are pregnant women. So are people with chronic conditions such as asthma, diabetes, heart disease and neuromuscular diseases including muscular dystrophy. Some countries report more deaths among the obese.
Still, some of the people who've died didn't have obvious health risks.
"People who argue we're seeing the same death rates miss the point — they're in young adults. To me, that shouldn't happen," said one infectious disease specialist, Dr. Richard P. Wenzel of Virginia Commonwealth University. He spent the past few months visiting South American hospitals to help gauge what the Northern Hemisphere is about to face.
Children, however, are the flu's prime spreaders. Already, elementary schools and colleges are reporting small clusters of sick students. For parents, the big fear is how many children will die.
Panicked crowds flooded India's hospitals in August after a 14-year-old girl became that country's first death. In the U.S., regular flu kills 80 to 100 children every winter, and the Centers for Disease Control and Prevention has reports of about three dozen child deaths from swine flu.
Even if the risk of death is no higher than in a normal year, the sheer volume of ill youngsters means "a greater than expected number of deaths in children is likely," said Dr. Anne Schuchat, director of the CDC's National Center for Immunization and Respiratory Diseases. "As a society, that's something that's much harder for us."
Swine flu quietly sickened hundreds in Mexico before U.S. researchers stumbled across two children in San Diego who had the same mystery illness. A world already spooked by the notorious Asian bird flu raced to stem the spread of this surprising new virus. Mexico closed schools and restaurants, and barred spectators from soccer games; China quarantined planeloads of tourists. But there was no stopping the novel H1N1 — named for its influenza family — from becoming the first pandemic in 41 years.
Well over 1 million Americans caught swine flu in spring and summer months when influenza hardly ever circulates; more than 500 have died.
In July, England was reporting more than 100,000 infections a week.
Argentina gave pregnant women 15 paid days off last month at the height of its flu season, hoping that staying home would prove protective.
In Saudi Arabia, people younger than 12 and older than 65 are being barred from this November's hajj, the pilgrimage to holy cities that many Muslims save up their whole lives to make.
And in Australia — closely watched by the U.S. and Europe as a predictor for their own coming flu seasons — hospitals set up clinics outside the main doors to keep possible flu sufferers from entering and infecting other patients.
"While this disease is mild for most people, it does have that severe edge," said Australia's health minister Nicola Roxon, who counted over 30,000 cases in a country of nearly 22 million. That's comparable to its last heavy flu season in 2007.
Cases are dropping fast as winter there ends. But Australia still plans to start the world's first large-scale vaccinations next month in case of a rebound, inoculating about 4 million high-risk people.
Most amazing to longtime flu researchers, this new H1N1 strain seems to account for about 70 percent of all flu now circulating in the world. In Australia, eight of every 10 people who tested positive for flu had the pandemic strain.
That begs the question: Do people still need to bother with regular flu vaccine?
Definitely, stressed CDC's Schuchat, who plans to get both kinds. There's still enough regular flu circulating to endanger people, especially the 65-and-older generation.
Notably, South Africa is having a one-two punch of a flu season, hit first with a seasonal strain known as H3N2 and now seeing swine flu move in.
Wash your hands, sneeze into your elbow, stay home so you don't spread illness when you're sick. That's the mantra until vaccine arrives.
This week brings a key milestone. Hundreds of U.S. adults who rolled up their sleeves for a first shot in studies of the swine flu vaccine return for a blood test to see if they seem protected. It will take government scientists a few weeks to analyze results, but the volunteers get a second vaccine dose right away, in case the first wasn't enough.
The vaccine, merely a recipe change from the usual flu vaccine, seems safe. Federal authorities two weeks ago gave the go-ahead to start children's vaccine trials.
"It's been a piece of cake," said Kate Houley of Annapolis, Md., who jumped at the chance to enroll her three sons, ensuring that if the vaccine really works, they'll have some protection as school gets started. Eleven-year-old Ethan was among the first to be vaccinated by University of Maryland researchers and didn't even report the main side effect — a sore arm.
In the U.S., Britain and parts of Europe, vaccinations are set to begin in mid-October, assuming those studies show they work.
First in line:
Pregnant women. Despite accounting for about 1 percent of the U.S. population, they've been accounting for 6 percent of the swine flu deaths.
Children and young adults from 6 months to 24 years. Babies younger than 6 months can't get flu vaccine, so their parents and other caregivers should be inoculated to protect the infant.
Health care workers.
Younger adults with risky health conditions.
Schools around the U.S. are preparing to inoculate children in what could be the largest campus vaccinations since the days of polio. The government has bought 195 million doses and will ship them a bit at a time, starting with 45 million doses or so in October, to state health departments to dispense.
The Association of State and Territorial Health Officials is negotiating with pharmacists to help perform those vaccinations. Massachusetts even is deputizing dentists to help give swine flu vaccine, and passed emergency regulations to encourage more health care workers to get either the shot or a nasal spray version.
What if people not on the priority list show up? The idea is for pharmacists to gently encourage them to come back a few weeks later, said the association's executive director, Dr. Paul Jarris.
A concern is whether enough people are worried about swine flu to get vaccinated.
"Complacency is a big challenge," said CDC's Schuchat. "We are trying to strike a balance between complacency and alarm."
Ten-year-old Isabella Nataro had a cousin sent home from summer camp because of an outbreak, and she readily agreed when her mother, a University of Maryland vaccine researcher, signed her and her brothers up for a study of the new shot. (The store gift card that participating kids receive after each blood test was a bonus.)
"I'm kind of worried about my friends if swine flu does come to our school," the suburban Baltimore girl said. "I hope everybody else at my school gets a chance to get it."
Associated Press writers Kristen Gelineau in Sydney and Michael Warren in Buenos Aires, Argentina, contributed to this report.
(AFP) – August 29, 2009
PARIS — Swine flu spreads four times faster than other viruses and 40 percent of the fatalities are young adults in good health, the world's top health official warned in an interview appearing Saturday.
"This virus travels at an unbelievable, almost unheard of speed," World Health Organisation Director General Margaret Chan told France's Le Monde daily in an interview.
"In six weeks it travels the same distance that other viruses take six months to cover," Chan said.
"Sixty percent of the deaths cover those who have underlying health problems," Chan said. "This means that 40 percent of the fatalities concern young adults -- in good health -- who die of a viral fever in five to seven days.
"This is the most worrying fact," she said, adding that "up to 30 percent of people in densely populated countries risked getting infected."
Chan's warning came a day after the WHO said the virus had overtaken others to become the most prevalent flu strain.
"Evidence from multiple outbreak sites demonstrates that the A(H1N1) pandemic virus has rapidly established itself and is now the dominant influenza strain in most parts of the world," the UN agency said in a statement.
"The pandemic will persist in the coming months as the virus continues to move through susceptible populations," it added.
Chan underlined that emergency and healthcare services in several countries had come under strain and stressed that resources allocated for cancer patients and those suffering from heart disease should not be diverted.
"One must not rob Peter to pay Paul," she said. "All governments must prepare for the worst."
She said the most important thing in the battle against the virus was "political leadership."
More than 2,180 people around the world have died from the virus since it emerged in April, according to the latest WHO figures.
Chan also said that it could be months before sufficient vaccine is available to combat the pandemic.
She put world production capacity at 900 million doses a year, for a global population of 6.8 billion people.
Even if this was an unprecedented effort, and authorities were speeding up procedures for getting vaccines to the market, there should be no question of compromises on their safety and effectiveness, Chan said.
Britain and France received their first batches of swine flu vaccine this week. Australia on Friday said a massive swine flu vaccination programme would start in October and Turkey hopes the first supplies of the vaccine will come by that time.
While 90 percent of severe and fatal cases occur in people aged above 65 in seasonal flu, most of those who die from swine flu are under the age of 50.
A "very severe form of disease" affecting the lungs and causing severe respiratory failure among young and healthy people was being reported, WHO said Friday, adding that highly specialised care was required.
Large numbers of such patients could therefore "overwhelm" intensive care units and disrupt the provision of care for other diseases, it warned.
In the southern hemisphere where the flu-prone winter season is tailing off, the WHO said cities in several countries had reported that nearly 15 percent of hospitalised cases required intensive care.
By Thomas H. Maugh II
Los Angeles Times
August 25, 2009
As many as 300,000 could clog intensive care units in heavily affected regions, a new report says. But the CDC director notes that the H1N1 outbreak also could be much milder.
Reporting from Atlanta - Nearly 2 million Americans could be hospitalized during this winter's novel H1N1 influenza pandemic, with as many as 300,000 clogging intensive care units in heavily affected regions, according to a report released Monday by the President's Council of Advisors on Science and Technology.
Overall, 20% to 40% of the population could develop symptoms of the strain commonly known as swine flu, and 30,000 to 90,000 could die, according to the report. During a normal flu season, the virus kills about 35,000 Americans.
The difference this year is that pandemic H1N1 is killing middle-aged adults and adolescents, whereas seasonal flu kills primarily the elderly.
The numbers confirm those previously released by the Centers for Disease Control and Prevention, said CDC director Dr. Thomas R. Frieden, but he emphasized the great unpredictability of flu outbreaks and cautioned that this winter's could be much milder.
The figures are not a prediction but a possibility, said epidemiologist Marc Lipsitch of the Harvard School of Public Health, who helped prepare the 86-page report that is available on the White House website.
Researchers expect the high incidence of infections because the new flu is dramatically different from strains that have been circulating in recent years, so that the bulk of the population has no residual immunity.
"This isn't the flu that we are used to," said Kathleen Sebelius, secretary of the Department of Health and Human Services, at a news conference at the CDC headquarters in Atlanta. "We won't know until we are in the middle of the flu season how serious the threat will be."
The report also made several recommendations, including:
* A senior member of the White House staff should be responsible for coordination of all decision-making about the pandemic. The most likely candidate would be the president's homeland security advisor.
* The CDC's surveillance systems should be expanded to improve the chances of detecting new variants of the virus.
* The government should accelerate production of vaccines to have them become available in the middle of September rather than the middle of October, as currently planned. That would allow an initial immunization of 40 million of the most vulnerable people, including pregnant women, health workers and children.
To achieve that goal, vaccine manufacturers should be allowed to fill vaccine vials and prepare them for shipping while they await results from the clinical trials, a process known as "fill and finish." The process normally takes a month, and waiting for results from clinical trials before beginning it would significantly delay distribution.
Sebelius said that manufacturers have been given such permission.
She also noted that no final decision had been made about using the vaccine. But, she said, "we are anticipating moving ahead with vaccination" if the clinical trials show that it works and do not raise any questions about safety.
Experts still think that two doses will be necessary to stimulate immunity because of the lack of previous exposure to the strain.
"By Thanksgiving, we should have a large group of people immunized," she said.
Lisa Schnirring Staff Writer
Aug 21, 2009 (CIDRAP News) – The World Health Organization (WHO) yesterday released new guidelines for using antivirals to treat patients with novel H1N1 influenza infections, signaling a shift toward reserving the medications for people with severe infections and those at high risk for complications.
The new recommendations for managing pandemic H1N1 infections with antivirals are included in a 91-page document on pharmacologic management of all influenza types. An earlier document on clinical management of novel flu patients, issued in May about a month into the novel flu outbreak, briefly reviewed the role of antivirals, but did not give detailed information about their use in different patient populations.
The WHO, in a briefing note today on the new guidance, said the new guidelines were developed by an international expert panel that reviewed all available safety and efficacy studies. They focused on the neuraminidase inhibitors, oseltamivir and zanamivir, because the pandemic H1N1 virus is susceptible to both drugs (and is resistant to the older adamantane drugs). The panel concluded that both drugs can significantly reduce the risk of pneumonia and the need for hospitalization.
Healthy patients with uncomplicated infections should not be treated with antivirals, the group wrote. Some countries, such as the United Kingdom, have been prescribing oseltamivir for any patient with a suspected or confirmed novel flu infection.
For patients who have severe illness or are in a deteriorating condition, the WHO recommends oseltamivir treatment as soon as possible, preferably within 48 hours, though the drug should still be given even if started later.
Pregnant women and those with underlying medical conditions such as asthma, obesity, or diabetes should be treated with oseltamivir or zanamivir as soon as possible after the onset of flulike symptoms, the WHO experts advise.
Because about 40% of severe case are occurring in otherwise healthy children and adults, the WHO urges healthcare providers to be alert for sudden deterioration in clinical condition, which would warrant higher doses and longer duration of oseltamivir treatment than normally prescribed. Danger signs include symptoms such as shortness of breath, difficulty breathing, changes in mental status, and a high fever that persists.
The WHO noted that two recent reports in medical journals raised questions about the usefulness and side effects of antivirals in children. The expert panel considered those reports in making its recommendation that children who have severe or deteriorating illness, plus those who have underlying medical conditions, receive antiviral treatment, the agency said. However, the group said healthy children older than 5 years should not be given antivirals unless their illness persists or worsens.
Tamiflu and Relenza are key to fighting the flu virus. But medical authorities warn: Use only when needed, and use them correctly.
By Shari Roan, Los Angeles Times
August 24, 2009
Indiscriminate use of antiviral medications to prevent and treat influenza could ease the way for drug-resistant strains of the novel H1N1 virus, or swine flu, to emerge, public health officials warn -- making the fight against a pandemic that much harder.
Already, a handful of cases of Tamiflu-resistant H1N1 have been reported this summer, and there is no shortage of examples of misuse of the antiviral medications, experts say.
People often fail to complete a full course of the drug, according to a recent British report -- a scenario also likely to be occurring in the U.S. and one that encourages resistance. Stockpiling is rife, and some U.S. summer camps have given Tamiflu prophylactically to healthy kids and staff, and have even told campers to bring the drug to camp. Experts anticipate more problems in the fall as children return to school and normal flu season draws nearer.
"Influenza viruses mutate frequently and any viral resistance could be acquired easily," said Dr. Anne Schuchat, director of the National Center on Immunization and Respiratory Disease at the Centers for Disease Control and Prevention in Atlanta. "It won't surprise us if we see resistance emerge as a bigger problem in the fall or in the years ahead."
Prescribed in pill form, Tamiflu (oseltamivir) works by preventing the flu virus from leaving infected cells and spreading to new ones. Because a vaccine against pandemic H1N1 influenza will not be widely available for several months, Tamiflu and to a lesser extent Relenza (zanamivir), an antiviral that acts similarly, are key medical tools for fighting the pandemic in the meantime.
On Friday, however, the World Health Organization advised doctors that even those who are sickened with swine flu do not need to be given Tamiflu or Relenza if they are only mildly or moderately sick and are not in a high-risk group (such as children under 5, pregnant women and those with an underlying health condition).
Both drugs can help prevent illness in people exposed to the virus and reduce illness severity in people already sickened with it. On Aug. 14, after U.S. national soccer team forward Landon Donovan was diagnosed with H1N1 flu, players, coaches and support staff of the U.S. and Galaxy teams were advised to take Tamiflu as a preventive measure.
Tamiflu was chosen a few years ago for stockpiling by the federal government to deal with future pandemics.
Health authorities in the United States and elsewhere are keeping a sharp eye on prescriptions of the drug as they prepare for a surge of H1N1 cases in the fall. The U.S. government has issued detailed guidelines on prescribing antivirals. But health professionals may not follow the recommendations or may give in to patients who pester them for prescriptions that are ill-advised, said Dr. Robert Schechter, acting chief of the immunization branch of the California Department of Public Health.
"These medicines can be very helpful to those who could get very sick," Schechter said. "But excessive use will accelerate the development of resistance and lead to the lack of a medication for everybody."
Anxiety over indiscriminate use is growing, and taking the medications cavalierly is not without consequence. British health authorities reported Aug. 2 that cases of side effects from Tamiflu had doubled in the prior week, coinciding with the July 24 launch of a program in England to provide antivirals to anyone with H1N1 influenza who requests it over the phone or online.
In the first three days of the program, 150,000 packets of Tamiflu were dispensed and 293 cases of side effects were reported. Tamiflu can cause vomiting, diarrhea and mild neuropsychiatric effects.
Some U.S. health authorities have also expressed concern over misuse of the medications. Last month, the CDC urged directors of summer camps to stop handing out Tamiflu to healthy campers.
Americans are known to hoard antivirals: A 2006 study showed that heightened anxiety over a possible avian flu pandemic caused Tamiflu prescriptions to soar 300% in 2004 and 2005.
Just as with antibiotics, of central importance to antivirals' success is taking them properly, including completing the recommended course.
However, a study published in late July found poor adherence among children in London who took Tamiflu for prevention of pandemic H1N1 in the spring.
Less than half of the grade-school-age children and only 76% of the 13- and 14-year-old students completed a full course of medication.
More than half of the children reported side effects, such as nausea, stomach cramps and trouble sleeping. Almost one in five reported a neuropsychiatric side effect, such as poor concentration, confusion or bad dreams, even though the U.S. Food and Drug Administration says neuropsychiatric side effects are rare.
Moreover, a study published this week found that Tamiflu and Relenza are unlikely to prevent complications, such as asthma flare-ups or ear infections, in children who have seasonal influenza. But they do increase the risk of vomiting.
The authors of the study, published in the British Medical Journal, said they don't know if their findings can be generalized to the pandemic flu strain.
Antiviral drugs can be underutilized as well as overused, Schechter said. Some Californians who have died from novel H1N1 influenza did not receive antivirals.
"I'm afraid the medications are not being used in some instances where they should," he said. "But there are also international reports of resistance developing. Both of those extremes are concerning."
A handful of resistant H1N1 cases have been reported worldwide among people who had taken Tamiflu preventively: three in Japan, and one each in Canada, Hong Kong and Denmark.
Those cases are not surprising nor of great concern to health authorities, said Dr. Tim Uyeki, a medical epidemiologist with the CDC. They are cropping up sporadically and don't seem to be spreading from person to person.
"The most important question for public health is not whether sporadic cases occur but whether there is ongoing transmission of oseltamivir-resistant strains," Uyeki said.
The most perplexing case of Tamiflu resistance arose in June when a San Francisco teen who had flown to Hong Kong was found by authorities there to be ill with pandemic H1N1 flu. The girl, who recovered, had never taken Tamiflu.
A state investigation of people who were in close contact with the girl, as well as tests of 251 H1N1 virus samples from sick patients in California, has not turned up evidence of a resistant strain circulating here, Schechter said.
But nothing, in theory, would stop such a strain from developing, then circulating. In recent years, several strains of regular, seasonal H1N1 influenza have developed resistance to antiviral medications.
And a study published in March on the spread of the H5N1 avian flu, which has been circulating worldwide in bird flocks in recent years and has killed 262 people, showed the virus rapidly developed resistance to a different class of antiviral drugs, adamantanes.
"With bird flu, we found some resistance started in China and spread throughout the world in a few years," said study author Daniel Janies, an evolutionary biologist at Ohio State University. "Overuse contributes to resistance. Basic natural selection predicts it. We can demonstrate why you should not use these drugs unless you have to."
Other antiviral drugs exist, but the pandemic H1N1 virus is resistant to the adamantane class. If it develops resistance to Tamiflu also, only Relenza would be left to treat the illness, barring the development of new antiviral medications.
Relenza, Schechter said, is indicated only for ages 5 and older. Used less commonly than Tamiflu, it is inhaled as a powder, and people who are seriously ill or have difficulties with breathing cannot take it.
"The more choices you have, the better for treatment," Schechter said. "To lose any one of those options would pose great challenges for treatment of those who are most vulnerable or likely to die."
Grahame L. Jones contributed to this story.
August 12, 2009
The “superbugs” are here and they are in the supermarket meat aisle. According to the New York Times, scientists discovered MRSA, an antibiotic-resistant staph infection, in supermarket pork in Louisiana and Washington D.C. Meanwhile, a brand new strain of MRSA was found earlier this year in US pigs (and pig farmers), raising fears of even more virulent, possibly deadly, strains arising soon.
The cause of this explosion of superbugs in livestock is clear — the routine administration of antibiotics to healthy animals in factory farms.
In response to this crisis, Rep. Louise Slaughter (D-NY) has again introduced into the House of Representatives the Preservation of Antibiotics for Medical Treatment Act. PAMTA would restrict the use of sub-therapeutic doses of entire classes of antibiotics in farm animals and has the support of public health officials and agricultural experts alike.
MONDAY, Aug. 10
A French study estimates that more than 12 percent of people discharged from a hospital into home health care are infected with MRSA, or methicillin-resistant Staphylococcus aureus, and about 20 percent of them may transmit the organism to others in their household.
The researchers, Dr. Jean-Christophe Lucet, of Bichat-Claude Bernard Hospital in Paris, and his colleagues, screened 1,501 hospitalized adults for MRSA before they were discharged and found that 191 (12.7 percent) were infected. For the next year, those found to be infected and other people in their households were checked for MRSA every three months.
The 191 people with MRSA had 188 household contacts who took part in the study. Of those contact, 36 (19 percent) acquired MRSA, but none of them developed an infection. People most likely to be colonized with MRSA included those who were older and those who helped provide health care for the infected person. Sharing the same bed or bedroom did not increase the risk of MRSA transmission, according to the study.
The findings suggest that MRSA transmission is most likely among people who are at high risk for hand contamination while caring for people, the study's authors noted.
Because no infections developed in any of the household contacts who acquired MRSA, it's not clear whether such transmission poses a serious public health problem, the researchers said. Regardless, "household contacts should apply infection control measures similar to those recommended in the hospital setting," they wrote.
Of the people discharged from the hospital with MRSA, about half of those followed for a year were found to be clear of infection, especially those who had become more self-sufficient in daily activities, the researchers said.
WASHINGTON (AP) - The aggressive antibiotic-resistant staph infection responsible for thousands of recent illnesses undermines the body's defenses by causing germ-fighting cells to explode, researchers reported Sunday. Experts say the findings may help lead to better treatments.
An estimated 90,000 people in the United States fall ill each year from methicillin-resistant Staphylococcus aureus, or MRSA. It is not clear how many die from the infection; one estimate put it at more than 18,000, which would be slightly higher than U.S. deaths from AIDS.
The infection long has been associated with health care facilities, where it attacks people with reduced immune systems. But many recent cases involve an aggressive strain, community-associated MRSA, or CA-MRSA. It can cause severe infections and even death in otherwise healthy people outside of health care settings.
The CA-MRSA strain secretes a kind of peptide - a compound formed by amino acids - that causes immune cells called neutrophils to burst, eliminating a main defense against infection, according to researchers.
The findings, from a team of U.S. and German researchers led by Michael Otto of the National Institute of Allergy and Infectious Diseases, appeared in Sunday's online edition of the journal Nature Medicine.
While only 14 percent of serious MRSA infections are the community associated kind, they have drawn attention in recent months with a spate of reports in schools, including the death of a 17-year-old Virginia high school student.
Both hospital-associated and community-associated MRSA contained genes for the peptides. But their production was much higher in the CA-MRSA, the researchers said.
The compounds first cause inflammation, drawing the immune cells to the site of the infection, and then destroy those cells.
The research was conducted in mice and with human blood in laboratory tests.
Within five minutes of exposure to the peptides from CA-MRSA, human neutrophils showed flattening and signs of damage to their membrane, researchers said. After 60 minutes, many cells had disintegrated completely.
"This elegant work helps reveal the complex strategy that S. aureus has developed to evade our normal immune defenses," Dr. Anthony S. Fauci, NIAID director, said in a statement. "Understanding what makes the infections caused by these new strains so severe and developing new drugs to treat them are urgent public health priorities."
Dr. George G. Zhanel, a medical microbiologist at the University of Manitoba in Canada, said the study was the first he had seen that identifies the peptides involved.
This shows at least one of the reasons CA-MRSA is able to cause serious problems, Zhanel, who was not part of the research team, said in a telephone interview.
Findings like this may help lead to better treatments, such as ways to neutralize the peptides or to activate the immune system to defeat them, he added.
Dr. Lindsey N. Shaw of the division of cell biology, microbiology and molecular biology at the University of South Florida, also was enthusiastic about the research.
"Specifically identifying a factor which seemingly makes CA-MRSA more pathogenic than HA-MRSA is a real find," Shaw, who was not part of the research group, said via e-mail. The "molecules identified in the study are indeed novel."
Zhanel noted that while hospital-based MRSA seemed to concentrate on "sick old people," the community-based strain can break out in on sports teams, prisons, cruise ships and other places where people are not necessarily sick or have weakened immune systems.
In a worrisome development, he noted that the more aggressive strains have started appearing in hospitals.
Dr. Clarence B. Creech, an assistant professor of pediatric infectious disease at Vanderbilt University, said every time scientists find a new way that staph uses to make people sick, "we open up the field of developing new vaccine targets and new drug targets."
"This is one of the papers we can look to as we develop new vaccines and drugs," Creech, who was not part of the research team, said in a telephone interview.
The research was funded by the National Institutes of Health, the German Research Council and the German Ministry of Education and Research.
Consumer Reports Health.org
You might already worry that hospitals aren't as safe or sanitary as they should be, but nurses say you don't know the half of it. That is the startling conclusion of our first side-by-side surveys of hospital conditions from two very different perspectives: those of nurses and patients.
In the surveys, conducted by the Consumer Reports National Research Center, we heard from subscribers who told us about their own or a loved one's most recent hospital stay, and nurses reported on their most recent week at work.
5 STEPS TO A SUCCESSFUL HOSPITAL STAY
- Step 1: Do Your Homework
- Step 2: Plan for a Smooth Admission
- Step 3: Avoid Chaotic Care
- Step 4: Stay Vigilant for Problems
- Step 5: Plan Ahead for Discharge
- Wash up, Doc
- Whom to call
- Check up on your hospital
Their responses show that hospitals look very different depending on your vantage point. About 4 percent of patients told us they saw problems with hospital cleanliness, compared with 28 percent of nurses. Thirteen percent of patients said that their care wasn't coordinated properly, but 38 percent of nurses said that was a problem. Five percent of patients, but 26 percent of nurses, said hospital staff sometimes did not wash their hands.
In spring 2009, we surveyed a national sample of 731 nurses who cared directly for patients in emergency rooms, critical-care units, operating rooms, and other areas of the hospital. For the patient's viewpoint, in spring 2008, more than 13,540 readers told us about their own or a family member's hospital stay during the previous year.
We also collected suggestions from dozens of interviews with hospital officials, doctors, registered nurses, social workers, dietitians, and hospital pharmacists -- and patients who were willing to share their experiences with us.
Here's their combined wisdom on how to get through a hospital stay safely and with minimal confusion, from the initial choice of where to go all the way through to your discharge.
Step 1: Do Your Homework
Fifty-nine percent of patients in our survey did not enter the hospital through the emergency room, so they might have had a choice of which hospital to go to. But 65 percent simply went to the hospital their physician recommended or was affiliated with. Forty percent chose a hospital for its location, and 28 percent because it was in their health plan's network.
(Respondents were asked for their top three reasons.)
Only 11 percent chose the hospital for its record in treating their condition, and only 2 percent on the basis of the hospital's ratings in books or magazines or online. That's unfortunate, because hospital quality differs, and there's limited but growing public information about it, but you have to find it and make proper use of it. (We've listed some online sources of hospital information in Check up on your hospital.)
If you, like 99 percent of our respondents, have health insurance (our readers are not representative of the U.S. population and are exceptionally well insured), start by getting an up-to-date list of the hospitals, physicians, and specialists in your plan's network. And if you're going to have surgery, don't forget the anesthesiologists. Be sure to understand and observe your plan's coverage rules, especially any preauthorization requirements.
If you or a family member has a chronic medical condition that can lead to frequent hospitalization, such as heart disease or respiratory problems, you might benefit from research even more than people headed for elective surgery. Nonsurgical patients we surveyed, though generally positive about their experiences, were less so than surgical patients. They had more trouble getting the attention of doctors and nurses and more difficulty getting pain treatment and the information they needed about medications and diagnostic tests.
Patients who need highly specialized or technologically difficult treatments, such as surgery for esophageal cancer, a pediatric heart condition, or a brain aneurysm, should make a special effort to locate a hospital and surgeon with extensive and regular experience in that specific surgery. Research has shown that a key to a good outcome in those difficult cases is the experience of the surgeon and hospital. If you can't find what you need from the public resources we've provided, call doctors or hospitals directly and ask how often they do a specific procedure or take care of patients with your condition.
Another important piece of information that's often difficult to get: the ratio of nurses to patients. In our survey, patients who reported that the staff was responsive to their needs and who were satisfied with their overall nursing care were more satisfied overall with their hospital stay.
Other research has linked higher nurse-staffing levels with greater patient satisfaction scores and lower complication and mortality rates. "They can attend to patients' needs more quickly, respond to issues like pain management, and can probably do a better job of giving discharge instructions, all the things that go into having a more satisfied patient," says Ashish Jha, M.D., associate professor of health policy and management at the Harvard School of Public Health.
To find out the nurse-patient ratio of the hospitals you're considering, call the hospitals and ask, says Cheryl Peterson, R.N., director of nursing practice and policy for the American Nurses Association. Peterson says the association does not advocate any particular ratio, but adds, "If I was going into a medical-surgical unit and I had a nurse with more than five patients, I'd get a little worried." That could happen to you. In our survey, 31 percent of nurses reported that in an average hour on a shift they provided direct care for six or more patients.
- Check your health plan for its rules on hospitalization.
- Research hospitals online.
- Ask about a surgeon's experience with unusual or complex treatments.
- Ask about nurse-patient ratios.
Step 2: Plan for a Smooth Admission
Errors in medication are a leading cause of preventable injury to hospital patients in this country, and research suggests that mix-ups are especially likely during "care transitions," when patients are admitted, are transferred from one ward to another, or are discharged from the hospital.
But it is estimated that less than 2 percent of hospitals in the U.S. have comprehensive electronic records systems that make patient information readily available anywhere in the hospital. That means that you'll have to be your own record keeper. Rita Kobert, 51, of Fredericksburg, Va., who has a seizure disorder, learned that lesson long ago. "If I fall from a seizure or something and have to go to the hospital, I already have a printout of medications, past surgeries, things like that," she says. "If you smack your head, you're out of it for a little while sometimes."
Everyone should follow Kobert's example. Keep an up-to-date list of your current medications and dosages, including over-the-counter drugs and dietary supplements, in your handbag or wallet at all times. (Include your emergency contact information and your primary-care provider's.) Nurses in our survey said that's one of the most important things you can do to help ensure better hospital care.
If you have a chronic condition or a significant medical history, take a written summary with you, including dates of significant events, treatments, and tests, so you can fill out forms accurately.
Patients with a limited command of English should call ahead to make sure the hospital has doctors or staff who speak their language or interpreters and translated documents.
If your admission is planned, pack a small bag of personal items, including some family pictures to comfort you, and books, magazines, and a portable music player with headphones to help pass the time. Check with the hospital about cell phones and laptop computers. They're usually OK except in or near intensive-care units, where they might interfere with sensitive equipment. Ask whether there's a secure place to keep them when you're away from your room.
For safety reasons, hospitals prefer to supply all medications, says Bona Benjamin, director of medication-use quality improvement at the American Society of Health-System Pharmacists. If you're concerned that your particular medicines might be unavailable, call the hospital in advance and ask to speak with its pharmacist. If you're being hospitalized by someone other than your primary-care doctor, remember to let him or her know that you're going to the hospital. And when you get there, be sure to fill out forms authorizing the hospital to send records of your stay to your primary-care doctor. Make sure you have an "advance directive" (available at www.caringinfo.org) that gives your preferences for care in the event you are ill with no prospect of recovery and unable to express your wishes.
You might be surprised to discover that you've never met the doctor who will actually take care of you in the hospital. A new breed of physician known as a hospitalist, a specialist trained specifically to practice in-hospital medicine, might be in charge of your care. "It's likely that over half of Medicare fee-for-service patients in the U.S. are cared for by hospitalists," says Mark V. Williams, M.D., professor and chief of the division of hospital medicine at Northwestern University Feinberg School of Medicine. Although off-site doctors might come to check on patients only once a day, hospitalists are available around the clock.
Lingering trust issues remain. An editorial in the April 2009 issue of the Journal of Hospital Medicine said hospitalists are often portrayed as doctors who work "for the hospital and not the patient, an employee focused on efficiency and rapid discharge rather than continuous medical care." To allay any concerns, feel free to ask the hospitalist to consult with your regular doctor before you agree to have particular tests or procedures and to keep the lines of communication open.
If you, like 41 percent of our respondents, enter the hospital through the emergency room, expect a more difficult experience all around. ER patients and families were far less satisfied than non-ER patients with every measure of staff attentiveness, including pain control, nurses' responsiveness, having their questions answered promptly, and getting explanations of medications and tests.
Waiting time is the top cause of patient dissatisfaction, says Howard Blumstein, M.D., medical director of the emergency department at Wake Forest University Baptist Medical Center and a vice president of the American Academy of Emergency Medicine. "The longer we make you wait, the more dissatisfied you will be."
If you have a chronic condition that lands you in the hospital occasionally, try to avoid going through the ER. But don't hesitate to call 911 if you have a true medical emergency, such as severe physical trauma, difficulty breathing, sudden chest pain, serious loss of blood, a possible broken bone, a sudden inability to use one of your limbs, a loss of vision, unexplained seizures or convulsions, or a severe headache.
- Take a list of medications and a brief health history to the hospital.
- Speak with the hospital pharmacist about special medications.
- Keep your regular doctor in the loop.
- Understand the hospitalist's role.
- Avoid the ER except for genuine medical emergencies.
Step 3: Avoid Chaotic Care
When Jim Costigan, 69, of Edison, N.J., was hospitalized in December 2008, two doctors ordered separate tests, each of which required fasting, he said. But they didn't coordinate their schedules. "I don't mind fasting for a procedure," Costigan said. "But when I wind up not eating for 72 hours, that's when it gets out of hand."
Disjointed care is seen as a problem by both patients and nurses, our surveys showed. Thirteen percent of patients and family members who monitored care told us they had problems with care coordination. Thirty-eight percent of the nurses, who have a more complete picture of what's going on in hospitals, said they saw problems in the coordination of care, such as unnecessary or duplicate tests or treatments.
Disjointed care usually stems from having multiple doctors involved in your case, which can lead to confusion and miscommunication—such as when the two doctors inadvertently condemned Costigan to three straight days of hunger pangs. A March 2007 study in the New England Journal of Medicine estimated that the typical fee-for-service Medicare beneficiary sees seven doctors each year—two primary-care physicians and five specialists—from four practices.
Uncoordinated care can also be dangerous when it puts patients at increased risk of infections and medical errors that can occur when different doctors independently prescribe drugs or order tests.
Whether your hospital stay is planned or unplanned, do your best to take along a knowledgeable family member or friend to run interference for you when you are too sick or too sedated to advocate for yourself. This person can monitor your care, ask about treatment options, and speak up for you if you can't. Most nurses in our survey also said it would help if patients or their relatives or friends kept a written log of tests, treatments, drugs, changes in condition, the names of hospital caregivers, and notes of doctors' visits.
If your admitting doctor or hospitalist isn't doing a good enough job of coordinating your care, you have some options. Fifty-two percent of nurses in our survey agreed that patients should work closely with a patient advocate, social worker, or case manager to coordinate care.
But patients usually have to ask for such help, and only 9 percent of patients and 17 percent of their relatives (12 percent overall) in our survey did so. They might not have known they can summon those allies simply by using their bedside phone
Use the call button for urgent requests, such as alerting a nurse if the patient's condition deteriorates suddenly or pain is inadequately controlled. But be aware that 34 percent of nurses in our survey said they had to take longer than 5 minutes to respond at least once in their most recent work week because of inadequate time or not enough staff or other resources.
That's not surprising, considering that American Hospital Association statistics show a shortage of registered nurses, nursing assistants, licensed practical nurses, and pharmacists. "If you don't have enough RNs on the unit, we're not going to be able to pay as much attention" or be as responsive to call buttons and requests to treat pain, says Cheryl Peterson of the American Nurses Association.
So when calling for a nurse it's important for patients and family members to articulate what's wrong. Specify whether you're short of breath, in pain, or just want more ice water, so whoever answers the request knows whether to send a nurse, an aide, or an orderly.
And if there's something you need or think you might need, let the nurses know about it an hour before they change shifts, says Laura Pike, a registered nurse in San Diego. "Sometimes patients can feel almost abandoned during change of shift," she says.
And be nice. In our survey, just 33 percent of nurses strongly agreed that patients respect nurses' contribution to their care; 78 percent said patients and relatives might find that being respectful to hospital staff would "help very much" in getting better hospital care.
"In a hospital, you definitely catch more flies with honey than you do with vinegar," says Howard Abramovitz, 51, of Brooklyn, whose mother was recently hospitalized. "You assert your rights when you have to, but if you don't need to, make nice with everybody because hopefully they'll make nice with you, too."
- Have a friend or relative with you as much as possible during your stay.
- Keep a bedside log of tests, treatments, and consultations.
- Identify a single individual to coordinate your care, whether a physician, hospital social worker, case manager, or patient advocate.
- When using the call button, be specific about your needs.
- Be respectful to the staff, but don't hesitate to ask to speak to a nursing supervisor if you feel your needs aren't being met.
Step 4: Stay Vigilant for Problems
Just because a hospital looks clean and well run doesn't mean it is. It's estimated that more than 100,000 patients die needlessly every year in U.S. hospitals and health-care facilities, infected because of the staff's sloppy compliance with cleanliness policies or injured because simple safety checklists were not followed. In our patient survey, 7 percent said an infection developed during or within a month of their hospital stay. Of those, 41 percent said the infection extended their hospital stay; the median was six days.
Little progress has been made implementing key measures to protect patients. That's why patients and watchful family members and friends must do what they can to guard against preventable errors.
For instance, our surveyed nurses confirmed serious problems in hygiene. Twenty-six percent reported observing hand-washing lapses.
"It seems like a simple little thing, but doctors and nurses pick up a lot of nasty germs and then transmit them to other patients," Blumstein, of Wake Forest, says. "By far the best way of preventing that is to wash your hands. But it's easy to forget. So you might want to pay attention to whether or not the doctor or nurses wash their hands or use that alcohol-based hand-sanitizer stuff."
Mistakes don't stop at hand-washing lapses. Eleven percent of surveyed nurses said that in their most recent work week, they observed "incorrectly administered medication or dosage," and 9 percent said doctors had prescribed the wrong medicine or dosage. (We didn't ask whether the nurses intervened.)
Patients should take steps to protect themselves. Forty-six percent of nurses said it would help very much if patients checked the medications being administered to them during their stay. But only 28 percent of the patients and 35 percent of the family members (31 percent overall) in our survey said that they did so.
Patients we interviewed said it sometimes took a lot of persistence to get answers. "You really have to be your own patient advocate," says Duane Rayford, 50, of Desert Hot Springs, Calif. He's on kidney dialysis, he says, and has been in and out of three hospitals since October 2008. "We had to constantly ask questions like, 'What about this?' 'What happens if this happens?' 'Is there another way to do this?' 'What else can we do?' " Rayford says. Eventually he got the information that he needed.
- Make sure caregivers wash their hands.
- Check medications and doses before you take them.
- Be insistent if you're unhappy with your care or don't understand something.
Step 5: Plan Ahead for Discharge
Your caregivers say it's time for you to leave the hospital. That's great, but it's no time to let down your guard. You're actually approaching one of the most dangerous times of your hospital stay.
Research suggests that patients who don't understand their discharge plans or how to manage their drug regimen are at increased risk of developing a drug interaction or some other problem that lands them right back in the hospital. Eleven percent of the patients in our survey were in the hospital because of a complication from a previous hospitalization or surgery. Of those patients, 19 percent said they had contracted an infection from their previous hospital stay.
Our analysis of government patient surveys found that patients gave most hospitals low ratings for discharge instructions. (In our own survey, which was not a representative sample of all patients, the vast majority of respondents said they felt adequately informed about the medications and other care they'd need after discharge and had a contact for any questions or problems.)
One way to head off problems, our nurse respondents said, is to ask the hospital's patient advocate, social worker, or case manager to help review your discharge plans. One key step is called "medication reconciliation," which consists of comparing the medications you took in the hospital with the ones you were previously taking at home to make sure you leave with the medication regimen you need, no more, no less. If you don't see medication reconciliation in your discharge plan, insist that it be provided.
Another critical step: Before you leave the hospital, schedule an appointment with your primary-care doctor within a week after your discharge. Double-check to make sure your doctor receives copies of your hospitalization records and discharge plan. In fact, it's a good idea to take copies to your appointment, just in case. Patients should get follow-up care to "make sure that they're remaining stable and that there aren't any interactions with medications and so forth," says Williams of Northwestern University.
A surprising number of people neglect that step, according to a study, co-written by Williams, which found that almost 20 percent of nearly 12 million Medicare patients discharged from the hospital were readmitted within a month. In half of the nonsurgical cases, researchers found no bill for a follow-up visit to a physician's office, suggesting that inadequate post-discharge care might have contributed to the return hospital trip, according to the study, published in the April 2, 2009, issue of the New England Journal of Medicine.
What if the hospital wants to send you home before you feel ready? Ten percent of the patients we surveyed said they ran into that problem. Of that group, 54 percent requested a postponement and 42 percent of those were allowed to stay longer.
- Make sure you understand plans for your discharge.
- If you're not satisfied, ask for help from your hospital's patient advocate, social worker, or case manager.
- Insist on a medication reconciliation between home and hospital drugs.
- See your primary-care physician within a week of your discharge and arrange for him or her to get copies of your hospital records.
July 21, 2009
Researchers at the University of Texas Southwestern Medical Center have figured what genes turn on and off in a person's immune system when he or she has a severe staph infection.
The work, done on children with severe Staphylococcus aureus infections but applicable to all people, could lead to better treatments for these diseases, including the methicillin-resistant (MRSA) version known as the "super bug" because most antibiotics do not work on it.
According to the findings, published in the online journal PLoS One, the genes in children's innate immune system, which provides the most immediate response to infection, became overactive when S. aureus hits. Meanwhile, the genes in the children's adaptive immune systems, which recall past battles to better fight later infections, are shut down.
"It's a very sophisticated and complex dysregulation of the immune system, but our findings prove that there's consistency in the immune response to the staphylococcus bacterium," lead author Monica Ardura, an instructor of pediatrics at UT Southwestern, said in a school news release. "Now that researchers know how the immune system responds, the question is whether this methodology can be used to predict patient outcomes or differentiate the sickest patients from the less sick ones and, ultimately, how this knowledge can be used to develop better therapies?"
She emphasized, though, that the findings were only a snapshot of what occurs during a staph infection at a single moment.
The researchers conducted gene expression profiling with blood taken from 53 otherwise healthy children who had contracted one of the strains of S. aureus during a five-year period and 24 healthy control patients.
The team plans to try to study other conditions surrounding the period before, during and after infection in patients, and how different staph-infection therapies affect treatment.
By Ginny Graves
August 4th, 2009
When the swine flu burst onto the scene in April, the bug arrived with a few particularly ominous signs: The flu was resistant to a class of drugs often used to fight flu in the past, and experts were surprised that a nonhuman virus could have such rapid human-to-human transmission. Why was Swine Flu resistant to current medicines, and was this strain a new supergerm?
Flu bugs develop drug resistance when a virus mutates in a way that makes medications ineffective. Overusing and misusing antiviral meds can cause the problem. But mutations can also crop up spontaneously, even when the drugs aren’t overprescribed, says Anne Moscona, MD, a flu expert and an infectious-diseases physician at Weill Medical College of Cornell University and New York Presbyterian Hospital.
“Swine flu seems to respond to Tamiflu, but we weren’t sure at first. And we’re seeing more strains of other types of flu, including some bird flu, that are resistant to it. That’s been sobering for lots of people in public health because Tamiflu is the drug the country has been stockpiling for a possible pandemic,” she says. “The issue we’re facing now is ‘What do we do if the drugs we’re counting on don’t work?’”
This question is being asked with increasing urgency these days, as more and more bugs, including some truly nasty bacteria, become impervious to the effects of our best drugs. Acne and some STDs aren’t clearing up the way they once did.
More worrisome, methicillin-resistant Staphylococcus aureus (MRSA)—bacteria that are resistant to methicillin, a common antibiotic—now kills more people in U.S. hospitals than HIV, AIDS, and tuberculosis combined. And, scarier still, the bug is becoming increasingly common outside of hospitals, affecting everyone from infants with ear infections to young, healthy athletes. And MRSA, experts warn, is just the tip of the drug-resistance iceberg.
“Drug-resistant bacteria have developed in large part because of our overuse and misuse of antibiotics—and it has led us to a crisis point,” says Helen W. Boucher, MD, a specialist in the division of infectious diseases at Tufts Medical Center in Boston. “We’re even seeing bugs today that are resistant to all antibiotics.”
But while some germs may be outpacing our ability to kill them, we’re not completely defenseless. In fact, there are plenty of things we can do to slow their spread. Here, five of the scariest threats right now, and what you can do to keep yourself—and future generations—safe.
Scary strains of flu
In 2005, two teenage girls in Vietnam died of avian (bird) flu. The news was alarming because both had been treated with Tamiflu, the drug governments stockpile to fight the avian virus. In fact, lab tests showed both girls had developed Tamiflu-resistant viruses. More bad news came in January of this year when researchers at the University of Colorado announced that more than 30% of the bird flu samples they analyzed were resistant to adamantanes, older antivirals doctors might use if Tamiflu doesn’t work.
As of May this year, bird flu had killed 261 of the 424 people who have been diagnosed with it worldwide since 2003, according to the World Health Organization. “It’s incredibly deadly,” Dr. Boucher says. “It doesn’t spread efficiently from person to person—at least not yet—but a pandemic flu still tops the list of scary health nightmares, even in the United States, because there’s the potential for a highly contagious flu to sweep through the population before we can contain it.”
Such a flu could kill thousands—if not hundreds of thousands—of people, especially if the strain is resistant to Tamiflu. “It makes sense for countries to start adding Relenza, another newer antiviral, to their stockpiles, just in case we see a Tamiflu-resistant strain that’s highly contagious,” Dr. Moscona says.
Even if there are drugs that work against a virulent flu, they can’t necessarily be relied on to contain an epidemic. “Antivirals only work if you take them within two days of the first symptoms, and they’re much more effective if you take them in the first 6 to 12 hours,” Dr. Moscona says.
Some good news: Researchers recently identified human antibodies that seem to neutralize some flu viruses, including the bird flu strain—a finding that could lead to more-effective treatments. In the meantime, not getting the flu in the first place is a far better bet than trying to treat it. (In the United States, about 36,000 people die from the flu every year.) To avoid it:
* Get an annual flu vaccination. The viruses in the vaccine (based on the type or strain of flu researchers think is most likely to hit) change every year, so get vaccinated each year—and early. It takes about two weeks for flu-fighting antibodies to develop, so get vaccinated in September or early October to protect yourself from early-arriving bugs.
* Wash your hands. The flu virus can live for up to 72 hours on surfaces like doorknobs, light switches, and TV remote controls—and if you get it on your hands and touch your eyes or nose, you could get sick. That makes hand-washing the most effective daily defense. Wash briskly with plain old soap and water for 30 seconds.
* Fight the flu with vitamin D. “One study found that people who took vitamin D supplements were less likely to have cold and flu symptoms,” says Michael F. Holick, PhD, MD, professor of medicine, physiology, and biophysics and director of the Vitamin D, Skin and Bone Research Laboratory at Boston University School of Medicine. Dr. Holick says 1,500 to 2,000 I.U. of vitamin D not only bolsters the immune system but also may help prevent infection.
Methicillin-resistant Staphylococcus aureus (MRSA)
In December 2005, when 14-month-old Bryce Smith came down with a cold—his first ever—the pediatrician told his mom he’d feel better in a few days. He didn’t feel better, and by New Year’s Day Bryce was in the emergency room. An X-ray showed that he had pneumonia, and a CT scan revealed something even scarier: His right lung was filled with a thick, gelatinous fluid.
The doctors rushed the baby into surgery, where they discovered he was infected with MRSA—and the infection was so severe that it had eaten a hole through his lung. After 40 days on vancomycin, a superpotent antibiotic that can affect kids’ hearing, Bryce pulled through. “But we’re still worried about his hearing and how much damage the bacteria did to his lungs,” his mom says.
Bryce’s story is scary because it reflects a trend. “It’s most worrisome that MRSA can infect completely healthy people with healthy lifestyles, something that was almost unheard of 15 years ago,” Dr. Boucher says. About 12% of infections strike people who aren’t hospitalized, a percentage that is likely to increase as MRSA becomes more widespread.
Currently, about 40% of us have staph bacteria on our skin—and it rarely causes a problem. But about 60 to 70% of staph in U.S. hospitals has developed resistance to methicillin. Worse, a small percentage of the bugs are now resistant to vancomycin, the drug that saved Bryce’s life.
Although MRSA can cause pneumonia and blood infections and has recently been linked to children’s ear and sinus infections, it most often causes skin and soft-tissue abscesses. A MRSA infection looks like a pimple, boil, or spider bite, but it may quickly worsen into an abscess or pus-filled blister or sore. To protect yourself …
* Shun the staph. Wash your hands, especially after you’ve been in public places and touched handrails, grocery-cart handles, and other frequently handled objects. Experts estimate that staph is present on 2 to 3% of surfaces in public places—more in hospitals. Regular soap and water will remove most germs. Alcohol gels or wipes and antibacterial soap work, too, but there’s a chance that antibacterial soap contributes to antibiotic resistance, so it makes sense to avoid it.
* Cover up. Bandage all cuts, even paper cuts and blisters. Sterilize the stetho. Researchers recently found that one in three stethoscopes used by emergency-medical-service providers was contaminated with MRSA. Ask your doc to swab his scope with alcohol.
* De-germ the gym. Use a disinfectant wipe to swab the handlebars of equipment, and drape a clean towel over shared yoga mats and sauna and locker room benches. After each workout in a group environment, take a shower, soaping up thoroughly—and be sure your kids who play sports do, too.
* Don’t share. You’re at increased risk of MRSA if you share razors, soap, towels, or other personal items. Schools, day-care centers, and gyms may harbor the germ—one reason it’s important to get children in the hand-washing habit.
Clostridium difficile (C. diff.)
Amy Warren, 41, thought she was dying when, several weeks after giving birth to her daughter, she began having severe abdominal cramps and dozens of daily bouts of diarrhea. After several medical tests, a doctor identified her infection as C. diff., a gut bug that, thanks to its virulence and prevalence in hospitals has earned it the distinction of being called “the new MRSA.” (It sickens about a half-million people in the United States every year and contributes to between 15,000 and 30,000 deaths.)
Warren, who finally beat the infection after six months and three rounds of the potent vancomycin, says, “I had never even heard of C. diff. before. I’ve never been so sick in my life. I live in fear of getting this thing again.”
C. diff. is one of the most aggressive killers of hospitalized patients. But it’s increasingly affecting people in the community, and one of its most frightening qualities is that it can develop even after you’ve taken a single dose of antibiotics—for a sinus infection, say, or a urinary-tract infection—if the toxic bacteria is in your gut. “The drugs wipe out the healthy bacteria, which allows C. diff. to proliferate,” Dr. Boucher says.
The bacteria can produce toxins that destroy the lining of the gut, causing everything from mild diarrhea to a deadly condition known as toxic megacolon, in which the colon walls become so thin they rupture. The type of C. diff. Warren had—a mutated strain known as NAP 1, which has only appeared in the last decade—is particularly dangerous, producing roughly 20 times the amount of toxin as older strains and responding less favorably to antibiotics. To stay safe:
* Bust out the bleach. The bacteria’s hardy spores can survive for months on most surfaces (even dry ones) and aren’t killed with most cleaners. “You can only kill them with bleach,” says Stuart Levy, MD, president of the Alliance for the Prudent Use of Antibiotics and a professor of microbiology and medicine at Tufts University School of Medicine. On your hands, alcohol sanitizers do little to get rid of spores, but the friction of soap and water may remove it from your hands. “The best you can do is try to wash it down the drain,” says Louis Rice, MD, an expert on resistant bugs and chief of medical service at Louis Stokes Cleveland VA Medical Center. Also, be particularly vigilant about hand hygiene if you visit a hospital or extended-care facility; both are places where the toxin-producing bacteria thrive.
* Be proactive. If you have to take an antibiotic, take a probiotic at the same time to build up the healthy bacteria in your gut. “It might help protect against C. diff.,” Dr. Boucher says.
Drug-resistant gram-negative bacteria
Last year, Mariana Bridi da Costa, a 20-year-old Brazilian model, was diagnosed with a urinary-tract infection, and within weeks a bacterial infection had spread throughout her body. In an attempt to stem the infection, her hands and feet were amputated. But complications from the infection killed her.
In 2007, Ruth Burns, 67, of Columbus, Ohio, had surgery to relieve a pinched nerve. “She was supposed to be in and out in 24 hours, but she developed pneumonia and meningitis,” her daughter, Kacia Warren, says. Although she was treated aggressively with antibiotics, Burns died 17 days after her surgery. The cause of both deaths: drug-resistant gram-negative bacteria.
“These are some of the most antibiotic-resistant bacteria out there, and they can cause all sorts of infections,” says Barbara Murray, MD, director of the division of infectious diseases at the University of Texas Medical School. Although most infections occur in hospitalized patients, such as Burns, the numbers are quietly escalating in people who are not hospitalized, elderly, or immunocompromised.
“It’s a problem that’s poised to spin out of control,” Dr. Boucher says.
The germ that killed Burns, Acinetobacter baumannii, is nicknamed “Iraqibacter” because it has caused deadly infections in soldiers wounded in Iraq. Until a few years ago, most strains of Acinetobacter could be killed with a variety of drugs; for those that couldn’t, doctors relied on broad-spectrum antibiotics known as carbapenems.
Now, more and more strains of this bug are showing resistance to carbapenems—as are other gram-negative bacteria, including Pseudomonas aeruginosa, which killed Bridi da Costa; some strains of E. coli, the bug responsible for most urinary-tract infections; and Klebsiella pneumoniae, a strain of bacteria that causes a particularly severe type of pneumonia.
“The carbapenems are the best drugs we have against these bacteria,” Dr. Boucher says. “Without them, we’re looking at something pretty scary because there’s almost nothing in the pipeline—and gram-negative bacteria can be killers. They actually chew up the antibiotics used against them.” To fight back:
* Practice infection-protection. If you’re having surgery, ask the surgeon about infection rates. “Surgeons know their rate of infection for various procedures, and you have a right to know, too,” says Betsy McCaughey, PhD, founder of the Committee to Reduce Infection Deaths.
* Stay clean at the hospital. If you’re visiting a hospital, wash yourself and your clothes right after. Don’t use bar soap in any hospital bathroom or set your purse on the floor.
* Be pushy. Ask medical personnel to wash their hands. Don’t be falsely assured by gloves, McCaughey warns. “If caregivers have pulled on gloves over dirty hands, the gloves are contaminated, too.”
By DAVID BRIGGS
Thursday, August 6, 2009
Brian Smith, Missouri’s no-nonsense wrestling coach who still mixes it up on the mats, is not someone who scares easily.
But even Smith’s wife has raised an eyebrow over his near-obsessive fight against one microscopic opponent: MRSA, the potentially fatal skin infection.
Before the Tigers’ daily wrestling practices, no space on campus is cleaner than the high and windowless 6,240-square foot room on the fourth floor of the Hearnes Center. The mats are disinfected daily and cleaned every three months with an antimicrobial concentrate. Gear and mopheads are washed after every workout at temperatures 140 degrees or higher. An oversize fan was installed to circulate the air and, before entering practice, wrestlers step onto a pad saturated with cleaning solution.
The locker room? Professionally sterilized and outfitted with the latest antibacterial soaps.
“We’re fanatical about it,” said Smith, who receives e-mail alerts on national cases of MRSA. “I probably do more than most coaches do, but we’ve had issues with skin diseases and MRSA scares me.”
It has been six years since an MRSA outbreak among the St. Louis Rams raised widespread awareness of the one-time hospital superbug’s incursion into athletic settings. But at Missouri, and schools across the country, the battle to find the most effective ways to combat the flesh-eating bacteria resistant to many antibiotics is stronger than ever.
In the breakneck world of modern college athletics, Missouri’s trainers and coaches are increasingly asking athletes to hold up and practice better hygiene habits while searching for new technology to fortify training facilities.
The wrestling and football teams, for instance, have recently begun using a product called Hibiclens. The cleanser, a long-time staple in operating rooms now commercially available, claims to actively kill 38 types of bacteria for six hours.
Smith said his program has not had a case of MRSA. Head athletic trainer Rex Sharp said there “more than likely” has been a MRSA incident at MU, but there haven’t been numerous problems.
“We’ve just managed it well,” he said.
Missouri is fighting to keep it this way. The last decade has shown the dangerous possibilities when open wounds, skin-to-skin contact and moist locker room conditions mix with a deadly — and evolving — strain of staph.
MRSA, or Methicillin-resistant Staphylococcus aureus, was once relegated mostly to hospital settings and the chronically ill with weak immune systems inundated by batches of antibiotics. Not that locker rooms had been strangers to staph. About one in three healthy people carry staph on their skin or in their noses, according to the Centers for Disease Control and Prevention, and the bacteria can lie in wait for years.
Infections, however, were easily treated. Only when a mutated variety of staph began widely penetrating the general population about a decade ago did concern emerge.
In the sporting ecosystem, MRSA steadily became a hot-button issue. Infections, which upon entering the bloodstream can attack any organ or tissue, were ending careers.
Ricky Lannetti, a 21-year-old senior wide receiver at Division III Lycoming College in Pennsylvania, died from MRSA on Dec. 6, 2003. Washington Redskins defensive lineman Brandon Noble nearly had his leg amputated after contracting MRSA in 2005. And Cleveland Browns center LeCharles Bentley, a prized free-agent acquisition in 2006, has not played since a knee injury suffered during his first training camp led to a life-threatening staph infection that ate away the tissue in his knee.
An NFL survey revealed there have been 93 cases of MRSA since 2002, including eight among five Rams players in 2003. The study reflects a broader trend. According to a 2007 study conducted by the CDC, cases of MRSA treated at hospitals have more than doubled over the past six years, from 127,000 in 1999 to 278,000 in 2005. Deaths increased from 11,000 to 17,000.
Sharp believes MU was on the vanguard of the collegiate fight against MRSA, largely because of his service on the College and University Athletic Trainers’ Committee. Before the group’s annual convention in January 2005, Sharp knew little about this lurking threat. But when the meetings highlighted MRSA and ABC’s “Primetime” news show descended on the meetings in Louisville, he knew something needed to be done.
“We had always been good with wounds and been careful,” Sharp said. “But we became a little more proactive.”
Trainers started to immediately cleanse and dress even the smallest turf burns, while the football locker room was professionally cleaned. Sharp and his staff also preached better hygiene practices: No sharing towels or razors. Wear clean clothes. And shower, shower, shower.
“I’m an old man, and back in the day when we played, we showered,” Sharp said. “Now guys, they get done with their workouts and if they have to go to class, they just jump in their cars. We want to make sure we hit them as much as we can.”
Mike Harbert, who works for a medical marketing group in St. Louis, said 25 colleges in Missouri are using Hibiclens to fight MRSA. And Hickman wrestling Coach J.D. Coffman said his team takes the threat seriously.
Besides standard measures such as disinfecting the mats each day, Coffman encourages wrestlers to cut their fingernails short — MRSA can enter the body even through a small scratch. He also doesn’t want the tough-minded to shy from medical attention.
“The biggest thing is keeping them informed,” Coffman said.
Nobody in town takes the threat more seriously than Smith. At a recent Missouri youth camp, he wondered if he put too much disinfecting concentrate on the mats. The solution was burning the wrestlers.
But he knew one thing.
“Those mats were definitely clean,” he said, laughing.
Keeping them that way means everything. Nothing can kill a camp business faster than an outbreak of skin infections. Nothing can undermine a team’s success — and recruiting — like a bacteria-polluted facility.
Nothing consumes Smith’s attention more.
“My wife says I’m crazy,” Smith said. “But, hey, I’m careful.”
Reach David Briggs at firstname.lastname@example.org.
This article was published on page B1 of the Thursday, August 6, 2009 edition of The Columbia Daily Tribune.