SPOTLIGHT ON PREVENTION

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2011-06-20T13:17:00.000-05:00

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Norway’s solution: Stop taking so many antibiotics

2010-01-17T08:12:00.002-05:00

January 2010

OSLO, Norway (AP) — At Norway’s hospitals, there is no sign of a dangerous and contagious staph infection that killed tens of thousands of patients in the most sophisticated facilities of Europe, North America and Asia last year.

The reason: Norwegians stopped taking so many drugs.

Twenty-five years ago, Norwegians were also losing their lives to this bacteria. But Norway’s public health system fought back with an aggressive program that made it the most infection-free country in the world. A key part of that program was cutting back severely on the use of antibiotics.

Now a spate of new studies from around the world proves that Norway’s model can be replicated with extraordinary success, and public health experts are saying these deaths — 19,000 in the U.S. each year alone, more than from AIDS — are unnecessary.

“It’s a very sad situation that in some places so many are dying from this, because we have shown here in Norway that methicillin-resistant Staphylococcus aureus (MRSA) can be controlled, and with not too much effort,” said Jan Hendrik-Binder, Oslo’s MRSA medical adviser. “But you have to take it seriously, you have to give it attention, and you must not give up.”

The World Health Organization says antibiotic resistance is one of the leading public health threats on the planet. A six-month investigation by the Associated Press found overuse and misuse of medicines has led to mutations in once curable diseases like tuberculosis and malaria, making them harder and in some cases impossible to treat.

Now, in Norway’s simple solution, there’s a glimmer of hope. The Scandinavian country’s model is surprisingly straightforward:

Norwegian doctors prescribe fewer antibiotics than doctors in any other country, so people do not have a chance to develop resistance to the drugs.

Patients with MRSA are isolated, and medical staff who test positive stay at home.

Doctors track each case of MRSA by its individual strain, interviewing patients about where they’ve been and who they’ve been with, testing anyone who has been in contact with them.

Norwegians are sanguine about their coughs and colds, toughing it out through low-grade infections.

“We don’t throw antibiotics at every person with a fever. We tell them to hang on, wait and see, and we give them a Tylenol to feel better,” said infectious disease specialist Dr. John Birger Haug.

Forty years ago, a new spectrum of antibiotics enchanted public health officials, quickly quelling one infection
after another. In wealthier countries that could afford them, patients and providers came to depend on antibiotics.

Trouble was, the more antibiotics are consumed, the more resistant bacteria develop.

Norway responded swiftly to initial MRSA outbreaks in the 1980s by cutting antibiotic use. Thus, while they got ahead of the infection, the rest of the world fell behind.

In Norway, MRSA has accounted for less than 1 percent of staph infections for years. That compares with 80 percent in Japan, the world leader in MRSA; 44 percent in Israel; and 38 percent in Greece.

Cases have soared in the U.S., and MRSA cost $6 billion last year. Rates have increased from 2 percent in 1974 to 63 percent in 2004.

A mysterious adversary preys on the war's wounded

2010-01-15T07:51:00.003-05:00

A strange, drug-resistant bacterium was infecting troops. Few had heard of it, and no one was sure of its origin.

Rui Chong, LA Times Staff Writer

The young Army medic would not stop bleeding. He had been put on a powerful regimen of antibiotics by doctors aboard the hospital ship Comfort in the Persian Gulf. But something was wrong. He was in shock and bleeding from small pricks where nurses had placed intravenous lines. Red, swollen tissue from an active bacterial infection was expanding around his abdominal wound. His immune system was in overdrive.

How odd, thought Dr. Kyle Petersen, an infectious disease specialist. He knew of one injured Iraqi man with similar symptoms and a few days later encountered an Iraqi teenager with gunshot wounds in the same condition.

Within a few days, blood tests confirmed that the medic and the two wounded Iraqis were all infected with an unusual bacterium, Acinetobacter baumannii. This particular strain had a deadly twist. It was resistant to a dozen antibiotics. The medic survived, but by the time Petersen connected the dots, the two Iraqi patients were dead.

It was April 2003, early in the Iraq war -- and 4 1/2 years later, scientists are still struggling to understand the medical mystery.

The three cases aboard the Comfort were the first of a stubborn outbreak that has spread to at least five other American military hospitals, including Walter Reed Army Medical Center in Washington and the Army's Landstuhl Regional Medical Center in Germany.

Hundreds of patients -- the military says it has not tabulated how many -- have been infected with the bacterium in their bloodstream, cerebrospinal fluid, bones or lungs. Many of them were troops wounded in Iraq or Afghanistan; others have been civilians infected after stays in military hospitals.

At least 27 people have died in military hospitals with Acinetobacter infections since 2003, although doctors are uncertain how many of the deaths were caused by the bacteria.

The rise in infections has been dramatic. In 2001 and 2002, Acinetobacter infections made up about 2% of admissions at the specialized burn unit at Brooke Army Medical Center in Texas. In 2003, the rate jumped to 6%, and then to 12% by 2005. Other military hospitals have reported similar increases.

In the early days of the war, there were so many infections in an intensive care unit on the Comfort that a nurse posted a sign: "Acinetobacter Alley." In two months, the bacterium was found in 44 of the 211 patients wounded in battle.

It was getting out of control. Petersen pleaded for help on an infectious disease mailing list.
"Can anyone familiar with [the] soil biology of Iraq or the drug-prescribing practices of the pre-regime medical system explain the severe drug resistance pattern we are seeing among our trauma victims?"

It was no surprise that Petersen knew little about Acinetobacter -- which has long been seen as the slacker of the bacterial world. It's called Acinetobacter, from the Latin word for "motionless," because the bacterium lacks flagella or cilia to move. "Organisms that are relatively wimpy pathogens . . . are not high on people's list," said Fred Tenover, a microbiologist at the Centers for Disease Control and Prevention in Atlanta. The bacterium is persistent, however, and requires few nutrients. It lives naturally in soil and can survive for days on dry surfaces, such as doorknobs or hospital equipment. Acinetobacter usually threatens only the weakest of the weak, those whose immune systems are compromised because of old age, trauma or disease. Even then, garden-variety Acinetobacter is easily controlled with common antibiotics.

But the situation started to change about two decades ago.

Acinetobacter followed an evolutionary path trod by numerous other bacteria since World War II, when antibiotics were introduced widely. Bacteria not killed by an antibiotic would pass on their resistance to later generations. The process was quickened by the often profligate use of the drugs, which allowed more bacteria to develop resistance.

Today a host of diseases, such as tuberculosis and gonorrhea, have highly antibiotic-resistant strains.

"If we use antibiotics to kill off everything else, what is left standing is very, very drug resistant," said CDC epidemiologist Arjun Srinivasan. "Acinetobacter is one of those left standing."

Tenover first noticed a strain of Acinetobacter with some drug resistance in the mid-1980s while working at a veterans hospital in Seattle. Several years later, he met with Ghassan Matar, a visiting Lebanese scientist at the CDC, whose samples of Acinetobacter baumannii from patients in a Beirut hospital raised another red flag.

The infections were a legacy of years of fighting. Positive tests for Acinetobacter more than tripled at the hospital from 1983 to 1984 and stayed high for years after. The samples Matar brought were already resistant to two important classes of antibiotics.

In the following years, civilian hospitals in the U.S. and around the world reported sporadic outbreaks of drug-resistant Acinetobacter.

"You have an organism of relatively low virulence that became more important because you've run out of drugs to treat it with," Tenover said.

The question that Petersen struggled with was how this bug had found its way into modern military hospitals.

Doctors could beat back an infection with the strongest antibiotics, and hospitals could try to scrub away the bacteria. But those weren't solutions. They had to find the source of the contamination.

A Canadian soil scientist who worked in Iraq in the 1970s described high rates of antibiotic-resistant Staphylococcus bacteria in dirt samples.

The scientist surmised they were caused by the erratic distribution of antibiotics in Iraq. A shipment of drugs would arrive and doctors would use them until they ran out. Then they would prescribe whatever other antibiotic was sent next, the scientist said.

A microbiologist wrote to Petersen about Australian patients injured in the 2002 nightclub bombings in Bali, Indonesia, who returned home with astronomically high levels of very drug-resistant bacteria, including Acinetobacter.

"It gave me an idea that maybe it was something related to the process of aeromedical evacuation or the injury process," said Petersen, now 39.

After Comfort reported its first Acinetobacter cases, infections sprang up in military hospitals in the Middle East, Germany and the U.S. The facilities took the cases seriously.

The night Marine Maj. K.C. Schuring arrived at Andrews Air Force Base in Maryland, a doctor told him point-blank that if his fever didn't subside within three days, his left leg would probably have to be amputated. Schuring, barely conscious and lying on a gurney, heard the doctor tell him that the infection could spread: "This can kill you." He was taken to the National Naval Medical Center in Bethesda, Md., and immediately isolated. He heard the word Acinetobacter for the first time.

Schuring, who had been shot in both legs in Iraq, could take bad news, but this worried him. "I was happy they could treat it, though they said they couldn't necessarily cure it," he said. Whenever he left the room, he wore a yellow gown to alert others of his infection. Everyone who visited him donned yellow gowns and gloves.

In 2003, Dr. Clint Murray, then a 33-year-old Army major at a frontline aid station in Iraq, began to dig for answers. He started at the beginning.

Though some wounded soldiers were sent to aid stations such as Murray's, most were airlifted directly to more advanced facilities like the Combat Support Hospital in Baghdad.

Murray, an infectious disease specialist, asked a critical care doctor there to take samples from soldiers wounded by guns, improvised explosive devices, mortars or other weapons. As doctors scrambled to stabilize patients, the wounds were swabbed to collect bacteria. Most of the samples were taken within 20 to 40 minutes of the soldiers' injuries.

But out of the samples taken from 49 patients, the doctors found no Acinetobacter, though there were plenty of other bacteria, such as Staphylococcus.

That still left the possibility that dirt and dust from beyond the battlefield had blown into a wound.

Murray joined a group, including Petersen and Srinivasan, that focused on dirt around field hospitals in Iraq and Kuwait -- the next step in the medical evacuation chain that started at frontline aid stations and ended at hospitals in the U.S.

The group gathered 18 dirt samples around seven field hospitals, and also looked at 31 archived soil samples from around the combat zone. Only one of the soil samples -- taken from outside a field hospital mess hall -- turned up positive. The group compared it with strains collected from casualties at the field hospital in Baghdad and larger hospitals including Landstuhl in Germany, and found they were not related. Dirt, it seemed, was not the culprit.

In late 2004, Murray returned to Brooke Army Medical Center. He wondered whether soldiers were carrying the bacterium on their skin and infecting themselves when wounded. He set to work on a study swabbing the nostrils of 293 soldiers at Ft. Sam Houston, Texas, who had never been to Iraq or Afghanistan. None of the soldiers tested positive for Acinetobacter, Murray and colleagues reported in the journal Infection Control and Hospital Epidemiology in 2006. They seemed to be running up against a wall.

As the search continued, military doctors struggled to find an effective strategy to combat the bug. The treatment could be difficult.

Schuring said doctors experimented with different drugs. Schuring's situation was complicated by his allergy to penicillin. At one point, he was taking four antibiotics. The infection had already taken away his appetite and made him queasy. It took doctors about two weeks to narrow down his treatment to a relatively new intravenous antibiotic, tigecycline.

Doctors operated on him nearly every other day to clean out dead tissue in his legs. When the infection began to settle down, doctors installed a 21-inch stainless steel plate along his left thigh. The surgery made Schuring dizzy, but the doctors didn't want to give him a blood transfusion for fear of inciting a new infection. The treatment, Schuring said, was like going "through hell."

Evidence was building that the cause of the infections was something in the military trauma system. The hospital-based transmission made sense since the bacterium had already taken up residence in civilian hospitals.

Though preliminary typing found no link between the U.S. civilian strains and the military casualty strains, the conditions in military hospitals were just right for the bacterium, said Srinivasan, the CDC epidemiologist.

In the hectic environment of field hospitals, it was also difficult to impose strict infection-control measures, such as thorough cleaning of hands and equipment after each patient, Murray said.

The field hospitals had become the center of a perfect storm of trauma -- battle- hardened bugs preying on the weakest patients at their most vulnerable moments.

"Soldiers now survive injuries they wouldn't have survived before," Srinivasan said.. "That challenge creates soldiers who are sick, who are living in healthcare facilities for a long time and are more susceptible to hospital-associated infections."

It took about three years for Murray and his colleagues to look through the entire chain of trauma, from the battlefields to the field hospitals to the tertiary care center in Landstuhl and finally to the military hospitals in the U.S.

The results of their labor, published this May in the journal Clinical Infectious Diseases, showed that all seven field hospitals tested in Iraq and Kuwait had Acinetobacter in patient care areas.

"We can't be 100% sure, but the data supports that patients are probably getting exposed to Acinetobacter in field hospitals in Iraq," Murray said. How the bacteria became entrenched in the field hospitals is still unknown. But in many ways, it is irrelevant. It is there, and, as civilian hospitals have also found, it is not going away easily. The military strain of the bacterium has caused at least one civilian death. Acinetobacter was growing in the lungs and bloodstream of a 35-year-old man whose immune system was suppressed because he had a kidney transplant at Walter Reed in 2005. There were no signs of infection until the man came down with acute shortness of breath one evening and died soon after.

For the most part, doctors have figured out the most effective drugs against the bacterium -- an antibiotic called imipenem and an older class of drugs known as polymyxins. The drugs have made the infections fairly manageable. Through stricter controls, such as monitored hand-washing, infection rates have shown signs of dropping in some hospitals.

Petersen, who worked at National Naval Medical Center in Bethesda after the Comfort's mission ended, treated just one or two Acinetobacter infections in July, down from the highs of 15 to 20 a month in 2004 and 2005. This year, there have been only a few cases each month, according to hospital figures.

But Murray now wonders whether Acinetobacter was really the culprit after all. He and others looked at patients with the worst outcomes at Brooke's burn unit and found that Acinetobacter was associated with larger burns but was not causing more deaths by itself.

A study of 35 returning soldiers with the most extreme kinds of shin bone fractures found that Acinetobacter was the most common bacterium around fracture sites when the patients arrived, but it was easy to clear. Those who later suffered serious complications, including amputations, tended to be infected with other serious bacteria, such as Staphylococcus and Pseudomonas aeruginosa. Acinetobacter, it turns out, may only be a marker of vulnerability. "It is not the worst bug," Murray said.

The battle between bacteria and humans never ends. Recently, scientists have noted signs that Acinetobacter strains are growing resistant to polymyxins and imipenem, said Tenover, the CDC microbiologist.

There are, however, small victories for humans.

Just before Christmas, after a month of treatment, Schuring returned to his home in Farmington Hills, Mich. Schuring's wife, Lynn, was nervous about this strange bug her husband had brought back from the war. What if they kissed? What if her husband put down a drink and one of their young children took a sip? Would her parents, who are in their 70s, be at risk if they visited? Doctors assured her that this bug was no danger to the strong. So far, no one in the family has gotten sick.

But Schuring's doctor warned them that they must keep an eye out for any sign of the bacteria, which could lie dormant for years.

Schuring, now a 38-year-old lieutenant colonel, has continued to improve and hobbles around on his own two legs. He has one last surgery at Bethesda in January and then, perhaps, he will run marathons again.

"You know, this is a long process for these guys and their families," Lynn Schuring said. "I think we just take it one step at a time. . . . "Everything we've been through has taught me to take it one step at a time."

You've heard of MRSA, but what about Acinetobacter?

2010-01-15T07:50:00.000-05:00

LA Times
December 24, 2009

In the antibiotic-resistance world, MRSA gets most of the press. Sometimes, C. difficile works its way into a headline or two. But here's a reminder that other bacteria are growing stronger as well.

A study published online Wednesday in the journal Infection Control and Hospital Epidemiology found that Acinetobacter is building up resistance to the antibiotic imipenem, often used as a last resort to combat blood infections and pneumonia in hospitalized patients. The bacterium is usually only a problem in intensive-care units -- but has also infected troops wounded in Iraq and Afghanistan.

The research was supported by Extending the Cure, which is trying to call attention to antibiotic resistance or, more specifically, "extend antibiotic effectiveness."

Here's the research brief. And more on Acinetobacter from the CDC. Plus two earlier Los Angeles Times stories on the bacterium:

A mysterious adversary preys on the war's wounded: "A strange, drug-resistant bacterium was infecting troops. Few had heard of it, and no one was sure of its origin."

Deadly bacteria defy drugs, alarming doctors: "A new category of bugs becomes more resistant to treatment, and their toll -- which already includes a Brazilian beauty queen -- is expected to rise."

Think of it as an incentive for staying well. And using antibiotics wisely.

Patients Carry MRSA Between Hospitals

2010-01-15T07:45:00.000-05:00

1/13/10
Source: CDC/Janice Haney Carr

Emerging Health Threats: Disinfecting hospital patients can stop further spread, but community strains could slip under the radar.

By tracing the strains of multidrug-resistant Staphylococcus aureus (MRSA) that turned up in 450 hospitals across Europe over six months, scientists have discovered that patients transport the bug between healthcare centres. The research, published this week in PLoS Medicine, suggests that identifying and treating patients harbouring the ‘superbug’ could help to control infection rates.

“[C]ontrol efforts aimed at interrupting the spread [of MRSA] within and between health care institutions may not only be feasible but ultimately successful and should therefore be strongly encouraged,” write Hajo Grundmann, from the Dutch National Institute for Public Health and the Environment in Bilthoven, and colleagues.

This type of control strategy is likely to be effective, say experts. The UK already has policies in place which were designed to tackle spread of the bacteria between patients. But some scientists fear the picture is more complicated, suggesting that strains of MRSA emerging in the community may alter the dynamics of the disease in the future.

For their study, Grundmann and colleagues recruited 450 hospitals in 26 European countries and asked them to collect bacterial samples from patients with invasive S. aureus infections picked up while in hospital. Regional laboratories analysed more than 3000 isolates of the bacteria, and assessed how they related to each other by looking at one region of a specific gene, known as spa. The researchers then mapped these results geographically to get a better idea of the genetically diversity of MRSA strains on the continent.

Different spa MRSA types appeared in different countries, and the dominant ones clustered together in distinct geographical areas. The clustering suggests that the bacteria are spreading within networks of healthcare facilities, say the authors, and this shows that MRSA is spread by patients who are repeatedly admitted to different hospitals.

According to Barry Farr, from the University of Virginia Health System, USA, many other studies have reported the spread of MRSA clones within an individual hospital or a group of local healthcare facilities. This research helps to confirm that specific MRSA strains spread through healthcare facilities and suggests that better infection control in these locations could be “very beneficial”, he says.

“More than 120 epidemiological studies have reported that screening to detect MRSA colonisation coupled with contact isolation can control healthcare related spread,” adds Farr.

Screening patients to stop transmission

Despite these findings, there is no policy in place for MRSA screening in US hospitals. UK health authorities have taken a different tack. In England, since early 2009 patients admitted to hospital for non-emergency surgery have been screened for MRSA, says Richard James, from the University of Nottingham. By 2011, all patients — including those admitted for medical emergencies — will be screened, he adds.

This policy can potentially break the chain of MRSA transmission between healthcare facilities, says James. But for now, the tests used to identify MRSA in hospital patients take three days to complete. By the time healthcare staff receive the results any infected patients admitted for a short period may have left the hospital, and could have potentially spread the bug to others.

There are quicker testing alternatives, but these cost more, according to James. Some might say the testing is done simply to tick a box, he adds.

Nevertheless, screening policies still allow health authorities to intervene. The spread of MRSA could be reduced if patients released from hospital and known to be carrying the bug are given follow-up treatment with antiseptic shower gels and nasal creams to eliminate the bacteria. “If we use this information it will help us stay ahead of the game,” says James.

Community strains in the mix

Strains of the bacteria arising outside hospitals, known as community-acquired MRSA, are becoming an increasing problem in the UK and elsewhere in the world. In the USA, more than half of all MRSA infections are now picked up in the community. Scientists predict that once inside hospitals, community strains will take over from their healthcare counterparts as a source of infection.

James says that MRSA prevention policies focused on hospitals could miss this growing problem. “It would be a great surprise if community-acquired MRSA rates in England don’t follow what is seen in the USA,” says James. Health authorities in the UK are not actively looking for community MRSA.

Unlike strains circulating in hospitals, which typically affect vulnerable and older patients, community strains generally affect young, healthy people, causing skin and soft tissue infections. Most patients are treated outside the hospital by general practitioners, but studies in the USA have suggested these strains of the bacteria can still find their way into healthcare facilities.

Michael Millar, from Barts and The London National Health Service Trust, believes community MRSA strains can play a role in altering infection dynamics. “The past does not allow us to predict the future,” he says.

The paper gives us a snapshot in time of the MRSA situation in Europe, explains Millar, where so far MRSA has been mainly a hospital problem. “Unfortunately this data does not tell us what will happen next.”

Nose treatment cuts hospital-acquired infections

2010-01-07T08:39:00.000-05:00

Gene Emery
Wed Jan 6, 2010

BOSTON (Reuters) - If you're checking into the hospital for surgery, doctors may soon be swabbing your nose in an effort to prevent an infection from appearing after your operation.

Researchers in the Netherlands said on Wednesday they were able to cut the risk of a common bacterium by nearly 60 percent by first looking for signs of it in the nose and then treating it with an antibiotic nasal gel and full body wash.

The treatment combination also shaved two days off a typical 14-day stay in the hospital.

Hospital-acquired infections are a major problem in medicine, so doctors are always looking for the best way to reduce the risk.

About 27 million surgeries are done just in the United States each year, and in as many as half a million cases, infections occur at the site of surgery.

Up to 30 percent of those infections are caused by strains of the bacterium Staphylococcus aureus, which otherwise benignly resides in the nose and on the skin.

The new study, published in the New England Journal of Medicine, used a rapid test to identify which patients, most of whom were scheduled to undergo surgery, had the bacteria in at least one nostril.

The 504 patients treated with the antibiotic nose gel mupirocin, also known as Bactroban, and washed with chlorhexidine, a common ingredient in mouthwash, developed an S. aureus infection 3.4 percent of the time. The rate for 413 volunteers given placebo treatment was 7.7 percent.

The research team, led by Dr. Lonneke Bode of Erasmus University Medical Center in Rotterdam, estimated that 250 patients would need to be screened to prevent one infection.

"Preventing one infection will pay for thousands of these screenings," Dr. Henri Verbrugh of Erasmus, a coauthor of the study, said in a telephone interview.

Infections are also a problem when doctors put tubes into the body. Although his team did not evaluate enough patients to study the problem directly, "We feel this technology is capable of preventing those types of infections as well," Verbrugh said.

A second infection study, also reported in the journal, found that a chlorhexidine-alcohol combination produced 41 percent fewer surgical-site infections as the commonly used mixture of povidone and iodine, which gives a yellow-orange tinge to the skin.

In a commentary, Dr. Richard Wenzel of the Virginia Commonwealth University in Richmond said the chlorhexidine-alcohol mixture should replace the older disinfectant when scrubbing people for surgery, and the nasal disinfection technique should primarily be used for people undergoing cardiac surgery, receiving an implant, or whose immune system is likely to be affected.

HAI-Related Litigation: What Infection Preventionists Need to Know

2010-01-07T08:35:00.001-05:00

Kelly M. Pyrek, Infection Control Today
12/18/2009

Litigation related to healthcare-acquired infections (HAIs) is a trend that should be on every infection preventionist (IP)’s radar for the coming decade, especially in light of the fact that the frequency of hospital professional liability claims is increasing. According to a new study released by Aon Corporation in conjunction with the American Society for Healthcare Risk Management, these claims are on the rise and are expected to continue increasing at a 1 percent annual rate.

The study, the 10th annual Hospital Professional Liability and Physician Liability Benchmark Analysis, examines trends in frequency, severity and overall loss costs related to hospital and physician professional liability; 100-plus healthcare organizations representing more than 1,500 facilities ranging from small community hospitals to large multi-state healthcare systems provided loss and exposure data for the study. The study attributes the rise in claims to the downturn in the U.S. economy, changes to the Centers for Medicare and Medicaid Services (CMS) reimbursement rules regarding so called “never-events” and changes in public sympathy toward healthcare providers.

“Worsening economic conditions in 2008 may have influenced individuals to assert claims against hospital systems,” says Erik Johnson, healthcare practice leader for Aon’s Actuarial and Analytics Practice and author of the analysis. “From 2003 through 2007 public attention was directed on tort reform activity and prohibitive medical malpractice costs for physicians. This coincided with significant reductions in professional liability claims. As public attention shifted to other subjects, the momentum of the reductions dissipated. Recently, the public focus has evolved to discussions regarding waste, inefficiency and defensive medicine. It remains to be seen how this will influence the frequency of professional liability claims.”

The study also found that 1 out of every 4 claims and 24 percent of hospital professional liability costs are associated with hospital-acquired conditions such as infections and injuries, medication errors, retained objects during surgery and pressure ulcers. Juries may be starting to take notice of this trend; Hsieh (2009) reports that recently, a jury in Suffolk County, New York awarded $13.5 million to a 40-year-old woman who died of a flesh-eating bacteria that she contracted during chemotherapy treatment at Dana-Farber Cancer Institute. Hsieh (2009) also quotes Gloria Seidule, an attorney at Seidule & Webber, as noting, “Anyone providing healthcare to an individual is no longer going to have immunity for transmitting infections.” Seidule is also litigating a hospital-acquired infection lawsuit involving methicillin-resistant Staphylococcus aureus (MRSA). Hsieh (2009) also reports that Mary Coffey, an attorney at Coffey Nichols, recently won a $2.58 million verdict for a 69-year-old man who contracted MRSA through an IV that was administered in the ambulance following a heart attack. When doctors inserted a pacemaker, the infection spread, ultimately resulting in the loss of a kidney and a leg.

During the “Changing Legal and Regulatory Landscape” conference sponsored by the Association for Professionals in Infection Control and Epidemiology (APIC) held in November, a panel of experts addressed the legal issues surrounding HAIs. Panelist Russell Nassof, director of strategic initiatives at TRC, says, “Changes in the regulatory environment, reimbursement practices and legal standards along with drastic changes in healthcare itself are creating a potential ‘perfect storm’ of liability and increase risk for healthcare-associated infections in healthcare facilities today.”

Nassof notes that events that were previously thought of as risks are now considered to be preventable adverse events, and that IPs will play an even bigger role in protecting their hospitals against liability in the future. At issue is the increased transparency created within the healthcare system in general, which also triggered public reporting of infection rates data. Currently, just a handful of states do not have or have not considered adopting legislation mandating public reporting, and a federal bill related to MRSA is under consideration. According to Nassof, state hospital associations have opposed these reporting requirements due to fear of increased exposure to liability, issues related to reporting logistics, efficiency issues such as diverting resources from patient care and/or prevention efforts; and conflicting reporting requirements such as infection site and organism.

There are unanswered legal questions that are in this complicated mix, according to Nassof, and they include whether or not prescreening for infections such as those caused by MRSA is a Pandora’s box or a solid legal defense. Another wrinkle is the fact that CMS is currently not paying the differential related to hospital-acquired infections and conditions (as of Oct. 1, 2008, Medicare has stopped reimbursing for certain types of hospital-acquired infections; see related article on page 18), and Nassof says the door is open for CMS to cease payment completely for certain infections and conditions, and requiring hospitals to conduct root cause analyses or to apologize to patients and their families. “It’s a tricky legal situation,” Nassof says. “Can a facility apologize and still defend a claim before a jury?”

While the burden has always been on the plaintiff, Nassof says a recent case in the U.S. had the burden of proof shifting to the hospital, which had to prove that the patient did not get the infection at its facility. “There is the perception that there is potential negligence on the part of hospitals for not protecting patients. A strict liability standard has not been applied to HAIs... yet,” Nassof says. “Hospitals must develop legally defensible protocols and best practices, train staff to follow them, and document that they are being done.” Nassof advises IPs to don their legal hats because infection rate data that IPs collect could be damaging to the hospital and/or be used against it in a lawsuit.

APIC conference panelist Emily Rhinehart, RN, MPH, CIC, CPHQ, vice president of healthcare risk consulting for Chartis Insurance, says that at the present, HAI-related lawsuits are “few and far between but the legal landscape is changing.” She recommends that hospitals stick with evidence-based practices and carefully document in the patient’s medical record any departures from these protocols. “You can’t make it up when you are defending a case, so documentation is key,” Rhinehart says. She also recommends that expectations for patient care be made unambiguous, that compliance is ensured through the use of checklists and other tools, and that the entire process is monitored and documented. A good example is hand hygiene, Rhinehart says. “There is a strong public perception of the lack of hand hygiene in hospitals. The plaintiff could be perplexed by it and pursue a case.”

To that end, panelist Nicholas McConnell, director of the law firm Jackson & Campbell PC, added that most healthcare-related lawsuits are not about the quality of care but rather the atmosphere at the healthcare institution, and how healthcare providers present the clinical actions that were taken. “The hospital must explain why a particular outcome was allowed to happen, and so the imperative here is the standard of care, which can be found in the hospital’s own policies and procedures,” McConnell says. “At the heart of the case is did anyone depart from that standard of care? The proof is simple if the compliance is clearly lacking. And did that departure cause harm to the patient?” McConnell explains that while the law admires excellence, it does not demand it; however, a departure from the standard of care is a significant challenge to defend.

Antibiotic Overuse Threatens Modern Medicine: Experts

2009-12-23T06:59:00.001-05:00

Kate Kelland
LONDON
Tue Nov 10, 2009

LONDON (Reuters) - Overuse of antibiotics in Europe is building widespread resistance and threatening to halt vital medical treatments such as hip replacements, intensive care for premature babies and cancer therapies, health experts say.

Dominique Monnet of the European Center for Disease Prevention and Control's (ECDC) scientific advice unit said the "whole span of modern medicine" is under threat because bugs are become resistant to antibiotics, rendering the drugs useless.

"If this wave of antibiotic resistance gets over us, we will not be able to do organ transplants, hip replacements, cancer chemotherapy, intensive care and neonatal care for premature babies," he told reporters at a briefing.

Antibiotics are needed in all these treatments to prevent bacterial infection. But drug-resistant bacteria are a growing problem in hospitals worldwide, marked by the rise of superbugs such as methicillin-resistant Staphyloccus aureus (MRSA).

Such infections kill about 25,000 people a year in Europe and around 19,000 in the United States

On top of the risks to future treatments, Monnet said the costs of antibiotic resistance were already hurting -- and may hit healthcare budgets across the European Union yet harder if the problem is not addressed.

The six most common multi-drug-resistant bacteria -- often referred to as superbugs -- cause around 400,000 infections a year in Europe, killing around 25,000 people and using 2.5 million hospital days a year.

The ECDC, which monitors and advises on disease in EU, calculates that with a hospital day costing an average of 366 euros ($548), superbug infections are already sucking up 900 million euros a year in extra hospital costs, and a further 600 million euros a year in lost productivity.

"Across the European Union the number of patients infected by resistant bacteria is increasing and that antibiotic resistance is a major threat to public health," the ECDC said.

Britain's government was criticized by a parliamentary committee on Tuesday for failing to tackle the majority of hospital-acquired infections by narrowing its focus to two high profile ones -- MRSA and Clostridium difficult.

The ECDC conducted an "antibiotic awareness" campaign in November to urge doctors to stop overprescribing antibiotics.

Patients demanding antibiotics for viral infections often are not aware that they will not work, it said, but doctors are and should stop giving in to pressure.

Sarah Earnshaw of the ECDC's communications unit, pointed to a 2002 survey that showed 60 percent of patients do not know that antibiotics do not work against viruses like flu and colds.

"Patients often demand antibiotics," she said. And doctors often think, she said, that giving in is a quicker way to deal with a demanding patients than persuading them otherwise.

(Editing by Louise Ireland)

Antibiotic Overuse? Not in Norway

2009-12-23T06:54:00.003-05:00

By MARTHA MENDOZA and MARGIE MASON
Associated Press Writers
Excerpt

OSLO, Norway (AP) -- Aker University Hospital is a dingy place to heal. The floors are streaked and scratched. A light layer of dust coats the blood pressure monitors. A faint stench of urine and bleach wafts from a pile of soiled bedsheets dropped in a corner.

Look closer, however, at a microscopic level, and this place is pristine. There is no sign of a dangerous and contagious staph infection that killed tens of thousands of patients in the most sophisticated hospitals of Europe, North America and Asia this year, soaring virtually unchecked.

The reason: Norwegians stopped taking so many drugs.

Twenty-five years ago, Norwegians were also losing their lives to this bacteria. But Norway's public health system fought back with an aggressive program that made it the most infection-free country in the world. A key part of that program was cutting back severely on the use of antibiotics.

Now a spate of new studies from around the world prove that Norway's model can be replicated with extraordinary success, and public health experts are saying these deaths -- 19,000 in the U.S. each year alone, more than from AIDS -- are unnecessary.

"It's a very sad situation that in some places so many are dying from this, because we have shown here in Norway that Methicillin-resistant Staphylococcus aureus (MRSA) can be controlled, and with not too much effort," said Jan Hendrik-Binder, Oslo's MRSA medical adviser. "But you have to take it seriously, you have to give it attention, and you must not give up."

The World Health Organization says antibiotic resistance is one of the leading public health threats on the planet. A six-month investigation by The Associated Press found overuse and misuse of medicines has led to mutations in once curable diseases like tuberculosis and malaria, making them harder and in some cases impossible to treat.

Now, in Norway's simple solution, there's a glimmer of hope.

Dr. John Birger Haug shuffles down Aker's scuffed corridors, patting the pocket of his baggy white scrubs. "My bible," the infectious disease specialist says, pulling out a little red Antibiotic Guide that details this country's impressive MRSA solution.

It's what's missing from this book -- an array of antibiotics -- that makes it so remarkable.

"There are times I must show these golden rules to our doctors and tell them they cannot prescribe something, but our patients do not suffer more and our nation, as a result, is mostly infection free," he says.

Norway's model is surprisingly straightforward.

-- Norwegian doctors prescribe fewer antibiotics than any other country, so people do not have a chance to develop resistance to them.

-- Patients with MRSA are isolated and medical staff who test positive stay at home.

-- Doctors track each case of MRSA by its individual strain, interviewing patients about where they've been and who they've been with, testing anyone who has been in contact with them.

Haug unlocks the dispensary, a small room lined with boxes of pills, bottles of syrups and tubes of ointment. What's here? Medicines considered obsolete in many developed countries. What's not? Some of the newest, most expensive antibiotics, which aren't even registered for use in Norway, "because if we have them here, doctors will use them," he says.

He points to an antibiotic. "If I treated someone with an infection in Spain with this penicillin I would probably be thrown in jail," he says, "and rightly so because it's useless there."

Norwegians are sanguine about their coughs and colds, toughing it out through low-grade infections.

"We don't throw antibiotics at every person with a fever. We tell them to hang on, wait and see, and we give them a Tylenol to feel better," says Haug.

Convenience stores in downtown Oslo are stocked with an amazing and colorful array -- 42 different brands at one downtown 7-Eleven -- of soothing, but non-medicated, lozenges, sprays and tablets. All workers are paid on days they, or their children, stay home sick. And drug makers aren't allowed to advertise, reducing patient demands for prescription drugs.

In fact, most marketing here sends the opposite message: "Penicillin is not a cough medicine," says the tissue packet on the desk of Norway's MRSA control director, Dr. Petter Elstrom.

He recognizes his country is "unique in the world and best in the world" when it comes to MRSA. Less than 1 percent of health care providers are positive carriers of MRSA staph.

But Elstrom worries about the bacteria slipping in through other countries. Last year almost every diagnosed case in Norway came from someone who had been abroad.

"So far we've managed to contain it, but if we lose this, it will be a huge problem," he said. "To be very depressing about it, we might in some years be in a situation where MRSA is so endemic that we have to stop doing advanced surgeries, things like organ transplants, if we can't prevent infections. In the worst case scenario we are back to 1913, before we had antibiotics."

Forty years ago, a new spectrum of antibiotics enchanted public health officials, quickly quelling one infection after another. In wealthier countries that could afford them, patients and providers came to depend on antibiotics. Trouble was, the more antibiotics are consumed, the more resistant bacteria develop.

Norway responded swiftly to initial MRSA outbreaks in the 1980s by cutting antibiotic use. Thus while they got ahead of the infection, the rest of the world fell behind.

In Norway, MRSA has accounted for less than 1 percent of staph infections for years. That compares to 80 percent in Japan, the world leader in MRSA; 44 percent in Israel; and 38 percent in Greece.

In the U.S., cases have soared and MRSA cost $6 billion last year. Rates have gone up from 2 percent in 1974 to 63 percent in 2004. And in the United Kingdom, they rose from about 2 percent in the early 1990s to about 45 percent, although an aggressive control program is now starting to work.

About 1 percent of people in developed countries carry MRSA on their skin. Usually harmless, the bacteria can be deadly when they enter a body, often through a scratch. MRSA spreads rapidly in hospitals where sick people are more vulnerable, but there have been outbreaks in prisons, gyms, even on beaches. When dormant, the bacteria are easily detected by a quick nasal swab and destroyed by antibiotics.

Dr. John Jernigan at the U.S. Centers for Disease Control and Prevention said they incorporate some of Norway's solutions in varying degrees, and his agency "requires hospitals to move the needle, to show improvement, and if they don't show improvement they need to do more."

And if they don't?

"Nobody is accountable to our recommendations," he said, "but I assume hospitals and institutions are interested in doing the right thing."

Dr. Barry Farr, a retired epidemiologist who watched a successful MRSA control program launched 30 years ago at the University of Virginia's hospitals, blamed the CDC for clinging to past beliefs that hand washing is the best way to stop the spread of infections like MRSA. He says it's time to add screening and isolation methods to their controls.

The CDC needs to "eat a little crow and say, 'Yeah, it does work,"' he said. "There's example after example. We don't need another study. We need somebody to just do the right thing."

But can Norway's program really work elsewhere?

The answer lies in the busy laboratory of an aging little public hospital about 100 miles outside of London. It's here that microbiologist Dr. Lynne Liebowitz got tired of seeing the stunningly low Nordic MRSA rates while facing her own burgeoning cases.

So she turned Queen Elizabeth Hospital in Kings Lynn into a petri dish, asking doctors to almost completely stop using two antibiotics known for provoking MRSA infections.

One month later, the results were in: MRSA rates were tumbling. And they've continued to plummet. Five years ago, the hospital had 47 MRSA bloodstream infections. This year they've had one.

"I was shocked, shocked," says Liebowitz, bouncing onto her toes and grinning as colleagues nearby drip blood onto slides and peer through microscopes in the hospital laboratory.

When word spread of her success, Liebowitz's phone began to ring. So far she has replicated her experiment at four other hospitals, all with the same dramatic results.

"It's really very upsetting that some patients are dying from infections which could be prevented," she says. "It's wrong."

Around the world, various medical providers have also successfully adapted Norway's program with encouraging results. A medical center in Billings, Mont., cut MRSA infections by 89 percent by increasing screening, isolating patients and making all staff -- not just doctors -- responsible for increasing hygiene.

In Japan, with its cutting-edge technology and modern hospitals, about 17,000 people die from MRSA every year.

Dr. Satoshi Hori, chief infection control doctor at Juntendo University Hospital in Tokyo, says doctors overprescribe antibiotics because they are given financial incentives to push drugs on patients.

Hori now limits antibiotics only to patients who really need them and screens and isolates high-risk patients. So far his hospital has cut the number of MRSA cases by two-thirds.

In 2001, the CDC approached a Veterans Affairs hospital in Pittsburgh about conducting a small test program. It started in one unit, and within four years, the entire hospital was screening everyone who came through the door for MRSA. The result: an 80 percent decrease in MRSA infections. The program has now been expanded to all 153 VA hospitals, resulting in a 50 percent drop in MRSA bloodstream infections, said Dr. Robert Muder, chief of infectious diseases at the VA Pittsburgh Healthcare System.

"It's kind of a no-brainer," he said. "You save people pain, you save people the work of taking care of them, you save money, you save lives and you can export what you learn to other hospital-acquired infections."

Pittsburgh's program has prompted all other major hospital-acquired infections to plummet as well, saving roughly $1 million a year.

"So, how do you pay for it?" Muder asked. "Well, we just don't pay for MRSA infections, that's all."

Martha Mendoza is an AP national writer who reported from Norway and England. Margie Mason is an AP medical writer based in Vietnam, who reported while on a fellowship from The Nieman Foundation at Harvard University.

MRSA Leads to Worse Outcomes, Staggering Expenses for Surgical Patients

2009-12-20T10:31:00.001-05:00

ScienceDaily (Dec. 17, 2009)

Post-surgical infections significantly increase the chance of hospital readmission and death and cost as much as $60,000 per patient, according to Duke University Medical Center researchers who conducted the largest study of its kind to date.

"We conducted a multi-center study of multiple surgical procedure types among 659 patients to determine clinical and financial outcomes of surgical site infections that are directly attributable to MRSA (methicillin-resistant Stapylococcus aureus)," said Deverick J. Anderson, M.D., MPH, an infectious diseases specialist at Duke University Medical Center and lead author of the study. "We found the impact of methicillin-resistance on surgical patients is substantial and that preventing a single case of surgical site infection due to MRSA can potentially save hospitals as much as $60,000."

Previously published research on surgical site infections provided conflicting conclusions. For the Duke study, researchers looked at the 90-day postoperative period for patients over a five-year period in one tertiary care center and six community hospitals in the Duke Infection Control Outreach Network (DICON). Created in 1997, DICON assists community hospitals in improving quality of care and enhancing patient safety, while minimizing the costs associated with non-evidence based approaches to infection control.

The researchers compared hospital readmission, mortality, length of hospital stay and hospital charges for patients in three groups. Some had surgical site infections due to MRSA, some were infected with methicillin-susceptible Staphylococcus aureus (MSSA), and some were uninfected. The study evaluated deep-incision and organ/space infections, which are more severe than superficial infections at the site of incision. The findings are published in PLoS ONE.

"We found that patients with surgical site infections due to MRSA were 35 times more likely to be readmitted and seven times more likely to die within 90 days compared to uninfected surgical patients," Anderson said. "These patients also required more than three weeks of additional hospitalization and accrued more than $60,000 in additional charges."

The researchers found most of the outcomes for MRSA compared to MSSA were worse, as anticipated, however one finding was surprising, according to Anderson. "Our findings show that methicillin-resistance contributed to longer hospital stays and increased hospital charges but did not increase the risk of mortality," he said. The data shows that patients with surgical site infections due to MRSA compared to MSSA on average required six more days of hospitalization and incurred $24,000 in additional charges.

"For the seven hospitals we looked at, the total estimated cost resulting from surgical site infections due to MRSA was more than $19 million," Anderson said. "That's a staggering amount, which demonstrates an area of cost-saving potential for these institutions and other community hospitals."

The Duke study provides the first cost impact data tied to post-surgical MRSA infection in a large group of hospitals. "Given our estimated cost of one MRSA case, we can conclude that a $60,000 intervention to prevent even one of these infections would be cost-effective for an institution," Anderson said. "With this new financial data, greater emphasis should be placed on an effort to design and evaluate specific preventative interventions."

Other researchers involved in the study include Luke F. Chen, Kenneth E. Schmader, Yong Choi and Daniel J. Sexton of Duke University Medical Center; and Keith S. Kaye, formerly of Duke University Medical Center now at Detroit Medical Center.

MRSA Infections Nearly Doubled Over Last 10 Years: Study

2009-12-20T10:30:00.000-05:00

Published: November 27th, 2009

U.S. researchers indicate that there has been a 90% increase in antibiotic-resistant “superbug” infections since 1999, as strains circulating both in hospitals and the community continue relatively unabated.

The study, published in the CDC’s Emerging Infectious Diseases medical journal, pulled data from 300 microbiology laboratories. Researchers at the University of New Jersey found that not only is methicillin-resistant Staphylococcus aureus (MRSA) spreading outside of hospitals as well as within, but that outpatients being admitted to hospitals were major contributors to infections spread within hospitals as well.

According to the U.S. Centers for Disease Control and Prevention (CDC), there are more than 2 million hospital infections acquired each year, resulting in about 90,000 deaths annually. Another 1.5 million long term care and nursing home infections occur every year.

Methicillin-resistant Staphylococcus aureus, commonly referred to as a MRSA infection, has accounted for more than 60 percent of hospital staph infections in recent years. The CDC reports that about 126,000 hospital MRSA infections occur each year, resulting in about 5,000 deaths. But the researchers suggest that the number of deaths from MRSA in the U.S. is closer to 20,000 annually.

The rate of community-acquired infections (CA-MRSA) increased by about 33% annually, researchers found, resulting in an overall MRSA increase of 10% every year. And those infected individuals often made their way into U.S. hospitals, where they then infected hospital staff and other patients, even while hospitals slowed their own rate of infection, the study found.

“Outpatients, who outnumber inpatients by [about] 3:1, may play a major role in the spread of CA-MRSA strains from the community to the hospital through their interaction with hospital staff or use of similar hospital resources, such as surgical rooms,” researchers stated.

As more hospitals and medical facilities have begun to follow protocols designed to reduce the risk of hospital infections, those that have not established the standards or enforced the rules have been found by juries in medical malpractice lawsuits to be providing care that does not fall within the ordinary standard of care for the industry.

University of New Jersey researchers said that the community strains now entering hospitals are not replacing hospital strains, but instead are adding to the numbers of people infected, and said that strategies for prevention of infection and treatment of patients needs to be coordinated at the local level.

“Infection control policies should take into account the role that outpatients likely play in the spread of MRSA and promote interventions that could prevent spread of MRSA from outpatient areas to inpatient areas,” Researchers concluded.

Staph infections have risen by more than 90 percent, study finds

2009-12-20T10:27:00.000-05:00

By LAVANYA JOSE
STAFF WRITER, THE DAILY PRINCETONIAN

Published: Monday, November 30th, 2009

The number of cases of methicillin-resistant Staphylococcus aureus (MRSA) infections has increased by more than 90 percent over the last decade, according to recent research led by University scholars.
Ramanan Laxminarayan, a visiting scholar at the Princeton Environmental Institute, and Eili Klein, a visiting specialist in the ecology and evolutionary biology department, co-authored a paper on the spread of MRSA infections from 1999 through 2005.

In 2006, there were 278,203 reported cases of MRSA-related infection, more than double the number in 1999, according to the paper. As many as 17,280 people infected with MRSA died in 2005, more than the number of people who died of AIDS that year. The paper, published in the December 2007 issue of the journal Emerging Infectious Diseases, stressed that MRSA should be “considered a national priority for disease control.”

These infections are caused by the bacterium Staphylococcus aureus, which usually lives on the skin and in the nasal passages and can be harmful if it enters the body through a sore or cut.

The growing number of MRSA cases reflects the increasing resistance of Staphylococcus bacteria to antibiotics over the last few years. The researchers discovered that resistance to various antibiotics like ampicillin and erythromycin increased by more than 20 percent between 1999 and 2005, and the researchers said the widespread use of antibiotics in the past few decades has made their use less effective.

Klein explained that the increase in MRSA cases has consequences beyond health risks. People who have infections resistant to treatment face a number of extra costs because they “tend to stay longer in hospitals and may need more expensive drugs,” he said. For instance, the cost of treating MRSA infections can range between $3,000 and $36,000 more than a methicillin-sensitive infection, according to his research.

Klein added that he believes there is a need to reduce the inappropriate use of antibiotics, which helps the bacteria develop their resistance. For example, instead of prescribing antibiotics to patients who are sick and insist on being prescribed drugs to “make them feel better,” doctors should explain to their patients when they don’t need antibiotics, Klein said.

“Every time somebody uses an antibiotic, that reduces the number of times the antibiotic can ever be used because it’s going to create resistance,” he explained.

Laxminarayan referred all requests for comment to Klein.

The researchers also discovered another important trend in their data. Hospital-associated MRSA infections, occurring mostly in patients with weakened immune systems, have been more common than community-associated MRSA infections, occurring among those who pick up the bacteria in fitness centers, common restrooms and other public places. The researchers found that the percentage of hospital outpatients who reported community-associated MRSA infections had jumped drastically from about 10 percent to roughly 50 percent between 1999 and 2005. They concluded that community-associated MRSA infections are currently spreading more rapidly, and that they are possibly making their way into hospitals.

To prevent transmission between people in the outpatient and inpatient units, Laxminarayan and Klein, in their paper, called for stringent hand-washing and other infection-control practices in hospitals.

Let Me See You Wash Your Hands

2009-12-02T10:05:00.002-05:00

By IAN AYRES

One of the heroes of SuperFreakonomics is Ignatz Semmelweis — who crunched numbers in the 1840’s to champion the benefits of doctors washing their hands.

“The reason why unusual interventions are necessary is simply because voluntarism wasn’t working.” (I’ve written a bit about him myself and, for some odd reason, I just love to pronounce “Ignatz” out loud.) It has taken the medical profession a long, long time to get religion on hand sanitization.

But there is good news: Clean Hand programs are now the norm at hospitals. SuperFreakonomics explains how hand-hygiene compliance at Cedars-Sinai Medical Center “shot up to nearly 100 percent” after the hospital started using disgusting pictures of the bacteria found on the palm prints of physicians as screensavers. I can verify that other hospitals are copying this solution.

A couple of weeks ago, one of my coauthors had a health scare and was hospitalized for a night in New Haven. Her hospital ward was plastered with color photocopies of disgusting, bacteria-laden palm cultures.

I’m also impressed with the increasing practice of hand-sanitation in front of the patient. Many health care workers show you that they have just applied hand gel as they are coming in to examine you. We’re slowly getting to the point where patients might start calling out doctors who don’t sanitize in their presence.

Indeed, in addition to the disgusting hand cultures, hospitals might do well to post notices asking patients to challenge anyone who tries to treat without sanitizing in their presence. (This idea is a bit like the restaurants that say “your food is free if you are not given a receipt.”)

The reason why unusual interventions are necessary is simply because voluntarism wasn’t working. Giving health care workers the unaided choice resulted in too many people bypassing the hand-washing opportunity. Sadly, hand sanitation is a classic non-durable precaution. To be effective, it needs to be done repeatedly. Psychologically, it needs to become routine for us to have a chance of making the practice stick. (That’s how I finally got in the habit of using a seat-belt.)

Having won the day with hospitals, we should turn our attention toward schools. Sadly, most schools are at best stuck in voluntary regimes where students can wash their hands if they want to. My concern is that not enough students avail themselves of this option. Even if 80 percent regularly choose to sanitize (a pipe dream), the persistence of a recalcitrant 20 percent might undermine the public health benefits of sanitation.

If your school or place of business has public hand-sanitizers, I’d love to learn how often you have to refill the dispensers. If we know the rate of use and the number of people in the building, we can know the average rate of sanitation. I bet we’d find that the rate of sanitation would be very low. (I bet we’d find a similar result if we compared toilet paper use to soap use in school toilets. We should be very scared if there are 100 sheets of toilet paper used for every dose of hand soap.)

Schools should experiment with mandating routine, public hand sanitation. As a beginning, they might put hand gel dispensers in science class and ask the teachers to make sure that their students dose their hands at the end of class.

Mandating hand-sanitation might reduce sick days by as much as 20 percent. In fact, that’s what this 2002 study of 18 elementary schools (located in Delaware, Ohio, Tennessee, and California) found. The study protocol required multiple sanitations per day:

[T]he students were instructed to also use the waterless alcohol gel hand sanitizer when entering and leaving the classroom, especially first thing in the morning, before and after lunch, after recesses, after use of the restroom, and before going home. Students were also encouraged to use the sanitizer when they sneezed or coughed. Crucially, the study made teachers responsible for ensuring that the protocol was followed.

Compared with paired control group schools, students who were forced to clean their hands ended up with 19.8 percent fewer sick days (the full article is behind a firewall here; similar studies are abstracted here). And teachers’ absenteeism dropped by 10.1 percent. These figures ignore the beneficial effects on moms and dads and others who probably got sick less too.

As our nation suffers through another flu season, the spirit of Ignatz Semmelweis calls out to us across the decades for less discretionary hand sanitation.

Drug Resistant MRSA has Increased by 90% Over the Past Decade

2009-12-02T09:27:00.001-05:00

Featured TNM Health Update

A recent study conducted at the Princeton University has revealed that cases of the drug resistant bacterial infection MRSA have rapidly increased by as much as 90% over the past decade, and are still spreading at an alarming rate outside hospitals.

Researchers, led by Ramanan Laxminarayan, analyzed data on laboratory tests of a countrywide network of 300 microbiology laboratories across the US for the sake of study, and reported that two new strains of MRSA have been recently found circulating in patients, which are completely different from those discovered earlier.

"We found during 1999-2006 that the percentage of S. aureus infections resistant to methicillin increased more than 90 percent, or 10 percent a year, in outpatients admitted to U.S. hospitals. This increase was caused almost entirely by community-acquired MRSA strains, which increased more than 33 percent annually", shared the researchers.

Researchers discovered that a large number of people were now being diagnosed with MRSA, and the strains found in those patients were not replacing their older counterparts, but simply adding to them, thereby making the infection worse and more difficult to combat.

It has been estimated that nearly 20,000 people die every year in the US after contracting MRSA, and the infection's treatment can cost anywhere from $3,000 to over $35,000 per case.

Rougly 50% Of Patients In Intensive Care Suffer Infections

2009-12-02T07:31:00.000-05:00

Washington (SmartAboutHealth)

According to a new study, roughly 50% of patients who are in intensive care units suffer from infections.

The new study was carried out by researchers led by Dr. Jean-Louis Vincent of Erasme Hospital in Belgium.

The study analyzed data from one single day, May 8, 2007. The day consisted of looking at data on adults who were 18-years-old an dup from over 75 different countries.

There were over 13,000 patients involved in total that were put in over 1,250 intensive care units around the world.

Researchers confirmed from this data that 51% of those patients in an ICU were suffering from an infection.

32% of patients who were in an ICU for a day or less suffered from an infection, compared to 70% who spent seven days or more.
On top of that, they found that 71% were being treated with an antibiotic for an infection.

Breaking down the infections further, researchers confirmed that the majority of the infections, 64%, took place in the lungs.

South America was found to have the highest rate of infection.

The study has been published in the December 2nd issue of the Journal of the American Medical Association.

Lawmakers set to make healthcare changes

2009-12-02T07:29:00.001-05:00

The Washington Times
By Jennifer Haberkorn
December 2, 2009

Bracing for a lengthy debate that has been rambunctious since day one, lawmakers are preparing dozens of additional changes to Democrats' health care overhaul legislation.

Everything from the major flashpoints -- government-run insurance, Medicare spending and abortion -- to lesser-known topics such as hospital reimbursements and an in-home insurance plan are likely to face intense scrutiny on the Senate floor in the form of amendments.

Sens. Susan Collins, Maine Republican, and Joe Lieberman, Connecticut independent, plan to offer amendments to reduce the rate of hospital-acquired infections and change the way the small-business tax credits are structured, according to a Senate aide.

"I'd like to see more of a penalty for [government-backed] reimbursements to hospitals that have high rates of hospital-acquired infections," Ms. Collins told reporters on Tuesday.

Ms. Collins discussed both issues with White House health care "czar" Nancy-Ann DeParle in her Senate office on Monday, signaling just how closely Democrats are listening to her in hopes of getting bipartisan support for their bill.

Mr. Lieberman is also a swing vote, meaning that his and Ms. Collins' amendments are likely to get more than a glance from Democratic leaders. He is an independent and caucuses with Democrats but said he would support a Republican filibuster if the legislation contains a public insurance plan at the end of the debate.

Any amendment that significantly changes the legislation could change the dynamic of attracting 60 votes. Changes that pick up the support of some members could come at the cost of others. For instance, if an amendment to remove the public option passes, one or two moderate Republicans could come on board, but it could make liberal Democrats revolt.

The debate over the first two amendments has already been contentious. The Republicans' first amendment -- a proposal to eliminate nearly $500 billion in Medicare cuts -- was dubbed a "huge big belly-flop flip-flop" by Senate Majority Leader Harry Reid of Nevada.

Mr. Reid said Sen. John McCain's amendment was merely "one big earmark to the insurance industry" and not in line with the Arizona Republican and former presidential candidate's disdain for members of Congress favoring specific companies or industries in legislation.

Democrats say the proposed cuts would merely eliminate waste and fraud and not have an impact on benefits. But Mr. McCain and Republicans say there is no way to make such cuts without reducing seniors' care.

The Democrats' first amendment, from Sen. Barbara A. Mikulski of Maryland, was co-sponsored by Sen. Olympia J. Snowe, Maine Republican. It would give the health and human services secretary the authority to require insurers to cover additional preventive screenings for women. Just last month, controversial recommendations to limit screenings sparked worry that the Democrats' plan would ration care.

The debate is expected to last at least through the end of the year, with dozens of amendments offered by both sides.

Sen. Ben Nelson of Nebraska, one of the Democrats most skeptical of the legislation, said he plans to introduce amendments to insert abortion restrictions, strip the CLASS (Community Living Assistance Services and Supports) Act -- a program to fund in-home care for disabled Americans that some say has questionable funding -- and "deal" with the public insurance plan.

He declined to say how he plans to address the public plan, but said he prefers a state-based approach and would consider a plan in which states can "opt in" instead of opt out, as the bill currently is written.

Mr. Nelson said he would have a hard time voting for a health bill that doesn't have abortion restrictions similar to what the House passed last month. Their plan, with an amendment from Rep. Bart Stupak, Michigan Democrat, would prohibit patients on the public insurance plan from obtaining abortions without separate insurance. It sparked a firestorm from supporters of abortion rights who said the language went too far.

Other expected amendments include a repeal of the insurance companies' antitrust exemptions, from Sen. Patrick J. Leahy, Vermont Democrat, and cost-cutting measures from a group of moderate freshman Democrats.

Hospital infections disturbingly common worldwide

2009-12-02T07:27:00.001-05:00

CTV.ca News Staff
Date: Wednesday Dec. 2, 2009 7:23 AM ET

A huge new study finds that about half of all patients in intensive care wards around the world are battling some kind of infection.

The study, led by Dr. John Marshall of St. Michael's Hospital in Toronto looked at data from 1,265 intensive care units in hospitals in 75 countries.

It found that in one 24-hour period in 2007, more than half of the over 14,000 patients in ICUs that day had infections. Of those infected:

60 per cent had pneumonias
20 per cent were infections inside the abdomen
15 per cent were infections of the urinary tract
The longer the patients stayed in intensive care, the bigger their risk of becoming infected, the study findings suggest. The infection rate increased from 32 per cent for patients with an ICU stay of one day or less, to more than 70 per cent for patients with an ICU stay of more than seven days.

Not surprisingly, infected patients had longer ICU and hospital lengths of stay than those not infected.

Patients in ICUs who were battling infections were more than twice as likely to die than non-infected patients (25 per cent vs. 11 per cent). Their in-hospital death rate overall was also higher than non-infected patients (33 per cent vs. 15 per cent).

It's been well-documented that infections can increase the risk of death in the hospital. But the authors estimate they also account for about 40 per cent of total ICU health care costs.

"One of the things that this study actually allows us to do, is to begin to get a sense as to how much of the burden of infection is an added burden on a patient who is already at risk of dying because of the underlying diseases that led them to be in the intensive care unit," Dr. Marshall said in a statement.

Countries in Central and South America had the highest infection rates while more developed countries such as Australia and New Zealand had the lowest rates.

There are a number of things doctors could do to limit infections in hospital, write two doctors in an accompanying editorial, Dr. Steven M. Opal, of Warren Alpert Medical School of Brown University in Providence, R.I., and Dr. Thierry Calandra, of Centre Hospitalier Universitaire Vaudois and University of Lausanne in Switzerland.

Firstly, doctors should work to combat antibiotic resistance by limiting the use of antibiotics to patients who clearly have bacterial infections and then discontinue their use when their possible benefits have been obtained.

But even more important, new drugs need to be developed to replace the increasingly obsolete classes of antibiotics that currently exist, they insist.

"A 'post-antibiotic era' is difficult to contemplate but might become a reality unless the threat of progressive antibiotic resistance is taken seriously," the authors write.

GOP lawmaker wants tougher penalties for hospital infections

2009-12-02T07:25:00.000-05:00

By Matthew DoBias
December 1, 2009

A key Republican being courted as a possible swing vote on healthcare reform by Senate leaders and the White House said she would press for stricter penalties against hospitals that have high rates of hospital-acquired infections.

Sen. Susan Collins (R-Maine) is readying an amendment that would subject hospitals to a higher penalty—and earlier on in the process—than is currently included in the Senate's health reform package.

Under the current bill, starting in 2015, hospitals in the top 25th percentile of rates of hospital-acquired infections would be subject to a 1% penalty under Medicare. Collins' provision, however, would move up the penalty date two years to 2013 and could increase the actual penalty as well.

Collins discussed the measure with White House officials. “That's one specific idea that we requested that they seemed interested in helping us on,” she said, referring to administration officials Nancy-Ann DeParle and Jeanne Lambrew.

Additionally, Collins said that she's considering amendments that deal with affordability, small-business tax credits and a raft of other provisions.

Collins' recommendations, however, could have added traction. A moderate, Maine Republican—like her counterpart Sen. Olympia Snowe—is seen as a possible swing vote for a legislative package that so far is backed only by Democrats. Having a handful of Republicans on board would give Democrats more wiggle room to pass a bill that requires 60 votes in the Senate.

Collins said she continues to oppose the legislation as it is currently written but left the door open for a change of heart. “There would have to be substantial changes, but I certainly hope that would be possible,” she said. “I think there is unease on both sides of the aisle about specific provisions in this bill and that it's possible that we can come up with alternatives that will garner bipartisan support.”

Half of World's ICU Patients Have Infections: Study

2009-12-02T07:22:00.001-05:00

By Maggie Fox, Health and Science Editor
December 1, 2009

WASHINGTON (Reuters) - Half of all patients in intensive care units around the world have infections, and more than 70 percent are being given antibiotics -- a trend that could help more drug-resistant superbugs emerge, researchers reported on Tuesday.

Patients who had infections were more likely to die, especially of bloodborne infections known as sepsis, the survey of more than 13,000 patients found. They also spent more time in the ICU at greater expense to hospitals and patients.

But one of the biggest concerns was the widespread use of antibiotics in patients who were not infected -- a practice that has been shown to lead to antibiotic resistance, when germs defy common drugs.

"Importantly, the incidence of sepsis is increasing, as is the number of consequent infection-related deaths," Dr. Jean-Louis Vincent of Erasme University Hospital in Brussels, Belgium and colleagues wrote in the Journal of the American Medical Association.

For the study, Vincent's team surveyed 13,796 adults in 1,300 intensive care units in 75 countries on one day -- May 8, 2007.

The analysis took some time and revealed that 51 percent of the patients had infections and 71 percent were receiving antibiotics, either as treatment or to prevent infection.

In 64 percent of cases, the lungs were infected, and infections of the abdomen and bloodstream were also common.

The most common bacteria was Staphylococcus aureus, but E. coli and a family of bacteria called Pseudomonas were also common.

"Infection and related sepsis are the leading cause of death in noncardiac ICUs, with mortality rates that reach 60 percent and account for approximately 40 percent of total ICU expenditures," the researchers wrote.

TROUBLING TRENDS

Dr. Steven Opal of Brown University in Rhode Island and Dr. Thierry Calandra of Vaudois Hospital Center in Lausanne, Switzerland, who were not involved in the study, saw several troubling trends.

For instance, a type of bacteria known as gram-negative now account for 63 percent of infections. "This is not a favorable trend, because resistance among gram-negative bacteria is increasing and the number of therapeutic alternatives to treat these infections is diminishing," they wrote in a commentary.

The heavy use of antibiotics in ICUs can make such units into epicenters for bacteria to mutate into drug-resistant forms and to spread, they added.

But critical care doctors have little choice, they noted.

"Early intervention with appropriate antibiotics is lifesaving in patients with severe infection, yet the profligate use of antimicrobial agents contributes to progressive antimicrobial resistance," they wrote.

Doctors are penalized if they fail to treat with an antibiotic, but little happens if they over-treat patients.

And few good tests are available to tell if a patient is really infected or just carrying a germ. "With few alternatives available, it is understandable why intensivists opt for liberal antibiotic use and rely heavily on these therapeutic agents to carry patients through critical illness to recovery," Opal and Calandra wrote.

Without some "radical" new technology, such as vaccines or immunotherapy, there is little hope for the situation to improve, they added.

Swine Flu Seen as Cresting

2009-11-23T07:34:00.000-05:00

NOVEMBER 23, 2009
By BETSY MCKAY

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

2009-11-23T07:32:00.000-05:00

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

2009-11-03T05:34:00.000-05:00

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
*Distractions

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?

2009-11-03T05:31:00.000-05:00

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 Métiers 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

2009-11-02T18:58:00.000-05:00

(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.

Antibiotic research: the kryptonite of superbugs

2009-10-20T19:09:00.000-05:00

By Barry Eisenstein

HOSPITAL-ACQUIRED infections are a scourge that kill and injure patients and impose a heavy cost burden on the nation’s health care system, so much so that policy makers are debating the idea of rewarding hospitals that reduce their infection rate and punishing those that don’t. This makes sense, but it will not solve an important corollary public health crisis - the shortage of antibiotics to treat the current and the coming wave of superbugs.

The incidence of infections from drug-resistant bacteria such as MRSA (Methicillin-resistant Staphylococcus aureus), commonly known as “staph’’ infection, continues to rise in hospitals and in community settings. In 1980, roughly 3 percent of staph infections were diagnosed as MRSA; today that number has reached 60 percent.

The Centers for Disease Control and Prevention reported that nearly 19,000 deaths were associated with MRSA in 2005. And in a disturbing new development, the CDC has reported evidence of a link between bacterial infections such as pneumonia caused by MRSA and the H1N1 virus among patients who have died from the virus.

While the incidence of MRSA rises, the treatment landscape is shrinking. Today, many of our antibiotic medications are not as effective as they once were. Every use of an antibiotic, including the widespread use of some for non-therapeutic purposes in livestock and poultry, increases the selection of naturally resistant bacteria, the rare bacteria that mutate to the resistant state, and the transfer of resistance genes to formerly susceptible pathogens. As these organisms survive and multiply over time, the once small number of resistant organisms becomes dominant, resulting in an increasingly dangerous number of drug-resistant bacteria.

In the face of the rising wave of drug-resistant bacteria, one would think that drug manufacturers would be busy trying to develop new antibiotics. Sadly, this is not the case. Right now there are very few new antibiotics being developed in the United States or elsewhere. This dearth of new treatments was the subject of a recent report from the London School of Economics and Political Science. It warned that “only a handful of new antibiotics are in development, and all in the early stages.’’

What has brought us to this perilous situation? Since doctors now recognize the need to be prudent with antibiotic use, newly approved antibiotics do not have the commercial success they once might have had. As a consequence, drug manufacturers have abandoned antibiotic development in favor of more commercially reliable medications, particularly ones given for chronic (rather than acute) diseases.

To confront this crisis Congress needs to take strong steps to increase the supply of new antibiotics. First, Congress should establish a federal anti-infective review board to guarantee antibiotics stewardship. Stewardship programs aim to ensure proper use of antibiotics in order to provide the best treatment outcomes, to lessen the risk of adverse effects (including antimicrobial resistance), and to promote cost-effectiveness. The review board would be responsible for compiling data on antibiotic use and setting guidelines, based on evidence-based medicine, for when certain drugs should be used or held.

Second, Congress should create a number of economic incentives specifically designed to foster innovation in antibiotic development. These incentives should include tax credits for research and development, which would enable manufacturers to take on the risks and costs associated with developing new treatments that otherwise may not be undertaken. These credits would also alleviate some of the hesitations manufacturers have about bringing a new product to market.

In the same context, Congress should extend the right of a manufacturer to be the sole producer of an antimicrobial product from the current five years to 10. Granting a manufacturer a longer period to offer a product increases the likelihood it can recoup its costs and in turn reinvest in delivering the next generation of antibiotics.

Taken together, these steps would help protect the current supply of antibiotics, and encourage more drug developers to invest in this crucial area of research. This is not a matter of industry economics, but of having the ability to protect public health from the threat posed by the current and future wave of drug-resistant bacteria.

Dr. Barry Eisenstein is senior vice president for scientific affairs at Cubist Pharmaceuticals and a clinical professor of medicine at Harvard Medical School.

Excerpted from Globe Newspaper Company.

MRSA presents a growing danger

2009-10-19T06:51:00.000-05:00

"World MRSA Day” was celebrated this month. What are Onslow Memorial Hospital, Onslow Health Department, Onslow Caring Community Clinic, local doctors and nurses, Onslow schools, Coastal Carolina Community College, as well as local, state, and federal government officials, television and newspapers doing to educate the public about this deadly disease?

I don’t have an answer, do you?

MRSA is an acronym for methicillin-resistant staphylococcus aureus. It has been described as “Superbug” because it is resistant to most antibiotics. The disease can cause deadly infections in patients in health care facilities and in the community. The disease can enter through cuts and abrasions in the skin and some research investigators believe it can enter just through the skin alone just by touching contaminated surfaces and items or skin-to-skin contact with someone who is colonized with MRSA.

MRSA can be transmitted sexually or by a handshake. It can cause skin infections that may look like a spider bite, a pimple, rash or a boil and even large abscesses. They may appear red, swollen, painful or have pus or other drainage. Some people may have chills and fever, feel nauseous and acute pain. In serious cases, the patient may feel lethargic (fatigue) and headaches.

MRSA infections can cause other ranges of symptoms depending on the part of the body that is infected, such as bloodstream infections, pneumonia and urinary tract infections. It may also enter the bone marrow, causing osteomyelitis, and destroy heart valves, causing endocarditis. And it can cause septicemia, toxic shock and death.

The disease is easily spread in areas where people share crowded living conditions such as hospitals, nursing homes, schools, gyms, military barracks, prisons and call centers, but it can also be contracted anywhere people share items. Anyone of any age can be infected.

Approximately 2 percent of the U.S. population is now colonized with MRSA, which means they are carrying the infection in their bodies.

Unfortunately, the cases of MRSA are not being recorded in most states as they should be. In North Carolina, the N.C. Communicable Disease Manual states that individual MRSA infections are not reportable under N.C. law; however, outbreaks, defined as two or more cases linked in time and place, should be investigated by the local health director if they represent a significant threat to the public health. Also, colonization surveys are time and resource intensive and are not generally necessary to direct control or prevention efforts. In short, North Carolina thinks it costs too much to keep accurate records. Other states may think similarly; however, the CDC has been able to get enough information to record that this deadly disease killed 18,650 people in the U.S., compared to 16,000 people who died from AIDS in 2005.

There is no vaccine, or cure, but there is some treatment, which may not last since the disease has mutated into at least 16 strains and some reports say it may be about to become an airborne disease. Also, there is research going on about the disease, but since it has been around since 1960 and with lack of reporting of cases and lack of knowledge about the disease, many people will continue dying from MRSA.

Until the medical research community and funding for such research decides to commit to education and research to eliminate MRSA, instead of such things as finding the latest erectile dysfunction pill, the public will continue suffering from this epidemic and we are left with what seems to be the be-all and end-all of treatment — the phrase “wash your hands.”

Maybe Tony Shalhoub’s Adrian Monk character is not as crazy as people think.

Jimmy E. Gay
Jacksonville

Findings of the International Nosocomial Infection Control Consortium (INICC)

2009-10-14T13:42:00.000-05:00

Health-care associated infections rates, length of stay, and bacterial resistance in an intensive care unit of Morocco ...

Most studies related to healthcare-associated infection (HAI) were conducted in the developed countries. We sought to determine healthcare-associated infection rates, microbiological profile, bacterial resistance, length of stay (LOS), and extra mortality in one ICU of a hospital member of the International Infection Control Consortium (INICC) in Morocco.

Method: We conducted prospective surveillance from 11/2004 to 4/2008 of HAI and determined monthly rates of central vascular catheter-associated bloodstream infection (CVC-BSI), catheter-associated urinary tract infection (CAUTI) and ventilator-associated pneumonia (VAP).

CDC-NNIS definitions were applied. device-utilization rates were calculated by dividing the total number of device-days by the total number of patient-days.

Rates of VAP, CVC-BSI, and CAUTI per 1000 device-days were calculated by dividing the total number of HAI by the total number of specific device-days and multiplying the result by 1000.

Results: 1,731 patients hospitalized for 11,297 days acquired 251 HAIs, an overall rate of 14.5%, and 22.22 HAIs per 1,000 ICU-days. The central venous catheter-related bloodstream infections (CVC-BSI) rate found was 15.7 per 1000 catheter-days; the ventilator-associated pneumonia (VAP) rate found was 43.2 per 1,000 ventilator-days; and the catheter-associated urinary tract infections (CAUTI) rate found was 11.7 per 1,000 catheter-days.

Overall 25.5% of all Staphylococcus aureus HAIs were caused by methicillin-resistant strains, 78.3% of Coagulase-negative-staphylococci were methicillin resistant as well.

75.0% of Klebsiella were resistant to ceftriaxone and 69.5% to ceftazidime. 31.9% of E.Coli were resistant to ceftriaxone and 21.7% to ceftazidime.

68.4% of Enterobacter sp were resistant to ceftriaxone, 55.6% to ceftazidime, and 10% to imipenem; 35.6% of Pseudomonas sp were resistant to ceftazidime and 13.5% to imipenem.LOS of patients was 5.1 days for those without HAI, 9.0 days for those with CVC-BSI, 10.6 days forthose with VAP, and 13.7 days for those with CAUTI.Extra mortality was 56.7% (RR, 3.28; P=<0.001) for VAP, 75.1% (RR, 4.02; P=0.0027) for CVC-BSI, and 18.7% (RR, 1.75; P=0.0218) for CAUTI.

Conclusion: HAI rates, LOS, mortality, and bacterial resistance were high. Even if data may not reflect accurately the clinical setting of the country, programs including surveillance, infection control, and antibiotic policy are a priority in Morocco.

Author: Naoufel MadaniVictor RosenthalTarik DendaneKhalid AbidiAmine Ali ZeggwaghRedouane Abouqal

Credits/Source: International Archives of Medicine 2009

Hospital bug rate at record low

2009-10-10T14:37:00.000-05:00

Eleanor Bradford, Health correspondent
BBC

Clostridium difficile rates are down 42% on the same period last year Rates of infection from Clostridium difficile and MRSA in Scotland have been cut, figures have shown. Infections of elderly people caused by C. diff have fallen to a record low, according to the quarterly Health Protection Scotland report.

And cases of illness caused by the drug-resistant so-called superbug, MRSA have also dropped. The decreases were welcomed by Health Secretary Nicola Sturgeon, but she warned against complacency.

C. diff rates have fallen 42% compared with the same period last year, while MRSA rates are down 25%. The latest figures show there were 996 new cases of C. diff in people over 65 between April and June, compared with 1,152 in the previous quarter.

There were also 311 cases in people aged 15-64, but this was the first time statistics for this age group had been collected and officials said the figure should be treated with "caution".

Today's figures showing record lows in clostridium difficile and MRSA are good news, but we're not out of the woods yet.

Look a bit closer and you see that today's figures only give us part of the picture. C. difficile infections have only been counted since 2003, by which time we knew we had a problem.

We are also only comparing the figures for C.diff in the elderly. We've only just started counting C.diff amongst the under-65's. There were 311 cases between April and June alone.

When it comes to MRSA there's more evidence of an established decline - but only in MRSA infections in the blood. We're not counting wound infections or the worrying emergency of MRSA in the community.

If we're doing the right things we should see a fall in C.diff and MRSA across the board.

Good hygiene is important, but our over-use of antibiotics caused this problem in the first place and that's what we need to tackle to have any hope of bringing it under control.

A Scottish government spokeswoman said that within the new age group being monitored for C. diff, the overwhelming majority of cases recorded were in the upper end of the age range.

The equivalent quarter of last year saw 1,732 cases of C diff in the over 65s.

Meanwhile cases of MRSA fell from 171 in the first quarter to 145 in the second.

A spokeswoman said MRSA figures have been monitored since the start of 2003, while C. diff has only been centrally monitored since the last quarter of 2006.

Ms Sturgeon said: "I have made tackling hospital infections a top priority and I am encouraged that today's figures show our strenuous efforts appear to be reaping rewards.

"We are confident that we now have the right initiatives in place and the figures back this up. We are seeing significant and sustained reductions in infections which is good news for patients throughout Scotland."

Various efforts have been made to cut infection rates with a national MRSA screening programme, more careful prescribing of antibiotics and reminders for people to wash their hands.

Ms Sturgeon added: "However, there is no room for complacency. I want us to continue this excellent progress as we drive to eliminate all avoidable infections from our hospitals."

But Scottish Labour's health spokeswoman Cathy Jamieson said rates of C. diff in NHS Grampian, NHS Borders and NHS Orkney are rising.

She said: "I am very concerned that the rate of C. difficile cases is still rising in some parts of Scotland.

"Whilst NHS staff deserve credit for the overall reduction shown by today's figures there are huge regional variations in the performance of Scottish hospitals and there is absolutely no room for complacency."

Swine Flu: What you need to know

2009-10-06T18:26:00.000-05:00

Is the vaccine safe? What if one child in a family is sick? What are the symptoms? When should a person go to the hospital? The man in charge answers these and other questions about this fall’s influenza pandemic.

As director of the National Institute of Allergy and Infectious Diseases, Dr. Anthony Fauci is the government's point man for tracking flu and finding answers to it. He and his team have been monitoring the H1N1 swine flu pandemic since its early days this spring. With the flu spreading rapidly now, and a new vaccine arriving this week, Fauci met Tuesday with USA TODAY's editorial board to address the many questions that are on people's minds. The following Q&A is adapted from that session and edited for length and clarity.

Question: Who is at risk? And how much risk is there?

Answer: The H1N1 virus that's circulating now, for 99% of the people, is a relatively mild to, at most, moderate influenza. However, the people who get into trouble are highly disproportionately young people. Generally, about 70% of them have an underlying condition. And about 30% of them are otherwise healthy. So even though the numbers are very small of people who get hospitalized and sometimes die, the striking thing about it is that you never see that in seasonal flu. I've been in infectious diseases for decades and I've never seen, in seasonal flu, a normal, robust healthy person die from influenza. Everyone I've seen die from influenza have been people who were elderly or sick. So this is a tough message here.

Is this a real serious problem? Well, it depends on who you are. But pregnant women get into trouble. There have been 28 deaths so far among pregnant women, and the people who get into trouble are disproportionately young. The other possible thing that's sort of the gray cloud over everything is that the virus can mutate and become virulent. And if it maintains its high transmissibility and mutates to become virulent, then we have a really, really serious problem. Which we don't have now.

Worried about whether you should get the swine flu vaccine? Fauci explains which groups are most at risk.

Find more of the taped Fauci interview here.

The first batch of about 600,000 vaccines arrived (Monday), with about 6 million by the end of the week and then 40 million by middle of October. What is an interesting sociological problem is the attitudes that people have toward vaccines. They perceive this as a new vaccine (and wonder) is it really safe, have you rushed it, is there more danger to the vaccine than the flu?

Q: What's the answer?

A: This really is not a new vaccine. No matter how much we try, it's a tough message to get across. Every year when we put out the seasonal influenza vaccine we change it slightly from year to year to match the drift in the virus in society. In essence, it's what we call a "strain change." That's exactly what we're doing with this H1N1 vaccine. But because it's been billed as a pandemic virus that's new to society, people are perceiving this is an untested, brand new vaccine. One of the problematic issues in biology is that nothing is 100% safe. It is as safe really as any of the vaccines that we take each year with a strain change. But that sometimes is a difficult message to get across.

Q: Has it been tested as much as seasonal vaccines are?

A: Last year, we gave about 100 million doses of seasonal flu vaccine, so you could say, by extrapolation, that it was tested on 100 million people. It was new, but it was given to 80 million people the year before in a little different version. So in the tests that we've done you get a little redness and swelling. Rarely, you get a fever. But there have not been what we call serious, adverse events that are associated with the vaccine.

Q: Has there been testing of the combination of the two vaccines seasonal and swine flu? And should people get both?

A: First of all, there's no problem with giving both together. You get as robust a response if you give one alone as if you give them together. That's the injectable version. There is an exception, that you should not give the flu mist of H1N1 at the same time as the flu mist for seasonal flu because you have the same antigen in the nasal passage competing with each other for the immune response.

Q: What about a combination of one injection and one mist?

A: That's OK. So you could give a flu mist of seasonal flu and a shot of H1N1. That's not a problem.

Q: How long does the shot take to give a person full immunity?

A: We generally say three weeks for it to reach its peak. But in the clinical trials that we did at the NIH, we were seeing very good responses at 10 days.

Q: How long will it be before everyone who wants the vaccine can get it?

A: Logistically, probably late November. There are five target groups that we're trying to get it to. Whereas it's the elderly who are at risk for seasonal flu complications, it's the younger people who are at more risk for pandemic H1N1 complications. The five groups who need to get the vaccine first are: pregnant women, at the top of the list. The caretakers of children less than 6 months old. The reason is you can't vaccinate a child who's less than 6 months because their immune system is too immature. So the way you protect the child is you form a cocoon effect around him by vaccinating the people who are taking care of the child. The third group is health care providers. The fourth group is young individuals from 6 months to 24 years, and the fifth group includes individuals from (age) 25 to 64.

Q: Why aren't the elderly higher on the list?

A: The reason is interesting. Elderly individuals at some time in the decades of their life have come into contact with a virus that has some crossover similarities with the current H1N1, and they have partial immunity to it. Now that could have been people who were vaccinated for the famous swine flu in 1976 or people who were alive and around in the '50s or the '40s, when you had H1N1 still circulating that had some similarity to this. So if you're older, you're relatively protected from H1N1.

Q: You can safely assume that elderly people will be some of the first in line for the shot. Will they be turned away because they're not in the top five risk groups?

A: We're getting the message out to try to get it out to the five target groups first, and when you do that, then go and get the rest. But I have to tell you, I can't imagine if a 75-year-old grandmother comes up to a place and says, "I'd like my vaccine," that somebody will say, "No, go away and come back in two weeks." Somehow I don't see that.

Q: The flip side is people who fear they'll be forced to get the vaccine, such as health care workers. What about them?

A: At the federal level there will be no mandate. But the rationale for health care workers getting vaccinated is quite sound, because there are well-documented cases of health care workers giving influenza to patients. And health care workers who themselves get sick are not able to perform their function very well.

Q: Why do otherwise healthy people die from H1N1 while the great majority recover?

A: Honestly, we don't know. But it follows the pattern of biological variability. It's kind of a bell-shaped curve. There are some people who don't get sick at all and there are some people who get very ill and expire from the illness. And then there's the vast majority of people — in the bell-shaped curve — who do just fine after an illness. I believe that the 30% of the deaths among people who are otherwise healthy is the biological variability among the human species. There may be some genetic factors that are not recognized that don't allow them to respond very well to influenza, even though everything else about them is healthy. And that holds true for a lot of diseases.

Q: Of the fatalities, how many are preventable with early intervention through Tamiflu or some other means?

A: I can't give you a precise number, but there are three things that would help to lessen the morbidity and mortality. First is proper and early diagnosis. The other thing is Tamiflu. Tamiflu helps if you give it early, and the earlier, the better. But from 30% to 40% of the deaths that have occurred thus far have had a serious superimposed bacterial pneumonia, which is highly sensitive to penicillin. So if they had been treated early, they may have survived.

Q: What is the course of the disease for the people who become severely infected? What physically happens?

A: It generally starts off with severe pulmonary disease — difficulty breathing, viral pneumonia, super-imposed in about 40% of them with bacterial pneumonia, and you either recover from it or you progress and you unfortunately and tragically die. When you get very serious pneumonia and you have real difficulty exchanging oxygen, that doesn't stay limited to the lung. Once your system starts to deteriorate, you go into renal failure, you go into heart failure, you get shock, you get super-imposed infections and you get an irreversible situation.

Q: Do you see any disconnect in the federal guidance which seems to be: Don't go to the emergency room unless you're very sick and don't administer Tamiflu unless someone's in a high-risk group. By the time that happens, is it too late for some people?

A: The messaging is difficult. I know, I try it out with people like my sister, who's a really smart non-medical person and she asked a question of me. She said, "Tell me, what do you mean by really sick? How do you determine if you have plain old flu, you should go home, take some anti-inflammatories, take some chicken soup, you don't need Tamiflu, you don't need anything."

But if you look at my children, for instance, their response to being sick is off-the-board variability. One is stoic — she never says anything's wrong — and the other is melodramatic. Everything is. So who's really sick and who is not?

If somebody really understood mild illness, it's that you get a sore throat, you get a low-grade fever, you get some aches, you feel badly, you go home. Over a period of 24 hours, if you don't get significantly worse, you just want to stay in bed. You're coughing a little, but you're not having any difficulty breathing. That's when you stay at home. Don't go to the emergency room. Call up your doctor. You probably don't need Tamiflu. But any difficulty in breathing — where you really feel like you have a problem with breathing — you absolutely go to the emergency room, go to the doctor, you probably get in the hospital and you need Tamiflu.

Q: An otherwise healthy 14-year-old girl in Texas came down with the flu. She went to see a doctor, who citing CDC guidelines sent her home without treatment. She later died. Does this kind of case suggest that you need to revisit those guidelines?

A: The guidelines were made for the purpose of not overwhelming the system with everyone who gets a sniffle and thinks they have the flu going to the emergency room. In such cases, two bad things can happen: Many of the people in the emergency room likely have the flu, so if you didn't have it when you went in, you're probably going to have it when you go out. And the other is, not allowing the health care providers to really take care of the very sick person. The one accident that happens with somebody who really looks like they're OK and then rapidly goes downhill ... that's unfortunate when that happens. But I'm not so sure that would require a changing of the recommendations and the guidelines.

Q: You've mentioned that young people are particularly vulnerable. Why?

A: Two reasons: the very fact that they've only been around for 10, 20, 30 years at the most; those individuals have much less of a chance in their lives to have come in contact with a virus that would give them a degree of cross-protection that we know is clearly protecting the 65-, 70- and 75-year-olds. Point No. 2, demographically, they cluster as opposed to older people who tend to go their own way. Everyone's a social being and interacts, but kids cluster in schools, in gymnasiums, in places like that. So it's a combination of a lack of underlying immunity and the way they live their lives.

Q: How many people were in the clinical trials of the current vaccine, and what, if any, side effects did you find?

A: A little bit over 3,000 people (including 600 children). But 100 million people got a strikingly similar vaccine last year, and there's no reason to believe that the safety profile of the H1N1 that went into the clinical trials just over the past couple of months is any different, or will be any different, from the safety profile of the vaccine that we administered last year.

Q: People might be fearful of Guillain-Barré syndrome. Can you talk about that?

A: Guillain-Barré is an autoimmune — meaning the body reacts against its own tissue — neurological disease that's characterized by ascending paralysis. People usually recover, but it's a very serious disease that can cause death. Guillain-Barré occurs in about one of 100,000 people in the United States. On a yearly basis, there's between 5,000 and 6,000 cases of Guillain-Barré. In 1976, there was a very well-recognized, historic incident called the swine flu affair. What happened is that a few hundred soldiers in Fort Dix, N.J., got a virus that was linked to a swine influenza. They isolated it. One soldier died. It was really a case study in why the president of the United States should never get involved in a vaccine program. People were so sensitized to this being another 1918 pandemic flu where 50 million to a 100 million people died worldwide that they said if it spreads throughout the world, or the United States, we could have another catastrophe. So they decided to manufacture a vaccine against this particular swine flu. The problem was that they brought in all of the big health pundits. They had (Albert) Sabin and (Jonas) Salk in the same room, which was very unusual since they hated each other. But they had them actually agree that we needed to make a vaccine, and we needed to administer it once we made it. That was the mistake because it violated a fundamental risk of vaccinology. As they were making it, it became clear that the swine flu never got out of Fort Dix. But nonetheless, they went ahead and vaccinated 40 million people against a pandemic that didn't materialize. So what you were left with was you had all the risk of the vaccine, and none of the risk of the pandemic.

Q: In the spring, schools with swine flu cases seemed uncertain as to when or whether they should close and send students home. Is there a formula school administrators can apply?

A: There were some sections of the country that were quick on the draw to close the schools and others where the parents complained that they didn't close it quickly enough. There is no mathematical formula, but the CDC has revised its guidelines and turned the knob more toward doing what you can within reason to not close the schools, because they found when they did there was a significant disruption of society out of proportion to what they thought the benefit of closing the schools. Namely, children who didn't go to school congregated in places that was almost equivalent to congregating in the schools. They'd go to a mall; they would not socially distance themselves from each other. So you're almost nullifying the very reason for keeping them out of school. And the way the recommendations go now are that if it's mild, encourage parents not to send sick children to school. If it gets worse than in the spring and goes from mild to moderate, you switch to active surveillance of kids who come in. You have somebody standing at the door, looking at the kids.

Q: Say you're a family of five and one of your children has been diagnosed with swine flu. What do you do?

A: If it's mild, then the kids who are in the family, if they don't have symptoms, they should go to school. If they develop symptoms, they don't. It's going to be very difficult for the parent. You just sort of try as best as possible to have few people interacting with the sick person. If it gets severe, and it's widespread, then the recommendation is that the household contacts of a sick person should not go to school or work for at least the 24 to 48 hours to see if they're actually infected.

Q: If you suspect that you've been exposed to swine flu, should you still get vaccinated?

A: Yes, because you just don't know. There are a lot of viruses out there that aren't necessarily influenza. If I had a laboratory test that definitively said, yes, you did get infected with H1N1, I would tell you no, don't get vaccinated because natural vaccination is the best vaccine you can give for yourself. But unless you're sure, I would go ahead and take it.

Q: Are you worried that in the media and in the general population, myths and misinformation are being spread?

A: We are putting in an extraordinary amount of time into messaging. We try to spend as much time as we possibly can with the media, on TV, in meetings like this, putting things on websites to try and dispel myths. I've been doing these public health-type things for a very long time, going back to HIV/AIDS and SARS and the anthrax attacks, and the ability of misinformation to get propagated continually astounds me. I mean, we even had a report that one of the TV programs asked me to dispel the myth that somebody was reporting that there were serious adverse events that occurred from the first H1N1 vaccine that was given to a group of kids about two weeks ago. There was no H1N1 vaccine that was given to anybody two weeks ago.

Q: What scenario keeps you up at night?

A: A lot of scenarios. I don't sleep very well! The thing that worries me the most is the combination of a highly transmissible respiratory infection, which influenza is the most likely, that is combined with a high degree of virulence. That's the thing that worries me the most, because that would out-terror any bioterror attack.

Q: Do you have any expectations that the virus will mutate this flu season in a way that might fit the scenario that you just described?

A: It is more likely than not that it won't, because it doesn't appear there are obvious pressures for it to change. Once it recirculates back, then I would say there's a better chance now that it would change. But when viruses mutate, they don't necessarily mutate toward a more virulent form.

Q: This flu will probably stretch the U.S. health care system. Will we see emergency rooms and doctors' offices overwhelmed?

A: Do I think it's going to be chaos? No, I really don't. Do I think it's going to be challenging to the health care system? Yes. Since most of the people who are getting infected are of the younger age group, I'm encouraged by what I'm seeing schools, particularly the colleges, setting up. Remember, the thing that's disturbing is its propensity to infect young people (but) a very small fraction gets seriously ill or require hospitalization or require respirators. But the number of people who are getting infected, this is a very, very small minority.

Posted at 12:15 AM/ET, October 07, 2009 in Q&A | Permalink

Is Your Beach Contaminated With MRSA?

2009-09-16T15:29:00.000-05:00

September, 2009
by Shari Roan
Los Angeles Times

Staphylococcus aureus is a common bug that can cause serious infections. An antibiotic-resistant strain, called MRSA (methicillin-resistant Staphylococcus aureus), has increased dramatically in recent years. It typically spreads in hospitals. But it's also found in healthy people in the community. It spreads from skin-to-skin contact with someone who is infected, or by touching surfaces contaminated with the germ.

Little is known about places in the environment where MRSA can hide. A study presented today, however, is the first to show that public beaches may be reservoirs for the bug. Staph was isolated in marine water and in intertidal beach sand in nine of 10 public beaches in Washington state, and half of the strains were MRSA, according to the study from researchers at the University of Washington. When examined, those strains appeared to be the type that spreads in hospitals rather than community-acquired MRSA.

How beaches are becoming contaminated with hospital-acquired MRSA is unknown, said the lead author of the study, Dr. Marilyn C. Roberts. The study was presented this morning at the Interscience Conference on Antimicrobial Agents and Chemotherapy in San Francisco.

"Where all these organisms are coming from and how they are getting seeded, we don't know," Roberts said. The samples were "grab-and-go" samples, meaning that researchers didn't spend a lot of time thinking about where to collect the samples. And, Roberts said, "the fact that we found these organisms suggests [beach contamination] is much higher than we normally thought."

Another study on beach sand, published in June in the Journal of Epidemiology, found that people who dug in the sand or covered themselves with sand were more likely to have diarrheal illnesses in the following week or two compared with beachgoers who just walked on the beach or lay on the sand. The most likely scenario for MRSA infection, Roberts said, is getting sand in a cut or abrasion. But the risk of getting MRSA at the beach cannot be estimated at this time.

"We don't know what the risk is because nobody's done a good study," she said.

Roberts also tested two beaches in Southern California and did not find MRSA. But that should not reassure beachgoers in California -- or anywhere. Testing of the samples from California beaches was delayed, which may have affected the quality of the test, Roberts said.

The best advice for beachgoers is to cover open skin wounds and wash off sand thoroughly. People who have weakened immune systems because of other illnesses should take special care with open wounds.

"I'm not telling people not to go to the beach," Roberts said. "But if, all of a sudden, you have a skin rash and it doesn't get better, you need to go and be seen."

WHO Says Swine Flu Down in Southern Hemisphere

2009-08-30T12:13:00.000-05:00

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.

Doctors Question WHO's Severe Swine Flu Warning

2009-08-30T12:10:00.000-05:00

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.

Return of Swine Flu: What's Ahead for Americans?

2009-08-30T11:46:00.000-05:00

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.

Swine Flu Spreading at 'Unbelievable' Rate: WHO

2009-08-30T11:43:00.000-05:00

(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.

Swine Flu Could Hospitalize 2 Million in U.S. This Winter

2009-08-26T13:28:00.001-05:00

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.

WHO: In Treating H1N1, Save Antivirals for High-risk Cases

2009-08-24T07:09:00.000-05:00

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.

Overuse of Antivirals Could Make H1N1 Pandemic Even Worse

2009-08-24T07:06:00.001-05:00

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.

Claim MRSA Found in Supermarkets

2009-08-15T08:06:00.000-05:00

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.

Staph Infection May Follow People Home From Hospital

2009-08-11T07:22:00.000-05:00

MONDAY, Aug. 10
HealthDay News

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.

Aggressive Staph Germ Found to Attack Immune System

2009-08-10T06:53:00.001-05:00

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.

731 Nurses Reveal What to Watch Out for in the Hospital

2009-08-07T08:41:00.003-05:00

Consumer Reports Health.org
August 2009

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.

Summing up

- 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."

Summing up

- 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.

Summing up

- 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.

Summing up

- 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.

Genes Turn On and Off?

2009-08-07T08:36:00.002-05:00

July 21, 2009
HealthDay News

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.

How to Combat the Latest Supergerms

2009-08-07T08:30:00.001-05:00

By Ginny Graves
August 4th, 2009
Excerpt

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.”

The Most Feared Opponent

2009-08-07T08:27:00.000-05:00

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 dbriggs@columbiatribune.com.
This article was published on page B1 of the Thursday, August 6, 2009 edition of The Columbia Daily Tribune.

Slime City: Where Germs Talk to Each Other and Execute Precise attacks

2009-07-18T08:19:00.002-05:00

by Wendy Orent DISCOVER MAGAZINE
From the July-August special issue, published online July 17, 2009

For 300 years, scientists thought of bacteria as individual killers, like a bunch of piranhas. Recently, we've found that's almost entirely wrong.

Perhaps you notice it after a visit to the dentist.You pass your tongue across the front of your teeth and they feel slick and squeaky-clean. Four hours later, although you might not yet be able to tell the difference, the beginning of a rough fuzz is growing. These are streptococci, the first bacterial settlers in the film that saliva deposits on your teeth. Another four hours and the bridge germs, the fusobacteria, have climbed on board. They are the ones that make it possible for the really bad actors, like Porphyromonas gingivalis, to grab on and start building colonies.

By the next morning, if you still have not brushed your teeth, a definite fuzzy scum is starting to form. If you could look at that fuzz under a microscope without disturbing its structure, you would see towers or entire communities of bacteria, each building upon others. Some of those microbes are dangerous indeed. P. gingivalis not only grows in the pockets of your gums, helping to loosen your teeth from your jaws, but also causes the release of inflammatory chemicals that get into your circulation, complicating diabetes treatment and possibly increasing the risk of heart disease. Traces of the germ have also been found in arterial plaque.

If you have ever been admitted to a hospital, it is very likely you have experienced another, related kind of scary bacterial growth—and in this case you almost certainly did not notice it. Hospitalized patients are routinely hooked up to urinary catheters that enable doctors and nurses to measure urine flow (not incidentally, the catheters also liberate health-care workers from having to take patients to the bathroom). Swiftly coated by a conditioning film made of proteins in the urine, the catheters are then inexorably covered by layers of interacting bacteria, which alter the chemistry of their surface and can cause crystals to form. Within a week, an infection is growing on the catheters of 10 percent to 50 percent of catheterized patients. Within a month the infection has reached virtually everyone.

These slimy bacterial colonies, known as biofilms, add a remarkable new dimension to our understanding of the microbial world. Ever since Louis Pasteur first grew bacteria in flasks, biologists have pictured bacteria as individual invaders floating or swimming in a liquid sea, moving through our blood and lymph like a school of piranhas down the Amazon.

But in recent years, scientists have come to understand that much, and perhaps most, of bacterial life is collective: 99 percent of bacteria live in biofilms. They vary widely in behavior. Sometimes these collectives are fixed, like a cluster of barnacles on a ship’s hull; other times they move, or swarm, like miniature slime molds. Bacteria may segregate into single-species biofilms, or they may, as in the case of dental bacteria, join together in groups that function like miniature ecological communities, competing and cooperating with each other.

The unifying factor in all these biofilms—the thing that makes them so strange and wonderful and dangerous—is that their cooperation is, in a sense, verbal. Using streams of chemicals that they pump outside their cell walls and membranes, they “talk” incessantly, among their own clones and species and even to unrelated bacteria dwelling nearby. Understanding that chatter could be vital for gaining the upper hand in the endless battle against infectious disease.

Biofilms were first discovered in 1978 in the clear waters of a frigid mountain stream in British Columbia. Microbiologist William Costerton, now of Allegheny General Hospital in Pittsburgh, and his team of scientists wondered why there were so few bacteria in the water, while billions upon billions of the germs nestled in the crevices of the streambed’s rocks. “We were finding 9 bacteria per milliliter in the water, but there must have been 100 million in a square centimeter when we took a rock out of a stream and brought it down to the lab,” Costerton says.

The bacteria were not just sitting idly on the rocks, he found. They were forming complicated structures, cities of germs encased in a slippery substance the bacteria exude called an exopolysaccharide matrix. This slime protects them from grazing amoebas and provides them with food that is excreted by bacteria within the biofilm or even bits of DNA released when other germs die.

When Costerton published his results, he coined the term biofilm and introduced a whole new understanding of how bacteria behave. “We reasoned one stubborn fact,” he recalls. “Bacteria have no idea of where they are. They are just programmed to do their thing.” In other words, they are always going to form biofilms —whether they are living on a rock or in the human body.
Two years later Tom Marrie, a young doctor working in Halifax, Nova Scotia, examined a feverish homeless man who had wandered off the street and into his emergency room.

The man had a raging staph infection and, on his chest, a lump the size and shape of a cigarette pack. It was an infected pacemaker, Marrie reasoned. For three weeks the man was given huge doses of antibiotics but did not get better, so Marrie and his team decided to operate. They invited Costerton to sit in. “If there were ever going to be a biofilm infection in a human being, it was going to be on the end of that pacemaker,” Costerton says. “We took out the pacemaker and there was our first medical biofilm. It was a great big thick layer of bacteria and slime, just caked on.”

Biofilms on implants are now recognized as a serious and growing health problem. Bacterial infections hit 2 percent to 4 percent of all implants. Of the 2 million hip and knee replacements performed worldwide each year, 40,000 become infected. More than a third of these infections lead to amputation, and not with very successful results: Most of those people die. “Implant operations have a 98 percent success rate, so people don’t want to talk about the infections,” Costerton says. “They’re a bit of a disgrace, really.”

Biofilm infections are not limited to implants. They can be found in the bodies of the young and the healthy. Many children suffer from undiagnosed biofilm infections in their ears, which require months of oral antibiotic therapy while the underlying infection smolders untouched. Millions of others live with chronic biofilms: urinary tract infections in women that last for years; prostatitis that no antibiotics permanently cure; bone infections (osteomyelitis) that cripple and immobilize people for the rest of their lives. Each year roughly 500,000 people in the United States die of biofilm-associated infections, nearly as many as those who die of cancer.

As Marrie’s experience shows, biofilms repel antibiotics, although scientists do not fully understand how. Some drugs cannot fully penetrate the biofilm’s protective matrix. In other cases, even though most of the germs die, enough remain alive to regroup and develop another biofilm. The matrix also keeps its resident germs under cover, hiding the chemical receptors on the bacteria so that drugs cannot latch onto them and kill the germs.

The study of this newly discovered behavior is rooted in the basic and ancient biology of bacteria. Geneticist Bonnie Bassler of Princeton University thinks group-living bacteria may give us a window onto the origins of multicellular life. “Bacteria grow best when each one does its own thing…together,” she says. “Bacteriologists had it wrong for the past 300 years—bacteria don’t live alone.”

As these social bacteria talk to each other, we can now listen in. Bassler and other scientists are learning how to eavesdrop on the chemical language of bacteria, seeking ways to scramble or block those messages. Disrupting the formation of films could be a powerful way to neutralize harmful infections.

Originally trained as a biochemist at Johns Hopkins University, the blue-eyed, athletic Bassler walked into a lecture hall on a whim in the late 1980s to listen to a talk by geneticist Michael Silverman of the Agouron Institute in La Jolla, California. It was one of only a handful of talks that the notoriously reserved Silverman had given in 10 years. Bassler was riveted by what she heard. Silverman talked about how bacteria make light inside the inch-long luminescent squid that live in the shallow waters off the Hawaiian coast.

Infant squid cannot glow until they excrete a mucuslike net to entrap the ubiquitous luminescent bacteria floating in the water. The squid draw captured bacteria into their “light pouches,” where the bacteria are bathed in nutrients —a diet richer than what they can find outside in the sea. In return, the bacteria (Vibrio fischeri, a close relative of the cholera germ) produce a dim blue-green light that is directed downward through small reflective organs in the squid to shine into the water below. When the squid swim at the ocean surface at night, hunting for shrimp, they are invisible to predators below because they look like moonlight on the water. Both squid and bacteria benefit. “The host wants the light, the bacteria get fed,” Bassler says.

The glow of V. fischeri provides an instructive glimpse into the communal behavior of bacteria. Autoinducers (chemical signaling molecules that produce more of themselves inside the cell) control the switch that turns the light genes off and on. Each bacterium secretes a bit of this light-evoking substance into the environment. When a crowd of bacteria and their autoinducers become dense enough, the lights in all the bacteria switch on at once. “This counting of heads is called quorum sensing,” Bassler explains. More broadly, this is how bacteria coordinate their actions in large groups: When the local concentration of autoinducers gets high enough, the bacteria know a crowd is present, and they flip over from solitary mode to group behavior.

The autoinducer molecule that triggers bacterial glow is made by a protein called LuxI, which has a very focused effect. “The molecule that the LuxI protein makes is acylated homoserine lactone, or AHL,” Bassler says. “Each LuxI protein and the molecule it produces is species-specific. There are two kinds of bacteria, and each talks in a different language. Gram-negative bacteria [which have a thin cell wall surrounded by an outer membrane] use the AHLs as autoinducers, while gram-positives [which have a thick cell wall] use peptides. This is a very ancient split.” When the V. fischeri make enough AHL autoinducer—called AI-1 for short—the cells wink on. But that is far from the only autoinducer.

Working with a related bacterium, Vibrio harveyi, in the early 1990s, Bassler discovered another kind of chemical signal that a wide range of bacteria emit. In many species this chemical, called autoinducer 2 (AI-2) has properties of a waste product, says molecular biologist Stephen Winans of Cornell University. AI-2 is the by-product of a complex process of metabolism in these species. Not all bacteria create AI-2, however. According to Winans, eons ago one line of early bacteria began to break down waste products along a pathway leading to the excretion of AI-2; another line did not. The latter are the bacteria that eventually gave rise to eukaryotic organisms, including humans. “That’s why you don’t excrete ?AI-2,” Winans says.

But Bassler found that AI-2 is much more than a waste product. “This little leftover molecule,” she says, got pressed into service as another bacterial language, one that can carry messages between different kinds of germs. Most forms of quorum sensing, including V. fischeri’s luminescence circuit, act as a private language—that is, each germ speaks only to others of its own kind. But AI-2 is a kind of bacterial Esperanto, Bassler determined. After she and her team purified the small AI-2 molecule and its protein receptor, they were able to show that the two form a lock-and-key structure, the telltale sign of a chemical signaling mechanism.

The big question was, what are different germs saying when they talk to each other? Bassler says that in some instances—such as in dental biofilms, in which some 600 species may be growing at a time—AI-2 is necessary for collective or cooperative behavior. First, though, the bacteria must be right next to each other to receive the signal, especially in a dynamic system like the mouth, where saliva is constantly washing across the teeth. The earliest colonists on freshly cleaned teeth, the streptococci, produce only low levels of AI-2; the fusobacteria produce moderate levels. The appallingly destructive germs love a very high level of AI-2, which sends them into overdrive. “They grow like gangbusters,” says Paul Kolenbrander of the National Institute of Dental and Craniofacial Research of the National Institutes of Health.

Quorum-sensing molecules also play an important part in bacterial virulence, or deadliness. If a lethal germ released toxic chemicals immediately after entering the host’s body, the immune system would quickly sense the toxin and go after the invader. So it pays for bacteria to wait, stealthily multiplying until the unwitting host is full of them. Then they can release their toxins all at once, overwhelming immunity and sickening or killing the host.

In their more recent work, Bassler and her colleagues are searching for ways to scramble the quorum-sensing signals of cholera germs. The researchers have demonstrated that in test tubes a particular chemical, called CAI-1, can induce deadly cholera cells to turn off their virulence genes.

Building on our understanding of how germs communicate, Naomi Balaban, a molecular biologist at Tufts University, has spent 17 years studying Staphylococcus aureus, a strain of bacterium that is the main cause of hospital-acquired infections.

Antibiotic-resistant forms of S. aureus, known collectively as methicillin-resistant Staphylococcus aureus, or MRSA, have spread widely in hospitals throughout the world, forming long chains of infection. There are 19,000 MRSA-associated deaths in the United States alone each year.

Other forms of MRSA have begun to spread outside of hospitals; one strain, known as USA300, is especially deadly. It has infected and killed children and athletes, and no one knows where it came from or exactly how it spreads, though athletic locker rooms have been implicated in some cases. Like other forms of staph, USA300 can form invisible biofilms outside the body, making it almost impossible to eradicate. It is difficult to judge the actual prevalence of MRSA, since many staph infections do not get much more serious than a small pimple.

Some cases do progress, though, and they may cause debilitating and almost untreatable soft-tissue infections like cellulitis and folliculitis, pneumonia, and often-fatal heart infections, or endocarditis. Another form of staph, Staphylococcus epidermidis, grows commonly in sheets of invisible biofilm on our skin, where it is normally benign. But if it is introduced into the body during a medical procedure—especially if a joint implant, catheter, or pacemaker is contaminated during insertion—both S. epidermidis and S. aureus can form dangerous biofilms that often cannot be treated without removal of the infected implant.

Balaban has discovered that all forms of staph, whether in a free-floating state or in a biofilm, have a complex form of chemical communication that can activate the agr (accessory gene regulator) system, producing a number of toxins. Somewhat controversially, Balaban also claims to have discovered another system that controls the agr system. The second system involves two proteins known as RNAIII activating protein (RAP) and TRAP, which Balaban calls “the most beautiful protein in the world.” TRAP is RAP’s target protein, Balaban says. It is found both on and within the staph cell. S. aureus secretes RAP into the environment, where the chemical collects and binds to the TRAP molecules on the cells.

When enough RAP molecules adhere to enough target molecules, staph bacteria switch on their cell-to-cell communication and stress-response systems and begin producing the toxin that makes them so lethal. S. aureus bacteria, depending on their strain, can produce 40 or more different toxins. The toxins break down the cells in the host—which could very well be you—in order to release nutrients to the germs. That is why staph infections can be so destructive. When there are enough staph germs present, the host’s immune system is overwhelmed, and tissues are destroyed at a frightening rate, leading sometimes to shock and death.

Balaban reasoned that if she could find a way to block RAP from reaching its target molecule, she could break down the signaling system that allows the release of staph’s devastating toxins. She discovered a chemical she calls RIP (RNAIII inhibiting peptide), which blocks RAP from linking to its target. It is as if an outfielder were standing ready to catch a fly ball heading his way, but he already has a grapefruit in his mitt, preventing the ball from going in. If RAP does not reach its target molecule, the whole communication process breaks down, toxins do not get made, and human immune cells converge on the now-helpless staph germs, ready to mop them up. Balaban claims that RIP can have this effect on free-floating and biofilm-embedded staph alike.

Bacteriologists had it wrong for the past 300 years—bacteria don’t live ?alone. They grow best when each one does its own thing...together.

Some researchers remain unpersuaded by Balaban’s work, however. Richard Novick of the NYU Langone Medical Center, a well-respected staph expert who was also Balaban’s postdoctoral adviser, insists that the TRAP protein does not have any known role in staph biology. In a series of letters to the journal The Scientist, he argues that only one quorum-sensing system has been discovered in Staphylococcus: the agr system. Neither Novick nor any other scientist has been able to reproduce Balaban’s RAP/TRAP experiments in the laboratory. Novick does acknowledge, though, that RIP works. “I don’t question that it has activity.

But whatever it’s doing, it’s not inhibiting agr,” he says. “I would guess it could work by interfering with assembly of a biofilm. It should not have any effect on planktonic Staphylococcus. If it did, I would have to revise my view.”

Despite these questions, RIP—which Balaban discovered in Novick’s laboratory—is in the first stages of preclinical testing as a new kind of antibiotic. It costs millions of dollars to develop drugs and get them tested in animals before they can ever be used in clinical trials for safety and efficacy in humans. Fortunately, Balaban has found a naturally occurring chemical equivalent to RIP: hamamelitannin, an extract of witch hazel bark. She has shown that this old-fashioned household remedy, long used by Native Americans, also serves to knock the ball from the outfielder’s mitt. In her tests, hamamelitannin has the same chemical effect as synthetically produced RIP.

Swine Flu Returns to Walt Disney World

2009-07-17T06:39:00.002-05:00

by Peggy Macdonald
Walt Disney World Recreation Examiner

July 16, 2009

Swine flu has not prevented guests from visiting Walt Disney World.

Walt Disney World had another brush with swine flu (H1N1) last week after a group of Mississippi tourists who had stayed at Disney's Pop Century Hotel were treated at Florida Hospital in Celebration, FL. The Mississippi group's chartered bus was en route to Mississippi when 12 to 14 members of the group began to experience flulike symptoms, according to the Orlando Sentinel.

Although one member of the tour group informed the Orlando Sentinel that at least one case of swine flu was confirmed, the test for the H1N1 virus takes several days, and it is unlikely that the hospital could have received results of the test so quickly.

Guests who visit the Walt Disney World resort come into frequent contact with other guests and surfaces that tens of thousands of guests touch each day. The moment a guest enters a Disney theme park, the guest is asked to place his or her index finger on a touch pad to verify that the park ticket belongs to him or her. The touch pads are not cleaned after each use, and Disney does not provide hand sanitizer. There are no sinks in the immediate vicinity of the touch pads.

The Disney parks would decrease the potential spread of swine flu and other diseases by installing hand sanitizer stations at the entrance to the parks. Hand sanitizer should also be made available near the attractions, so guests can clean their hands after touching safety bars and other ride surfaces. Swine flu at Disney World first made headlines last spring, when a girl traveling from Mexico was diagnosed with the disease. Although the girl's family did not stay on Disney property, they attended the Disney parks.

The swine flu/H1N1 virus is spreading across Central Florida. At the University of Central Florida, ten cases of the virus have been confirmed to date. The infected exhibited mild symptoms and either recovered fully or are currently being treated for the disease.

Swine flu treatment:

Swine flu has not led to decreased attendance at Walt Disney World's theme parks. Relatively few people have died from the disease in the United States. According to physician Robert Walton, M.D., when otherwise healthy patients receive immediate treatment with antiviral medication upon the first sign of infection, their chances of recovery are strong.

Swine flu prevention tips:

Wash your hands frequently with soap and water. Ideally you should wash your hands for at least 20 seconds.

Carry hand sanitizer for use inside the parks. You will undoubtedly come into contact with door handles, counters, and other surfaces that could be contaminated with germs. Tens of thousands of park guests and employees touch these surfaces daily.

Be prepared and keep your hands clean.

Refrain from touching your mouth, eyes, or nose in order to prevent the spread of germs. Make sure you wash your hands before eating or placing any objects in your mouth.

Cover your mouth and nose with a tissue when you sneeze or cough. Dispose of the tissue in the trash and wash your hands after sneezing or coughing.

Do not travel if you are sick. Instead call a doctor to discuss your symptoms and potential treatment.

Therapy Dogs May Carry Germs

2009-07-17T06:35:00.001-05:00

Study shows pathogens may transfer between patients and dogs in healthcare facilities.

By Wendy Bedwell-Wilson ( dogchannel.com)
Posted: June 23, 2009

A new study of therapy dogs shows these canine workers do more than share smiles; they can also share bacteria commonly found in hospitals.

In a paper titled, “Contamination of pet therapy dogs with MRSA and Clostridium difficile,” published online on March 28, 2009, in the Journal of Hospital Infection, researchers from the University of Guelph in Ontario, Canada, reported that methicillin-resistant staphylococcus (MRSA) and C. difficile may have been transferred to the fur and paws of these canine visitors when patients handled or kissed the dogs, or through exposure to a contaminated healthcare environment.

Investigators examined 26 therapy dog-and-handler teams between June and August 2007. Twelve teams visited acute-care facilities and 14 visited long-term care facilities. Prior to each visit, the dog’s forepaws and their handlers’ hands were tested for MRSA, vancomycin-resistant enterocci and C. difficile. In addition, the investigator sanitized her hands, handled each dog, then tested her hands for the same pathogens.

Testing was repeated on departure from the facility. The dog-and-handler teams were observed at all times during the visits, and all interactions with patients and staff were closely monitored.

Prior to the visits, none of the tested pathogens were found on the hands of the investigator or the handlers, or the paws of the therapy dogs. But after visiting an acute-care facility, one dog was found to have C. difficile on its paws. It was observed giving its paw to many of the patients.

When the investigator’s hands were tested after handling another dog that had just visited a long-term care facility, MRSA was detected, suggesting the dog had acquired MRSA on its fur. It had been allowed onto patients’ beds and was seen to be repeatedly kissed by two patients.

Finding MRSA on the hands of the investigator who petted a dog after its visit to the facility suggests that dogs that have picked up these pathogens can transfer them back to people. Even transient contamination presents a new avenue for transmission, not only for the pathogens evaluated in the study, but potentially for others, such as influenza and norovirus.

The authors conclude that to contain the transmission of pathogens through contact with therapy animals, all patients and handlers should follow recommended hand-sanitation procedures.

“It’s unrealistic to think that we can sanitize an animal visitor’s body between patients,” says investigator Sandra Lefebvre of the University of Guelph’s Ontario Veterinary College. “But we can and do ask human visitors to sanitize their hands so they don’t spread germs.”

More People Dead From U.S. HAIs in One Decade Than Total Toll of Americans Who Died in Battle in All Wars

2009-07-17T06:16:00.003-05:00

Victoria Nahum, Safe Care Campaign
July 2009

According to the U.S. Veterans Administration's latest numbers (Nov. 2008), the total fatalities of all soldiers who ever died during battle is 651,030. This number includes all wars the U.S. has been involved in, beginning with the American Revolution.

As awful as it is, having lost our good men to the ravages of war, unbelievably, this terrible number is far less than the number of patient fatalities caused by health care and community acquired infections just in the last decade.

Reference: http://www1.va.gov/opa/fact/amwars.asp

Killer Flu Strains Lurk, Mutate for Years Before They Go Pandemic

2009-07-17T06:14:00.000-05:00

DISCOVER MAGAZINE
July 2009

Genetic “pieces” of the 1918 flu virus, which killed between 50 and 100 million people worldwide, were likely circulating between pigs and people two to 15 years before the pandemic struck, according to a new study published in Proceedings of the National Academy of Sciences.

Catch two different flu viruses at once and a new one can emerge, something scientists call reassortment. Birds are the ultimate origin of influenza viruses, but because pigs can catch both bird and human flu strains, they’ve long been recognized as a species mixing vessel [AP].

The research shows that lethal flu strains may be the result of such reassortment of pre-existing strains, not a sudden genetic “jump.” It’s a cautionary tale for those studying the current swine flu outbreak, say researchers, as the findings suggest that the swine flu virus could evolve slowly over many years into a more dangerous form.

The analysis found that the 1918 epidemic was most likely created by interactions between human seasonal influenza and a flu strain circulating in pigs, which may have originated in birds. It had [previously] been thought that the 1918 virus emerged quickly, directly from a bird form [USA Today].

To come to the new conclusion, scientists used a computer program to construct flu strains’ evolutionary trees and find their common ancestors. They entered the genetic information of all known strains, including those that infect people, pigs, and birds. The program worked backward from genetic relationships and estimated dates to find where and when bits and pieces of deadly strains arose.

According to the new analysis, some genes of the [1918] virus may have been circulating as early as 1911. “Our results show that, in terms of how the virus emerged, it looks like much the same mechanism of the 1957 and 1968 pandemics, where the virus gets introduced into the human population over a period of time and reassorts with the previous human strain”

[Technology Review], says lead author Gavin Smith. The study showed that genetic variants of the 1968 flu, which killed nearly 34,000 people in the United States, began circulating one to three years earlier, while close relatives of the 1957 flu, which struck down about 70,000 Americans, circulated for two to six years before it struck.

The research offers clues as to how virulent strains develop and emphasizes the importance of monitoring existing ones. The authors’ biggest fear isn’t that the novel swine flu will mix with some regular winter flu as both types start circulating when cold weather hits — but that it might hang around long enough in places like China or Indonesia to [swap genes] with an extremely lethal bird flu that sometimes jumps from poultry to people [AP].

Information from the study could help scientists better predict which strains will arise, and whether these variants will be particularly deadly.

The Big Question: Is Swine Flu Mutating, and How Worried Should We Be?

2009-07-17T06:09:00.001-05:00

By Jeremy Laurance
THE INDEPENDENT - London

No parent can have read yesterday's headlines about the death of six-year-old Chloe Buckley from swine flu without a shudder. Teachers described the north London primary schoolgirl as "perfectly healthy" until she fell ill with a virus that her GP initially diagnosed as tonsillitis. Within 48 hours she was dead. Results of a post-mortem examination, which will confirm whether she had any underlying health problem, are awaited. A 64-year-old GP, Michael Day, from Bedfordshire, also died bringing the UK total of deaths to 17.

Does this mean the virus is becoming more severe?

No. The H1N1 swine flu virus is being intensively monitored around the world and there is no sign yet that it is mutating. That is to be expected. There is normally a period after a flu virus emerges when it continues to replicate and spread, before immunity to it grows (among those already infected) and it mutates into something else – which starts the cycle of infection all over again. Experts say that if deaths start occurring in clusters, that could be a warning sign that the virus is mutating into something more serious. For that reason all deaths should be scrutinised.

Why the disparity in people's reactions?

It is one of the many mysteries of flu. Some healthy individuals die each year from seasonal flu, while the majority of the population are only mildly affected, for reasons that are unexplained. Swine flu is so far causing only mild illness in the vast majority of people, but the most seriously affected have been predominantly young. Those with illnesses such as asthma, diabetes, and heart, liver or kidney disease and anyone with a suppressed immune system are more vulnerable. So are pregnant women – the growing foetus pressing on their diaphragm reduces their lung capacity and means if they get a respiratory infection it may be more serious. Obese people are also more vulnerable, possibly for the same reason. Of the UK's 17 deaths so far, at least 14 have been in people with underlying health problems.

Would these people have died anyway?

Probably not. Describing the victims as having underlying health problems conveys the impression that their deaths were unavoidable, even if they had not been infected. This is not the case. A person with asthma is vulnerable to flu because of their impaired lung function. But there is no reason why, if they can avoid the flu, they should not live a normal lifespan.

How many people have been affected in the UK?

The official tally is almost 10,000 cases confirmed by laboratory testing. But tens of thousands more, and probably hundreds of thousands, are estimated to have contracted the virus but not contacted their GP but dosed themselves with paracetamol and hot drinks at home. The Department of Health estimated that new cases were running at 8,000 a week and accelerating, with 100,000 cases a day predicted by the end of August. The age group most affected are children aged five to 14.

Is the death rate higher than for seasonal flu?

It is difficult to tell because there is a tendency in outbreaks of infectious disease to over-diagnose serious cases and deaths and underestimate the numbers infected (who may never contact their GP). Research published in Nature this week suggested that swine flu was nastier than ordinary seasonal flu, causing more lung damage in animals tested. Lung damage can lead to pneumonia, severe illness and death. A study published in Eurosurveillance last week concluded that the death rate was "relatively low... by historical standards". In an average year 4,000 to 12,000 mainly elderly people die from flu, and in an epidemic year that rises to 20,000 to 30,000. In the UK's last major epidemic in 1989-90, around 35,000 people died.

Will we all get swine flu?

No. Some people – the elderly – appear to have immunity against the virus, though it is not yet certain why. Having lived through previous seasonal epidemics and pandemics (in 1957 and 1968) they may have confronted a similar virus before and developed antibodies. Or it may be that the virus happens to have started spreading among younger groups and will reach the elderly later. The most serious illness has been in younger people. Current estimates are that 30 to 50 per cent of the population could be infected – compared with 10 per cent in an average seasonal flu year.

Is it unusual for flu to be spreading in the summer?

Yes. It hasn't happened for decades. Flu is a winter illness. The dampness and humidity in winter help the virus survive longer on surfaces like door handles so it can spread and people tend to mix more closely together in the colder, darker months. But swine flu has found the warm, dry days of summer no impediment, and has spread sooner than experts expected.

Why is the UK worse affected than other countries?

No one is sure. Heathrow is one of the world's major transport hubs, bringing travellers and their viruses from all over the world. The UK also has close links with North America, where swine flu began. The epidemic here may simply be more advanced than elsewhere, and other countries will catch up. Or it may be that we have more sophisticated surveillance systems and are better at tracking the spread of infection.

Is there a vaccine against swine flu?

Not yet, but it is on the way. The Government has ordered 130 million doses, enough to give a double dose – which will be necessary to induce immunity – to the whole population. First supplies are expected by the end of August, and enough vaccine to cover half the population is due by the end of the year. The remainder will be delivered in 2010. The Government will have to decide who is to receive the first doses. Children, the elderly, those with chronic illnesses, pregnant women and NHS frontline staff are likely to head the queue.

Is it a good idea to be vaccinated?

Probably, assuming it is safe and effective. Although swine flu is causing mild illness in most people now, most scientists think it will sooner or later mutate, possibly into a more virulent form. Experience in previous pandemics has shown that novel viruses may start by causing mild illness and end up causing more severe illness, two or even three years on. We could feel the effects of this pandemic for years to come and we don't yet know how severe it may turn out.

What else can we do?

Recognise the symptoms – sudden fever and sudden cough are typical of swine flu. Other symptoms may include headache, tiredness, aches and pains, diarrhoea, sore throat, sneezing, loss of appetite. Stay at home if you are infected and protect the vulnerable in your household by getting antiviral drugs – Tamiflu or Relenza – for them. Use a handkerchief to catch coughs and sneezes, wash your hands – a key transmitter of the virus – and clean surfaces such as door handles. Most people recover in a week, even without anti-viral medication.

Should we be afraid of swine flu? Yes and no. Why?

Yes.

* Although it is causing mostly mild illness now, it could mutate and become more virulent
* It is spreading faster than expected and people with chronic conditions and pregnant women are at risk
* The most serious illness has been in younger people, unlike seasonal flu which is worse in the elderly

No.

* Most people infected with swine flu have suffered nothing worse than a brief fever and a cough
* There is no sign yet that it is mutating, and even if it does it may not cause more serious disease
* With anti-viral drugs and a vaccine on the way we are better prepared than for previous pandemics

Britain Counts 55,000 New Case of Swine Flu in One Week

2009-07-17T06:05:00.001-05:00

Associated Press July 17, 2009

LONDON — The World Health Organization says it will stop counting individual cases of swine flu.

Tracking individual swine flu cases is too overwhelming for countries where the virus is spreading widely, the agency says in a statement. WHO will no longer issue global totals of swine flu cases, although it will continue to track the global epidemic.

WHO says countries should look for signs the virus is mutating, such as changes in the way swine flu is spreading, surges in hospital visits or more severe cases.

The agency asks countries to report their first confirmed cases, then provide weekly case numbers with a description of their outbreaks.

WHO had reported nearly 95,000 cases including 429 deaths worldwide. But the numbers are outdated, with Britain estimating it had 55,000 new cases last week alone.

WHO Stops Giving Global Swine Flu Tally

2009-07-17T06:03:00.001-05:00

(AFP) – July 17, 2009

GENEVA — The World Health Organisation said Friday that the swine flu pandemic is moving around the globe at an "unprecedented" speed as it stopped giving figures on numbers affected.

The WHO said in a information note on its website Friday that it would focus on regular updates from newly affected countries, in order to keep track of the global progress of the new influenza A(H1N1) pandemic.

The influenza pandemic had "spread internationally with unprecedented speed," according to the global health watchdog.
"In past pandemics, influenza viruses have needed more than six months to spread as widely as the new H1N1 virus has spread in less than six weeks," the WHO said.

The agency said the counting of individual cases was no longer essential to assess the risk from swine flu but would focus on new countries to be hit by A(H1N1).

"WHO will continue to request that these countries report the first confirmed cases and, as far as feasible, provide weekly aggregated case numbers and descriptive epidemiology of the early cases," it added.

While it eased its overall reporting requirement, the WHO called on all countries to "closely monitor unusual events," such as possible clusters of severe or fatal infections, or unusual patterns that might be associated with worsening disease.

The policy shift was partly motivated by the "mildness of symptoms in the overwhelming majority of patients, who usually recover, even without medical treatment, within a week of the onset of symptoms."

"Moreover, the counting of individual cases is now no longer essential in such countries for monitoring either the level or nature of the risk posed by the pandemic virus" or to guide the best response, the UN health agency added.

In some countries, the investigation and laboratory testing of all cases had absorbed huge resources, leaving health systems with little capacity to monitor severe cases or exceptional events that might mark an increase in the virulence of swine flu.

"For all of these reasons, WHO will no longer issue the global tables showing the numbers.

Infection Prevention Means Mega Savings

2009-07-13T06:42:00.000-05:00

July 10, 2009
By Althea Chang / Mainstreet.com

If the Obama administration devoted some of the $787 billion in economic stimulus funds to preventing deadly infections rampant in some hospital environments, billions of dollars would be saved in the long run, notes Consumer Reports… and not just by doctors.

How Infections Can Cost Us

Hospital acquired infections, by staph bacteria, for instance, slams patients with expensive bills and days of missed work. But they’re preventable, and health care reforms haven’t done enough to prevent them, according to Consumer Reports. Beyon that, hospital acquired infections costs the institutions $35 billion to $45 billion a year, according to Bill Vaughan, policy analyst for Consumers Union.

The Spread

One especially difficult infection spreading in hospitals is MRSA, a type of staph skin infection caused by bacteria resistant to common antibiotics. Staph is present on the skin of about 25% to 30% of the population without causing an infection, according to the U.S. Department of Health & Human Services, but surgical wound infections, bloodstream infections, and pneumonia can also be caused by staph infections. People with weakened immune systems, like hospital patients, may be more likely to get an infection.

An Ounce of Prevention

Just like recommendations to prevent the spread of the H1N1 swine flu, everyday prevention methods are basic.

To prevent getting or spreading an infection, wash your hands thoroughly with soap and water or use an alcohol-based hand sanitizers, keep cuts and scrapes clean and covered with a bandage until healed, avoid contact with other people’s wounds or bandages and avoid sharing personal items such as towels or razors, the Centers for Disease Control and Prevention recommends.

In addition, to prevent the spread of staph bacteria, the CDC urges) those with infections to tell any healthcare providers of their condition to avoid spreading it to them and other patients.

Three Reports of Oseltamivir Resistant Novel Influenza A (H1N1) Viruses

2009-07-10T19:36:00.000-05:00

From the CDC
July 10, 2009

On July 7, 2009 the World Health Organization announced the identification of a third person with oseltamivir resistant novel H1N1 virus infection.

All three people fully recovered after uncomplicated illnesses and did not have contact with each other. Two of the three people are reported to have developed illness while taking oseltamivir preventatively after an exposure to a close contact with novel influenza A (H1N1). The third person had no known exposure to oseltamivir.

Results from ongoing testing of novel influenza A (H1N1) viruses indicate that oseltamivir resistance remains rare.

The interim recommendations for the use of antiviral medications for chemoprophylaxis and treatment have not been changed http://www.cdc.gov/h1n1flu/recommendations.htm.

Judicious use of antiviral medications is recommended to reduce the possibilities of the development and spread of antiviral resistant influenza viruses.

Use of zanamivir or oseltamivir should be focused on treatment of persons with suspected novel H1N1 influenza who are 1) hospitalized or 2) at higher risk for complications due to influenza, even if hospitalization is not required.

Personal hygiene practices such as hand washing and practices to prevent the spread of an ill person’s respiratory secretions should continue during treatment because an infected person may continue to shed virus in respiratory secretions while on therapy.

Use of oseltamivir for chemoprophylaxis should be reserved for certain specific situations, such as when a person at high risk for influenza-related complications is exposed to a person with influenza.

Monitoring for antiviral resistance is ongoing and clinicians and state health departments should continue to follow state and national guidance for submission and testing of clinical specimens from persons with suspected novel influenza A (H1N1) virus infection.

More information will be provided as it becomes available.

Background

Since the first cases of novel influenza A (H1N1) virus were detected in mid-April 2009, more than 94,500 people with confirmed infection have been reported worldwide.

Until recently, all novel H1N1 viruses tested have been susceptible to oseltamivir and zanamivir (neuraminidase inhibitors), and resistant to amantadine and rimantadine (M-2 channel blockers, or adamantanes).

The World Health Organization recently announced the identification of three persons with oseltamivir-resistant novel influenza A (H1N1) virus infection; all viruses had the same mutation that confers resistance, H274Y (H275Y in N1 numbering), in the neuraminidase protein.

On July 3, The Hong Kong Department of Health reported a resistant virus isolated from a 16 year-old girl who had a fever upon arrival at the Hong Kong International airport on June 11, 2009. Her symptoms began prior to boarding the plane in San Francisco, California. The patient had not taken antiviral agents and reported no illness among close contacts.
On July 2, 2009, a person infected with an oseltamivir-resistant novel influenza A (H1N1) virus was reported from Japan from an illness on May 15, 2009. This patient also became ill while receiving oseltamivir for chemoprophylaxis.
On June 29, 2009, the National Influenza Center in Denmark reported an oseltamivir-resistant novel influenza A (H1N1) virus from an unknown date. The virus was isolated from a patient who became ill while taking a chemoprophylaxis dose of oseltamivir to prevent influenza infection after exposure to an ill person.

Guidance for the use of antiviral agents for novel influenza A (H1N1) infection has not changed and is available at: http://www.cdc.gov/h1n1flu/recommendations.htm.

The use of antiviral agents for treatment should be prioritized; zanamivir or oseltamivir are recommended for the treatment of persons with suspected novel H1N1influenza who are 1) hospitalized, or 2) at higher risk for complications due to influenza, even if hospitalization is not required.

Initiation of antiviral therapy should be as early as possible, preferably within 48 hours since symptom onset; however antiviral therapy for hospitalized persons is recommended even if it is not possible to begin therapy until more than 48 hours after symptoms began.

Despite treatment with antiviral agents, including treatment with the neuraminidase inhibitors, patients may continue to shed influenza virus and some persons may shed up to four or more days after beginning therapy. Therefore, patients should continue good hand washing and respiratory hygiene practices during the entire period on therapy to prevent the transmission of virus to close contacts.

Antiviral agents to prevent infection with novel influenza A (H1N1) virus should be used judiciously.

Most people who are infected with novel influenza A (H1N1) virus have had a self limited illness and have recovered without the need for antiviral medications.

Inappropriate use of oseltamivir for chemoprophylaxis could contribute to the development of oseltamivir resistance among novel influenza A (H1N1) viruses and the circulation of resistant viruses in the community.

Use of antiviral agents for chemoprophylaxis can be considered for persons at higher risk from complications due to influenza, or for health care workers with an exposure to influenza due to inadequate personal protective equipment.

Appropriate administrative controls (e.g. having health care personnel stay home from work when ill, and triaging for identification of potentially infectious patients) and personal protective equipment should be used to reduce the need for post-exposure chemoprophylaxis among health care workers.

Antiviral agents are discouraged for prevention of illness in healthy children or adults based on potential exposures in the community, school, camp or other settings.

In addition, there is no safety data regarding long term or frequent use of antiviral agents in children, and limited data for healthy adults.

Efforts to monitor for antiviral resistance among novel influenza A (H1N1) viruses are ongoing in the United States and internationally, but detection of oseltamivir resistance among novel influenza A (H1N1) viruses has been rare to date.

Clinicians and clinical laboratories should continue to test patients for novel influenza A (H1N1) infection, especially hospitalized persons with suspect novel H1N1 influenza, and submit clinical specimens or viruses to the local public health laboratory as described by each state health department.

State laboratories should continue to test for novel influenza A (H1N1) and seasonal influenza viruses and follow guidance issued by CDC for surveillance.

Reports on antiviral resistance testing in the United States will be available at: http://www.cdc.gov/flu/weekly.

TABLE: Persons at Higher Risk for Complications of Novel Influenza A (H1N1) Virus
Infection

• Children younger than 5 years old. The risk for severe complications from seasonal
influenza is highest among children younger than 2 years old.
• Adults 65 years of age and older.
• Persons with the following conditions:
- Chronic pulmonary (including asthma), cardiovascular (except
hypertension), renal, hepatic, hematological (including sickle cell disease),
neurologic, neuromuscular, or metabolic disorders (including diabetes
mellitus);
- Immunosuppression, including that caused by medications or by HIV;
- Pregnant women;
- Persons younger than 19 years of age who are receiving long-term aspirin
therapy;
- Residents of nursing homes and other chronic-care facilities.

For more information, please see the CDC website: http://www.cdc.gov/h1n1flu/recommendations.htm

Resistant Case of Swine Flu Found in S.F. Teen

2009-07-08T06:55:00.000-05:00

Matthew B. Stannard, Chronicle Staff Writer
Wednesday, July 8, 2009

A San Francisco teenager has been diagnosed with a strain of swine flu that is resistant to the common antiviral drug Tamiflu - an important milestone in the pandemic's evolution.

The case suggests swine flu - a form of influenza Type A, subtype H1N1 - is capable of not only developing drug resistance but also spreading between humans in that resistant form, said Dr. Arthur Reingold, professor at UC Berkeley School of Public Health.

California Department of Public Health spokesman Ralph Montano said the teenager had developed some symptoms prior to a trip to Hong Kong but did not seek medical attention before boarding a plane.

"Hong Kong officials screened the teenager on June 11, upon arrival at the Hong Kong International Airport, and they detected a fever," he said. "The teenager was isolated in a Hong Kong hospital as a precaution and was discharged seven days later, which would be June 18."

The World Health Organization identified the teenager's virus as Tamiflu resistant Tuesday, one of three cases the organization has identified in the past two weeks.

It is not surprising that a Tamiflu-resistant form of the virus would develop, Reingold said: If a virus finds itself within a host that is taking an antiviral drug as a preventive measure, that virus may mutate to a form that can survive that drug.

The two other resistant cases - in patients in Japan and in Denmark - were taking Tamiflu prophylactically, said Dr Keiji Fukuda, assistant director-general of the WHO.

But the San Francisco teenager was not, which gives her case added significance, Reingold said, because it suggests she caught the resistant variant from somebody else.

The resistant strains remain treatable with another drug, generically known as Zanamivir, Fukuda said.

How to Combat the Latest Supergerms

2009-07-08T06:49:00.000-05:00

By Ginny Graves / CNN Health

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?

Doctors say keeping your hands clean is key to preventing supergerm infections.

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, said Dr. Anne Moscona, 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 said. "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," said Dr. Helen W. Boucher, a specialist in the division of infectious diseases at Tufts Medical Center in Boston, Massachusetts. "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 percent 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," Boucher said. "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," Moscona said.

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," Moscona said.

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.) Health.com: 8 causes of chronic cough

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," said Dr. Michael F. Holick, professor of medicine, physiology, and biophysics and director of the Vitamin D, Skin and Bone Research Laboratory at Boston University School of Medicine. 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 said.

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," Boucher said. About 12 percent of infections strike people who aren't hospitalized, a percentage that is likely to increase as MRSA becomes more widespread. Health.com: The truth about staph

Currently, about 40 percent of us have staph bacteria on our skin-- and it rarely causes a problem. But about 60 to 70 percent 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 percent 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. Health.com: The germiest places in America

• 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, said, "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," Boucher said.

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," said Dr. Stuart Levy, 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," said Dr. Louis Rice, 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. Health.com: Five ways to prevent more antibiotic resistance

• 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.," Boucher said.

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, said. 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," said Dr. Barbara Murray, 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," Boucher said.

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," 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," said Betsy McCaughey, 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 warned. "If caregivers have pulled on gloves over dirty hands, the gloves are contaminated, too."

TB seems like the last thing you need to worry about in this day and age, but people in the United States still get the disease. (There are about 13,000 new cases a year.) In March and April alone there were reports of high school students in Florida, Pennsylvania, and New Hampshire being diagnosed with the illness.

"Two or three times a week there's news of an active TB outbreak somewhere in the United States," said Dr. Lee B. Reichman, executive director of the New Jersey Medical School Global Tuberculosis Institute. "For a disease that's supposed to have died out, that's a lot of sick people."

Although TB is treatable, new strains are cropping up that are resistant to antibiotics. Multidrug resistant TB (MDR TB) is impervious to at least two of the best first-line anti-TB drugs (isoniazid and rifampicin). Extensively drug-resistant TB (XDR TB), still relatively rare, is resistant to first- and second-line anti-TB medications, including injectable drugs. And both types are on the rise.

To keep it at bay:

• Get tested. If you've been around someone with active TB, ask your doctor to give you a blood or skin test.

• Take your meds. If you have TB that responds to drug treatment, taking the wrong dosage or stopping the drugs too soon (before the prescribed 6 to 9 months) may leave your body with lingering bacteria, and the germs that are still alive may mutate and develop resistance.

CDC Urges Health Care Professionals to Use Proper H1N1 Infection Control Measures

2009-06-24T08:02:00.002-05:00

Infected Workers Pose Risk to Patients, Colleagues
By David Mitchell
6/23/2009

At least 81 health care workers across the country have confirmed or probable cases of novel influenza A (H1N1), evidence that some workers are not following CDC guidance for personal protection from infectious disease.

Michael Bell, M.D., associate director for infection control in CDC's Division of Healthcare and Quality Promotion, said in a June 18 news conference that health care workers should use fit-tested respirators, gloves and eye protection when caring for a patient with probable H1N1 infection.

He also said that such patients should be placed in single-patient rooms to reduce the risk of transmission, and they should be instructed about proper respiratory hygiene and cough etiquette. Good hand-washing hygiene also is a standard precaution.

Aerosol-generating procedures should be performed in rooms with negative-pressure air handling to prevent spread to other parts of the facility, said Bell. And it is critical that infectious patients be identified "at the front door" in order to protect health care workers and other patients.

The CDC said in its June 19 Morbidity and Mortality Weekly Report or MMWR, that as of May 13, the agency had received reports of 48 confirmed or probable cases of health care workers infected with H1N1 in 18 states. Since that date, however, additional cases have since been reported and are under review, according to Bell.

Of the original 48 cases, CDC has detailed information for 26 patients, half of whom were deemed to have contracted the infection in a health care setting. Of those, 12 were possibly or probably infected through contact with an ill patient, and one case involved worker-to-worker transmission. Of the 26 cases, two workers were hospitalized; neither died.

Bell said that in the more recently reported cases, proportionately more instances of worker-to-worker transmission occurred.

"I think it's very important that health care personnel understand that if they're ill, especially during an epidemic of influenza like this, they need to stay home," said Bell, adding that health care facilities should have appropriate leave policies in place and ensure employees know they won't be penalized for using sick leave.

None of the 12 workers infected by ill patients reported adhering to all recommended infection control practices. Only five reported always using gloves, three used either a mask or respirator, and none used eye protection. The one physician who did use a respirator had not been fit-tested for the equipment.

INFECTION CONTINUES TO SPREAD

CDC officials said June 19 that there were 21,449 confirmed and probable H1N1 infections in the United States, with 87 confirmed deaths. The World Health Organization said June 19 there were 44,287 laboratory-confirmed cases worldwide, with 180 deaths.

Although CDC reports show that overall influenza activity in the United States decreased the week of June 7, with nine out of 10 surveillance regions reporting flu activity below baseline, Daniel Jernigan, M.D., Ph.D., deputy director of the CDC's Influenza Division, said during the June 18 CDC news conference there likely have been "hundreds of thousands" of cases in the United States, and the virus is expected to continue to spread here through the summer.

He added that the CDC is monitoring how the virus behaves during the flu season now going on in the Southern Hemisphere in preparation for the fall flu season in North America.

CDC ISSUES GUIDANCE FOR SUMMER CAMPS

Children have been among those most seriously affected by the H1N1 virus, and Jernigan said it was no surprise that outbreaks have been reported at summer camps in multiple states. Accordingly, the CDC has issued guidance for camps and parents of campers.

Briefly, the agency recommends that people who have had influenza-like symptoms within the past seven days should not attend, work or volunteer in a camp until at least seven days after their symptoms began or until they have been symptom-free for 24 hours.

Camp staff, volunteers and campers should be able to recognize flu symptoms -- in themselves or others -- and report them to staff. Ill campers and staff should be isolated and treated.

Among other highlights in the CDC recommendations:

Parents should plan ahead for the possibility that their child could become ill while at camp. Camps should communicate with local public health authorities to develop plans for addressing potential outbreaks. Hand-washing facilities should be readily available to campers and staff, and they should be reminded to use good hand and respiratory hygiene.

People 18 or younger with a confirmed or suspected case of influenza should not be given aspirin or aspirin-containing products because of the risk of Reye’s syndrome.

CDC URGES USE OF PNEUMOCOCCAL VACCINE

Finally, the CDC also has issued guidance for use of the 23-valent pneumococcal polysaccharide vaccine, or PPSV23, during the outbreak. CDC officials are drawing attention to the agency's existing recommendations that all people ages 65 and older and those ages 2-64 years who have certain high-risk conditions receive a single dose of PPSV23 because people in these groups are at increased risk for both pneumococcal disease and serious complications from influenza.

Those high-risk conditions are:
chronic cardiovascular disease,
chronic pulmonary disease,
diabetes mellitus,
alcoholism,
chronic liver disease,
cerebrospinal fluid leaks,
functional or anatomic asplenia, and
immunocompromising conditions.

Other high-risk patients indicated for PPSV23 vaccination are those ages 19-64 who smoke cigarettes or have asthma.

Swine Flu Pandemic Declared by World Health Organization

2009-06-11T12:08:00.002-05:00

The H1N1 virus is spreading in distinct regions of the globe. But the WHO says the pandemic is only 'moderate in severity' and cautions against overreaction by the public.

By Thomas H. Maugh II / Los Angeles Times
9:06 AM PDT, June 11, 2009

The World Health Organization this morning acknowledged what many health experts have been saying for weeks: The outbreak of novel H1N1 virus is now a pandemic.

In a letter sent to its member countries, the WHO said it is officially raising its infectious diseases alert to Phase 6, its highest level, in recognition of the fact that the virus is now undergoing communitywide transmission in Australia as well as in North America. Such spread in two distinct regions of the world is the primary criterion for raising the alert level.

But the agency said that the pandemic is only "moderate in severity" and cautioned against overreactions to the increased alert level.

The announcement marks the advent of the first global influenza epidemic in 41 years. The last one was the Hong Kong flu epidemic of 1968, which killed an estimated 1 million people worldwide.

So far, the H1N1 or swine flu pandemic this year has accounted for 27,737 laboratory-confirmed cases and 141 deaths, although health officials believe many times that number have been infected but have not been tested because their disease was mild.

A normal seasonal flu outbreak kills about 250,000 to 500,000 people worldwide.

In most industrialized countries, the rise in the alert level will have little practical effect because health authorities were already behaving as though a pandemic had been declared. In the United States, where there have been more than 13,000 cases and at least 27 deaths, "Our actions in the past month have been as if there was a pandemic in this country," said Glen Nowak, a spokesman for the Centers for Disease Control and Prevention.

But it will accelerate the production of a vaccine against the new virus. Several countries have signed contracts for the vaccine with manufacturers that call for its production if a pandemic is declared. Most of them have received so-called seed stock viruses from the CDC in the past two weeks, allowing them to begin the lengthy process of growing the virus in eggs and producing vaccines. But it will still take a minimum of four to six months for the vaccines to be available for use.

The announcement will have more impact on Third World countries, freeing up additional funds for treatment and prevention and helping to make stocks of antiviral drugs more readily available.

The WHO has hesitated to raise the alert level for fear that such an announcement would be misconstrued as an indication that the virus has become more pathogenic. WHO spokesman Gregory Hartl emphasized today that "Phase 6 doesn't mean anything concerning severity, it is concerning global spread. . . . Pandemic means global, but it doesn't have any connotation of severity or mildness."

In fact, he said, all evidence to date is overwhelming that the virus is mild in its effects. Experts fear, however, that as it passes through populations, it could mutate to become more lethal and return with increased force in the winter influenza season. That is what happened with the Spanish flu pandemic of 1918.

Officials had said they feared that the announcement would lead frightened people who are not really sick to overrun hospital emergency rooms, impairing the healthcare system's ability to treat the truly sick. That has happened in past outbreaks, and there is already some evidence that it is happening in South America, particularly in Chile, where the numbers of infected have been growing.

Dr. Keiji Fukuda, assistant director general of the WHO, also said earlier this week that he fears imposition of travel restrictions, border closing and bans on food imports -- all of which have already happened in the earlier stages of the outbreak.

thomas.maugh@latimes.com

In A Pandemic, Early Intervention Can Save Lives

2009-06-11T09:04:00.000-05:00

by Michael Cover

As we learn more about the evolving situation with regard the new strain of influenza circulating around the world, it is useful to look to our past experiences with pandemic influenza to learn and apply any lessons that can help mitigate morbidity and mortality.

Let’s call this a tale of two cities … in the 1918 Spanish Influenza epidemic, a minimum of 50 million people around the world died from the flu or from secondary infection. But not all localities experienced the same death rate, largely due to the public health guidance that was followed in that specific area. In the US, St. Louis and Philadelphia had vastly different outcomes, despite the fact that the same strain of influenza infected their communities.

In 1918, there were no influenza vaccines or antivirals and limited international travel. The public health responses were limited to isolating the ill, quarantining houses, closing schools, canceling worship services, restricting the size of funerals and weddings, closing saloons and theaters, restricting door-to-door sales, discouraging the use of public transportation, staggering the hours of business and factory operations, imposing curfews and, in some places, recommending the use of face masks in public.

By the time officials in Philadelphia determined they had a real public health threat, it was already too late. Influenza was rampaging through the city, in most part because city leaders had not followed public health guidance. They did not close schools and movie theaters in time. They succumbed to federal pressure to sell war bonds and allowed large public gatherings, including a citywide parade in support of war bond sales. The result was that in 16 weeks, more than 12,000 Philadelphians died, an excess death rate of 719 people for every 100,000 inhabitants.

The story in St. Louis was quite different. Two weeks before Philadelphia officials began to take action, physicians persuaded the city to require that flu patients register with the health department. Two days after the first cases of influenza, police helped enforce a shutdown of schools, churches and other gathering places. Public health guidance was issued on coughing, spitting, sneezing and other forms of transmission. The result? Excess deaths in St. Louis were 347 per 100,000 people, less than half the rate in Philadelphia. Early action saved thousands of lives.

In a 2007 statement, Dr Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases noted the importance of early intervention. “A primary lesson of the 1918 influenza pandemic is that it is critical to intervene early,” he said. “While researchers are working very hard to develop pandemic influenza vaccines and increase the speed with which they can be made, nonpharmaceutical interventions may buy valuable time at the beginning of a pandemic while a targeted vaccine is being produced.”

We do not yet know how severe this influenza infection will become. But we live in a very different world than our grandparents and great grand parents did in 1918. We have the capacity for vaccine development and production. We have access to antivirals and medical care. We know more about how to fight viral infections and secondary bacterial infections. But the best way to fight influenza may be by sticking to the simple, time tested methods.

So what are they? Simple. Follow the public health guidance from the CDC and other health institutions. Heck, follow the advice your mom probably gave you: know proper cough and sneeze hygiene. Wash your hands often. If you’re sick, stay home. For more information, go to http://www.pandemicflu.gov/

Bacterial Pneumonia Found to be a Major Cause of Death in Flu Pandemic

2009-06-11T09:01:00.001-05:00

From University of Pittsburgh Medical Center
By Matthew Watson, August 4, 2008

The August issue of Emerging Infectious Diseases (EID) includes two articles on the impact and implications of bacterial co-infection, and resulting pneumonia in influenza patients, during a pandemic.

Authored by Dr. John Brundage and Dr. Dennis Shanks, the first article is a retrospective epidemiological review that analyzes the unusual nature and severity of the 1918–19 influenza pandemic.1 Dr. Brundage’s claim is that the high case fatality rates seen during that pandemic were not due, as some historians have claimed, to primary pneumonia caused by a hypervirulant strain of the influenza virus. Rather, he maintains that many of the deaths that occurred during the 1918 pandemic resulted from co-infection and subsequent pneumonia caused by common respiratory bacteria.

The second article, authored by Gupta, et al., identifies bacterial pneumonia as a likely source of mortality during a pandemic and offers recommendations for addressing gaps in medical pandemic preparedness. While acknowledging the scarcity of recent data regarding the incidence of bacterial co-infection during a pandemic, Gupta notes that “secondary bacterial infection is a common cause of death in persons with seasonal influenza; co-infections have been found with ≈25% of all influenza related deaths.”2

Both Brundage and Gupta agree that the pathogens most likely to cause respiratory disease are Streptococcus pneumoniae, Staphyloccus aureus (both methicillin sensitive and resistant3) and Haemophilus influenza. Accordingly, the use of antimicrobial medications effective against these pathogens will be indicated—for either treatment or prophylaxis. However, due to the use of “just in time” supply chains, pharmaceutical shortages are likely. Consequently, both authors recommend that hospitals work with suppliers on stockpiling efforts in order to mitigate shortages.

The two papers also generally agree on the following recommendations aimed at reduction of mortality due to bacterial pneumonia for influenza patients in a pandemic:

To the extent possible, make vaccination against S. pneumoniae a priority prior to a pandemic event.
Once a pandemic has begun, vaccinate communities that are still unaffected with a strain-specific influenza vaccine, if available.

During a pandemic, isolate patients with symptomatic respiratory disease as much as possible.
Conduct surveillance to track pandemic-related bacterial infections and emerging antimicrobial resistance.
Conduct further research into bacterial pneumonias that occur secondary to influenza infection.

References:

Brundage JF, Shanks GD. Deaths from bacterial pneumonia during 1918-19 influenza pandemic. Emerg Infect Dis. 2008;14:1193-1199. http://www.cdc.gov/eid/content/14/8/pdfs/07-1313.pdf. Accessed July 24 2008.
Gupta RK, George R, Nguyen-Van-Tam JS. Bacterial pneumonia and pandemic influenza planning. Emerg Infect Dis. 2008;14:1187-1192. http://www.cdc.gov/eid/content/14/8/1187.htm. Accessed July 24 2008.
The Centers for Disease Control and Prevention. Severe methicillin-resistant Staphylococcus aureus community-acquired pneumonia associated with influenza—Louisiana and Georgia, December 2006–January 2007. MMWR. 2007;56:325-9. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a1.htm?s_cid=mm5614a1_e. Accessed July 24, 2008.

Swine Flu Outbreak Offers Sneak Peak of Pandemic to Come

2009-06-11T08:56:00.001-05:00

June 3, 2009
Statement of Worldwatch Senior Researcher Danielle Nierenberg to Mexican Congress

Washington, D.C.-As health officials scramble to develop a vaccine for the H1N1 virus, commonly referred to as swine flu, there is reason to believe that the current swell is merely a sign of the larger pandemic to come. We should regard the current outbreak of H1N1 as a bad dress rehearsal for opening night. It is not a question of whether the virus will reemerge, but when, and we are woefully unprepared.

Influenza pandemics are often preceded by "herald waves" of a flu strain at the end of one flu season, only to return stronger the next flu season, according to the U.S. Centers for Disease Control. This was true of the 1918 pandemic, which first emerged as a moderate flu virus in the spring and returned much stronger in the fall, killing as many as 40 million people worldwide. While much has changed since then, this new strain poses new challenges and we are not prepared to handle the consequences of quarantining and treating people who are infected or limiting global air travel and international trade.

Rather than focusing all of our attention on developing a vaccine, we must find ways to stop these diseases before they start. Prevention of zoonotic diseases-diseases that animals can transfer to humans-requires a fundamental change in the way we raise animals. We can begin by raising fewer animals for food overall and phasing out the most intensive confinement practices.

While the connection between the Granjas Carroll industrial pig operation in Vera Cruz, Mexico (a Smithfield Foods subsidiary) and the emergence of H1N1 is circumstantial, there is some evidence to suggest that factory farming practices are to blame. Crowded conditions and the genetic uniformity of animals on factory farms make them ideal incubators for disease. Furthermore, the overuse and misuse of antibiotics to combat these diseases create multidrug-resistant bacteria, making it harder to fight illness among animals and humans alike.

As we raise more animals in industrial-style operations, confining them by the tens of thousands, it is likely that we will see other diseases emerging and jumping the species barrier from animals to humans. Because of their genetic similarity to humans, pigs and chickens often serve as "mixing vessels" for various diseases, stirring up their genetic traits and making them easier to pass along.

As we brace for the next wave of the swine flu pandemic, perhaps we will all become more aware of the conditions under which more than 40 percent of the world's nearly 1 billion pigs are raised. Ultimately, we must realize that how we raise animals for food is inherently linked to our own health and the health of our environment.

This statement is based on remarks Danielle Nierenberg will deliver to members of the Mexican Congress on June 3, 2009.

WHO Set to Declare First Flu Pandemic Since 1968

2009-06-11T08:53:00.001-05:00

Thu Jun 11, 2009 8:31am EDT
By Stephanie Nebehay

GENEVA, June 11 (Reuters) - The World Health Organisation was poised on Thursday to declare that the new H1N1 virus has caused the first influenza pandemic in more than 40 years, health sources said on Thursday.

The move will trigger heightened health measures in the WHO's 193 member states as authorities brace for the worldwide spread of the virus that has so far caused mainly mild illness.

WHO Director-General Dr Margaret Chan was to hold a news conference on the outbreak at 1600 GMT. Flu experts advising Chan, who met earlier on Thursday, were expected to recommend moving to the top phase 6 on the WHO's six-point scale, the sources said.

That would reflect the fact that the disease, widely known as swine flu, was spreading geographically, but not necessarily indicate how virulent it is.

"Phase 6, if we call a phase 6, doesn't mean anything concerning severity, it is concerning geographic spread ... Pandemic means global, but it doesn't have any connotation of severity or mildness," WHO spokesman Gregory Hartl said.

"In fact, what we are seeing with this virus so far is overwhelmingly to date mild disease. So we would think that this event is really a moderate event for the time being, because the numbers are high but the disease is overwhelmingly mild," he told Reuters Television before the talks.

David Heymann, a former top WHO official now chairing Britain's Health Protection Agency, said that countries had tried to contain the virus through measures including school closures during the current phase 5. This has extended the precious time needed to prepare for a full-blown pandemic.

"During phase 5, the government and people in the U.K. have had the time to prepare for a pandemic -- this has hopefully decreased any surprise and concern that might be associated with a WHO announcement of phase 6, if one is made," he told Reuters.

As it spreads in humans, science cannot predict what course the virus will take, the disease it causes and the age groups infected, Heymann said. "The severity of that disease, the effectiveness of antiviral drugs and the stability of the virus must all be watched closely," he added.

A pandemic could cause enormous disruption to business as workers stay home because they are sick or to look after family members and authorities restrict gatherings of large numbers of people or movement of people or goods.

World markets shrugged off the possibility of a pandemic, as investors focused on possible global economic recovery.

AUSTRALIA LIKELY TRIGGER

Widespread transmission of the virus in Victoria, Australia, signalling that it is entrenched in another region besides North America, is likely to be the trigger for moving to phase 6.

Five people have been admitted to intensive care in Australia and more than 1,000 cases confirmed following widespread testing in the state. [ID:nSYD482995]

"We have tested 5,500 people in the last two weeks, that is more people than we test in our whole influenza season," said Victorian state premier John Brumby.

One health source, who declined to be named, said the experts were also expected to recommend finishing production currently under way of seasonal flu vaccine for the northern hemisphere next winter.

"They might say finish seasonal vaccine and say begin pandemic vaccine as soon as it is feasible," he said.

Drugmakers have obtained the new influenza A (H1N1) seed virus in the past two weeks, enabling them to begin the production process by growing the virus in eggs. [ID:nLA644931]

Company officials said on Wednesday that they were on track to have a vaccine against the new strain ready for the northern hemisphere autumn.

Seasonal flu each year kills up to half a million people, mainly elderly, and causes severe illness in millions, so a premature switch in vaccine production to cope with the new strain could put many people at risk.

The new strain can be treated by antiviral drugs oseltamivir, the generic name of Roche Holding's Tamiflu tablets, and Relenza, a spray made by GlaxoSmithKline.

The strain, which emerged in April in Mexico and the United States, has spread widely in nations including Australia, Britain, Chile and Japan.

Authorities in Germany have confirmed 27 cases of H1N1 at a school in the industrial Rhineland city of Duesseldorf, the most concentrated outbreak of the virus so far in Europe's biggest economy. [ID:nLB407116]

There have been 27,737 infections reported in 74 countries to date, including 141 deaths, according to the WHO's latest tally of laboratory confirmed cases, but the real number of people with the disease is likely to run into at least hundreds of thousands, as mild cases may not have been detected. (For more Reuters swine flu coverage, please go to: here ) (For WHO information on swine flu, go to: here ) (Additional reporting by Anne Richardson and Vincent Fribault in Geneva, Dave Graham in Berlin and Michael Perry in Sydney) (Editing by Jonathan Lynn and Richard Balmforth)

Bacteria, Not Flu, Fatal in Past Pandemics

2009-06-01T07:35:00.000-05:00

by Peter Collignon / Brisbane Times
May 29, 2009

IN THE past century we had three influenza pandemics. The worst was Spanish flu (1918-19), when tens of millions of people died.

The swine flu strain lacks one of the two essential characteristics needed to cause that kind of disaster. It readily spreads from person to person but it does not have a more aggressive (or virulent) effect in people compared to the winter flu strains.

The swine flu strain is not hyper-virulent. In the US, for every 1000 people who get infected, about 40 need to be admitted to hospital and one dies. Still aggressive, this virus is less so than many of the flu viruses that change slightly every year or so, and then circulate and cause epidemics (or pandemics) around the world, principally in winter.

This swine flu strain is an H1 strain. Variations of H1 strains have recirculated in people since 1918, and thus many may have some immunity already. This is reflected in the relatively low infection in people aged over 30. Even in children and young adults, with presumably little or no immunity, there does not seem to be excessive mortality compared to seasonal influenza. Again this reflects the relatively low virulence.

We need to consider what killed most people when new and virulent flu strains spread. It was bacteria, not the direct effect of the flu virus. Secondary bacterial infections, especially with pneumococcus and staph, caused nearly all deaths.

In 1918-19 there were no antibiotics. In the late 1950s when Asian flu struck, many deaths occurred because penicillin was the only antibiotic widely available and most strains of golden staph had developed resistance. Antibiotic resistance is a rapidly growing global problem.

Yet in Australia we still have a variety of antibiotics (especially injectables) that will work against nearly all strains of bacteria that might cause pneumonia.

Good hygiene can slow or stop the spread of flu virus. This means using alcohol hand rub and soap and water, masks and other general infection control measures, such as staying home if you are unwell.

We need to reconsider how we approach this virus. Flu strains every year cause proportionately more illness and deaths than this swine flu strain. Stricter controls will be necessary only when a new influenza arrives that is hyper-virulent and spreads easily.

Peter Collignon, an infectious diseases physician and microbiologist, is professor, school of clinical medicine, Australian National University.

Farms Feeding Us a Side of Disease?

2009-06-01T07:32:00.000-05:00

Experts wrangle over effects of antibiotics use in livestock
by Michael Schroeder and Jenni GlennThe Journal Gazette

Dr. Tim Barman, director of veterinary services for Cooper Farms in Ohio, prescribes antibiotics to keep disease outbreaks among 12,000 baby turkeys from getting “bigger and bigger.”

Farms often use antibiotics to promote growth in livestock, which health groups say contributes to drug-resistant bacteria in people. Baby turkeys are sectioned off in pens at Cooper Farms. A benefit of using antibiotics to treat illness rather than promote growth, Barman said, is that healthy animals grow faster.

The bacteria: Methicillin-resistant Staphylococcus aureus, or MRSA, is a type of bacteria that’s resistant to certain antibiotics such as methicillin, oxacillin, penicillin and amoxicillin. Common in nature, MRSA can exist on the bodies of humans and animals – on the skin, in the nose – without causing damage.

Deaths: In cases where MRSA enters the body, such as through a wound, it can lead to serious infections. MRSA is responsible for an estimated 94,000 serious MRSA infections and 19,000 deaths in the U.S. annually.

Signs and symptoms: Most staph infections, including those caused by MRSA, appear as a bump or infected area on the skin that may be red, swollen, painful, warm to the touch, perhaps draining. The symptoms may also include a fever.

MRSA strains: MRSA infections usually fall into one of two categories: hospital-acquired or community-acquired. When MRSA was discovered, people typically contracted it at hospitals and health clinics. In the past two decades, however, the number of MRSA infections in people who have had no connection to any health care setting has increased. But hospital-acquired MRSA still makes up the bulk of known MRSA infections.

The strain of MRSA that is regularly isolated from livestock, often referred to as ST398, is different from the strains responsible for hospital-acquired and community-acquired MRSA.

Livestock and MRSA: A Denmark study several years ago identified MRSA in both swine and people who worked with swine. Those who worked with the infected pigs were more likely to be infected than those who didn’t. MRSA has also been isolated in cattle and poultry. But the exact relationship between resistance to certain antibiotics used in livestock, such as pencillin G, and resistant bacteria infecting people is unclear and the subject of considerable debate among health and farm officials.

Legislation update

The Preservation of Antibiotics for Medical Treatment Act of 2009 was introduced and referred to the House Committee on Energy and Commerce and Rules Committee on March 17. It hasn’t moved since that day.

The debate on the use of antibiotics in farm animals is decades old. Similar legislation has failed to gain traction. Fort Wayne – In the wake of an international flu outbreak, pigs have been unfairly vilified.

The so-called swine flu, which now appears more benign than first thought, is typically passed from person to person, not pig to person.

But the new flu strain, a mix of human, pig and bird flu strains, is a reminder that people and animals share much, including disease and infection.

More than 350,000 people call Allen County home, and even the healthiest are susceptible to the flu and other ailments. And humans are not the only potential germ carriers here.

In addition to pets such as cats and dogs, about 13,400 cattle, 36,700 hogs and 2,400 egg-laying chickens are kept here, according to U.S. Department of Agriculture figures.

The implications of that aren’t lost on health organizations such as the American Medical Association, which supports federal legislation to restrict the use of antibiotics in livestock primarily for treating disease.

Proponents of the legislation say rampant antibiotic use contributes to the spread of antibiotic-resistant bacteria in people. Such bacteria include MRSA, or methicillin-resistant Staphylococcus aureus.

MRSA is responsible for an estimated 94,000 serious infections and 19,000 deaths in the U.S. annually, according to a 2007 report by the Centers for Disease Control and Prevention.

But industry officials and other opponents say banning certain antibiotics used in livestock in the U.S. – something already done in Europe – could have unintended consequences, such as driving up food costs and endangering public health.

Why it matters

Experts on both sides of the debate say people’s health – not just animals’ – could be affected by antibiotic use in livestock. The overuse of antibiotics, sometimes to help animals gain weight, could cause problems. But so could underuse.

Frequent use of antibiotics makes it easier for bacteria to build resistance to drugs. Some resistant bacteria can be passed between animals and people, but the extent to which people become infected because of resistance built up in livestock is unclear.

People-to-people transmission is blamed for most MRSA infections. Still, Dr. Deborah McMahan, Allen County health commissioner, says it’s important to use antibiotics responsibly in people and animals. Doctors are getting better about not using antibiotics unnecessarily in people, McMahan said, but there’s room for improvement.

MRSA is a complex problem, she said; it demands an approach that considers all potential contributors – major and minor. But without more data, McMahan isn’t sure how antibiotic use in a rural Allen County farm affects someone in downtown Fort Wayne.

Marianne Ash, a trained veterinarian, is director of biosecurity and preparedness planner for the Indiana State Board of Animal Health. Ash said "very, very few" human MRSA infections are of the animal strain. The issue, if it could be called that, isn’t even on the board’s radar, officials there said.

Based on current science, Ash doesn’t believe a ban on using antibiotics for growth promotion is warranted.

Veterinarians are more likely to be MRSA carriers than the general population. The same is true of doctors who treat people. Only when the drug-resistant staph infects a person, perhaps entering through an open wound, does it cause problems.

But Ash said pets are more likely to spread MRSA to people than farm animals.

"The real issue is with companion animals rather than livestock," she said.

Antibiotics’ benefit

Antibiotics keep livestock healthy and free of pathogens that could wind up in the food supply and cause food poisoning, said Ron Phillips of the Animal Health Institute, a trade association representing pet and livestock pharmaceutical manufacturers. Without these tools, farmers would have limited ways to treat illnesses in their herds and flocks.

Without antibiotics, Adams County farmer Ben Rediger estimates 30 percent of the 900 young dairy cows he raises would die. He uses the antibiotics to treat cows for respiratory illnesses, diarrhea or infections.

"They get sick just like people," he said.

Rediger said he uses the expensive medications sparingly. He watches for signs that a heifer isn’t feeling well and then administers antibiotics.

Those favoring limits on antibiotic use wish all farmers would be so particular.

But others advocate more widespread use of antibiotics. They say low doses of antibiotics keep animals healthy and reduce the risk of food poisoning for people.

Risks of antibiotics

Antibiotic resistance increases almost every time a drug is prescribed, regardless of whether the patient is a person or an animal, said Paul Ebner, an assistant professor of animal sciences at Purdue University. But Ebner said it is difficult to trace the origins of human antibiotic-resistant illnesses, partly because people overuse many medications.

Studies are examining whether antibiotic use on farms affects human health. But the American Medical Association isn’t waiting to push for limits.

The association opposes farmers using low-dose antibiotics as pesticides or growth promoters. Proposed legislation would require those wanting to use new animal drugs for purposes such as growth promotion to first demonstrate that the antibiotics won’t harm people.

The effectiveness of antibiotics "is being compromised by bacterial resistance, arising in part from the excessive use of antibiotics in animal agriculture," the association said in a letter supporting proposed legislation.

A strain of MRSA recently found in pigs and pig farmers in Illinois and Iowa is the same strain found in one-fifth of all documented human cases in the Netherlands.

The strain, sequence type 398, or ST398, hasn’t proved prevalent in the U.S. But its discovery here raises questions about the potential role of livestock in the spread of MRSA among people.

The study published in January in the online Public Library of Science journal was the first to document MRSA in swine and swine workers in the U.S. As far as the researchers knew, it was also the first to report the presence of the ST398 strain in the U.S.

The findings suggested that "agricultural animals could become an important reservoir for this bacterium," according to lead study author Tara Smith, an assistant professor of epidemiology at the University of Iowa, and other researchers.

But because similar antibiotic protocols were in place at all farms studied, the study’s authors said they couldn’t speculate on the relationship between antibiotic use in the pigs and MRSA.

How much is used

Various organizations – some defending antibiotic use and some concerned about it – estimate that between 30 percent and 70 percent of all antibiotics are used on farms, said Bob Martin, former executive director of the Pew Commission on Industrial Farm Animal Production.

The Animal Health Institute, a trade industry for animal medication manufacturers, uses the 30 percent figure. The Union of Concerned Scientists, which supports restrictions on nonessential livestock antibiotics, uses the 70 percent figure.

Phillips, of the Animal Health Institute, said pet and livestock owners spend about $5 billion a year on antibiotics, vaccines and other medicines.

In 2005, 24.4 million pounds of antibiotics were sold for use in livestock and pets, according to the Animal Health Institute. Most livestock antibiotics are used to treat diseases, but in 2007 about 13 percent were used to help animals grow faster. That use has drawn criticism from health organizations.

USDA figures show antibiotics might be used more widely for growth promotion than farmers care to admit. About 55 percent of hog farms feed antimicrobials – drugs to fight bacteria or viruses – to hogs that have been weaned from their mother’s milk, according to a 2006 agency survey of hog farmers.

Nearly 18 percent of dairy farms feed weaned dairy cows antimicrobials for disease prevention or growth promotion, the USDA found in a 2002 survey.

The agency did not have figures for beef cattle or poultry operations.

Mixed signals

Denmark banned growth-promoting antibiotics a decade ago, and opponents of antibiotic limits point to an increase in sick animals that needed antibiotic treatments. They say current farm practices would be more effective than a ban.

A ban in the Netherlands had similar results.

A 2002 World Health Organization report found the Danish ban was associated with slower growth and an increase in death and diarrhea in weaned pigs, but the changes weren’t seen in the older pigs.

The organization also said the ban could have indirectly increased salmonella resistance to the drug tetracycline. After the ban, farmers used the drug more often to treat sick animals. An increased resistance could lead to more human salmonella infections.

But the World Health Organization said the Danish ban produced "no serious negative effects." It found no reason why, under similar conditions, other countries couldn’t discontinue the use of antibiotics solely for growth promotion. In 2006, Europe banned the use of growth-promoting antibiotics.

The Danish ban could provide valuable future data on whether there is a relationship between human antibiotics resistance and doses given to animals, said Ebner, the Purdue assistant professor.

But there isn’t a simple cause-and-effect relationship between livestock antibiotic use and drug-resistant illnesses, he said. The relationship appears to be more complex than that.

Doctors: MRSA, Staph Cases on Rise

2009-06-01T07:30:00.001-05:00

By JOE SIMON and BRENDA J. LINERT / Tribune Chronicle
POSTED: May 31, 2009

The scary thoughts racing through the mind of Youngstown State University wide receiver Ferlando Williams when he discovered he had a staph infection wouldn't have been nearly as frightening 15 or 20 years ago.

That's because the development or ''mutation,'' as Dr. Anthony Cutrona of Youngstown called it, of staphylococcus has been quite extraordinary.

The bacteria has been affecting people, especially athletes, since before antibiotics were around. Cutrona said staph has caused pimples and many other common skin infections for years, yet its consequences become fierce when an open wound forms because it then invades the blood stream.

The severity of such an infection has become much more destructive over the years. As doctors have developed antibiotics to combat the effects of staph, innovative strains of the bacteria have evolved and become resistant to the medicines.

''Initially, in the early '50s, staph was sensitive to penicillin,'' said Cutrona, the chief infectious disease doctor at St. Elizabeth Health Center, Youngstown. ''Then in the '60s it became resistant to penicillin and we derived a synthetic penicillin that it was sensitive to. Then in the '70s it became resistant to that, and we named that type of staph MRSA.''

This new, more complex type of staph known as MRSA (methicillin-resistant Staphylococcus aureus) was mainly found in hospitals, Cutrona said. MRSA has the same effects as a regular staph infection, but it is more difficult to kill because of its resistance to medicines.

Staph continued to fend off the different antibiotics and advanced into yet another form around 1992, called USA300.

''It was a little different than the (MRSA) we see in the hospitals,'' Cutrona said. ''It had this virulent (poisonous) potential. It could invade and destroy tissue. Initially it started out in pediatric cases. Kids that developed pneumonia with MRSA ... it killed them. Then we saw outbreaks in different places. We saw it in prisons, we saw it in daycare centers, schools, locker-room facilities. And usually, this particular USA300, that was MRSA but from the community (not hospitals), when it started out, people thought they had insect bites.''

Instead, though, these small, reddish bumps sprouting near cuts and scrapes were the early signs of a vicious bacteria. From 1990 through 2000, this USA300 strand was very rare, Cutrona said. Yet since the turn of the century, it has become much more prevalent. Cutrona said he saw it ''two or three times a month'' at one point. The dangerous part of this strain is what happens if not treated.

In November, YSU's Williams had noticed a pimple-like bump on his left elbow but mistakenly believed it was just an insect bite.

Looking back, Williams now realizes how close he came to losing a limb, or worse.

''That was one of toughest times of my life,'' he said. ''Another day or so and that would have been it for me.''

Threats as serious as Williams' are not all that uncommon among athletes. That wasn't the case years ago when staph was just as prevalent but not as lethal.

Dr. Blaise Congeni, director of Pediatric Infectious Diseases at Akron Children's Hospital, agrees that the increase in the number of cases has been significant.

''We see a lot of athletes. There undoubtedly is a substantial increase in athletes - and non-athletes,'' Congeni said recently.

''What I can tell you, which is probably substantially more important in my mind, is a substantial number of humans carry staph on their skin or nose. Over 50 percent of the strains are of the MRSA variety. So we know that is increasing. Prior to 2003, it was zero. The strain we are talking about may have arrived on the scene about 2000. Before that, nobody was carrying MRSA of the community acquired variety,'' Congeni said.

Cutrona echoed that.

''We've always had staph around, it's just that this particular strain, this USA300, is loaded with a packet of enzymes called PVL (Panton-Valentine leukocidin), and it destroys tissue, it destroys white blood cells,'' Cutrona said. ''The outbreaks in the area have been notably seen, for example, in high school sport activity areas.''

The reason cases have been seen at area schools is mainly due to poor hygiene and not washing clothes, Cutrona said. When athletes perform in the same jerseys and undershirts on a daily basis, the bacteria is more likely to be picked up because of the damp and unclean conditions areas where staph forms. If an athlete then suffers a cut or abrasion, doesn't shower after practice and ignores signs of an infection, the bacteria can enter the bloodstream.

''You even see it in professional sports teams the Cleveland Browns had an episode of it,'' Cutrona said. ''It has to do with personal hygiene and locker-room hygiene. You'll get outbreaks because, if you think about it, a lot of guys who are athletes or jocks, they don't always follow the most hygenic lifestyle.''

Congeni agreed that hygiene and good skin care are the keys to avoiding staph.

''No. 1, we recommend that you try to keep the skin as intact as possible,'' Congeni said. ''As smooth as silk.''

$25 Manicure Turns Into $80,000 in Medical Bills

2009-05-20T11:33:00.001-05:00

By Sabra Gertsch
SEATTLE -- Cheryl Woolf began suspecting something was wrong when she left the nail salon.

"A $25 manicure turned into $80,000 in medicals," she said.

Woolf rarely gets her nails done, but with a big occasion approaching she treated herself to a little primping on a fateful day nearly four years ago. But the manicure turned out to be no treat.

"Felt something weird. l pulled back and I looked down and saw that my fingers were bleeding," she said. Her right middle finger was the worst.

"I knew something was wrong," she said. Three months later, Woolf found herself in a terrifying situation. "I couldn't walk. I was screaming. I thought if I quit breathing, the pain would stop. That's how bad it was," she said

Woolf was suffering from Methicillin-resistant Staphylococcus aureus (MRSA), an antibiotic-resistant type of staph infection -- deadly bacteria that feed on open wounds. She had never heard of it before it launched an attack on her system.

"No, they didn't tell me; I knew I was going to die," she said. Woolf says a hand specialist tried to remove the nail on her middle finger. "Piece of metal, a small sliver of metal came out of my finger," she said. Her doctors diagnosed her with pneumonia and sent her home with antibiotics. But the pain persisted. "My primary care physician says, 'Why are you complaining so much? (I said) 'Because it hurts. I don't know what's wrong,'" said Woolf.

No one may have listened at first. But after five visits to the emergency room, someone began listening to Woolf. By then, her right lung was full of MRSA-infected fluid."I said, 'What is that?' And they said, 'That's what's coming out of your lung,'" Woolf said.

The nail shop in Snohomish County now has a new owner, but in 2007 Woolf filed a lawsuit against the former owners and reached a private settlement.

According to Washington state licensing records, Phuong. Q. Tran violated safety and sanitation rules and was fined $500 on at least one occasion. But that's not the end of the story; Woolf's run-in with MRSA led to something else. "The silver lining in the cloud was they found cancer," she said. Woolf had also been suffering from breast cancer, and because she was under treatment for MRSA, her doctors detected it early.

"Thinking how really lucky I am. There's a purpose. I guess something kept pulling me back here," said Woolf.

MRSA can look like a spider bite, abscess or boil. It's more deadly than AIDS in the U.S., but it should not be a threat if it is treated right away.

Flu or No Flu - Wash Your Hands

2009-05-12T14:02:00.000-05:00

WALL STREET JOURNAL
May 12, 2009

Fear of swine flu is fading, but there are still plenty of reasons to wash your hands frequently.

The list of infections that can spread via unwashed hands reads like the Biblical plagues, including staph, strep, salmonella, E. coli, hepatitis, MRSA (methicillin-resistant Staphylococcus aureus), colds, flu and norovirus -- the infamous cruise-ship bug.

The importance of hand washing has been known since 1847, when a doctor named Ignaz Semmelweis suspected that maternity patients were dying in his Vienna hospital because med students treated them right after working on cadavers. When he instituted hand-cleaning, the deaths fell sharply.

The Centers for Disease Control and Prevention says hand washing is the most effective way to stay healthy. But many people don't do it often enough, or long enough, to be effective. Here's a guide:

The swine flu headlines have brought attention to the importance of hand-washing. Health columnist Melinda Beck describes the best way to wash off germs and protect against sickness.

When to do it. Wash your hands every time you use the bathroom. Every surface presents an opportunity for germs to hitchhike out. "Who thinks to clean the latch on the inside of the stall door? Try nobody," says Jim Mann, executive director of the Handwashing for Life Institute, which advises food-service providers around the world on best hand-hygiene practices.

Also wash your hands whenever you change a diaper, pick up animal waste, sneeze, cough or blow your nose; when you take public transportation, insert or remove contact lenses, prepare food, handle garbage and before eating. Few people are as conscientious as they should be. Mr. Mann recalls being in meetings to discuss hand hygiene: "Everybody shakes hands. You finish the talk, and everybody runs for the food line. Nobody washes their hands."

How to do it. Soap and water is the gold standard. In a recent study in the journal Clinical Infectious Diseases, researchers in Australia doused the hands of 20 health-care workers with human H1N1 flu virus. Soap and water removed slightly more virus than three alcohol-based hand rubs. When volunteers didn't clean their hands, most of the virus was still present an hour after exposure.

It's the mechanical process of washing that's so effective. Soap molecules surround and lift the germs, friction from rubbing your hands loosens them, and water rinses them down the drain.

Experts recommend using warm water -- mainly for comfort, so you'll wash longer. Use liquid soap if possible. Bar soaps can harbor germs, though they'll likely rinse off with water.

Use enough soap to build a lather. Lace your fingers together to cover all the surfaces. Rub the fingertips of one hand into the palm of the other, then reverse. Keep rubbing for as long as it takes to sing "Happy Birthday" twice. (Some experts prefer "Row, Row, Row Your Boat." But any tune will do as long as it lasts at least 15 seconds.)

"The typical 'splash and dash' that most people do doesn't do anything," says Mr. Mann.

Rinse thoroughly. Residual soap can make hands sore. Leave the water on while you grab a paper towel and use it to shut off the faucet. Take it with you to use on the door handle as well.

Drying lessons. Many hand-hygiene experts are down on hand dryers -- chiefly because few people have the patience to dry completely and end up wiping their hands on their clothes. "That's fine -- unless your pants have been down around your ankles in the stall," Mr. Mann says.

Air dryers can also blow remaining germs as far as six feet away.

Antibacterial soap? In 2005, a Food and Drug Administration panel voted 11-to-1 that antibacterial soaps are no more effective at keeping people healthy than regular soap. There may be some downside too. Some antibacterial ingredients like triclosan leave a residue on the skin that continues killing some bacteria. Critics worry that the remaining bacteria could become resistant, not only to soap but also to antibiotics. "To our knowledge, it's not happened, but it's theoretically possible," says Elaine Larson, a professor in the schools of nursing and public health at Columbia University. Another problem with antibacterial soap, she says, is that it gives people a false sense of security. "People think, 'Ah -- it's antibacterial. So the germs are gone.' That's a false perception," Dr. Larson says.

Hand sanitizers. It's not often that a personal-care product gets a presidential endorsement. Some drug stores sold out after Barack Obama echoed the CDC's recommendation that people use alcohol-based hand sanitizers when soap and water aren't available to help stop the spread of swine flu.

Experts say they must be at least 60% alcohol to kill germs. "Alcohol ruptures their cell membranes -- it causes them to explode," says Dr. Larson, although she notes that if your hands are visibly dirty, soap and water is much preferable.

Curiously, the FDA does not allow over-the-counter hand sanitizers to claim they kill viruses. The CDC's recommendations are based on information published since the FDA ruling, showing that alcohol-based sanitizers are effective at killing viruses, specifically the H1N1 strain, says Nicole Coffin, a CDC spokeswoman.

Can you overdo handwashing? Yes. "Try to strike a balance between being obsessive-compulsive and being reasonable," says Dr. Larson. "And if there is some kind of outbreak like with the flu or SARS, then there is reason for more caution."

Email healthjournal@wsj.com.
Printed in The Wall Street Journal, page D1

Report: Flesh-eating Bug Kills Cruise Ship Passenger in Hours

2009-05-07T15:32:00.001-05:00

USA Today 5/8/09

The British media today is abuzz over the story of a cruise ship passenger killed by so-called flesh-eating bacteria.

The BBC says 58-year-old Raymond Evans died within hours of showing symptoms of the disease, necrotising fasciitis, while on an unnamed cruise ship in the Mediterranean two months ago.

The news outlet says the passenger's widow testified this week in an inquest into the death that Evans had injured his knee when it gave out during a walk in a port. The ship's doctor, who examined the injury after the couple returned onboard, prescribed him antibiotics, but despite the treatment the knee continued to deteriorate and eventually was consumed by a "blotchy blackness" that spread to his chest, elbow and fingers.

The BBC says Evans was admitted to the ship's in-house hospital and, upon arrival in Alexandria, Egypt, rushed to a hospital on land. But he died within hours from multiple organ failure.

A pathologist at the inquest suggested Evans could have picked up the bacteria on the ship. "It could not have been anything to do with his initial knee injury because this progresses within hours," the pathologist said.

Doctor, Did You Wash Your Hands?

2009-05-01T06:13:00.001-05:00

Despite national campaigns encouraging patients to take an active role in improving hospital safety, many patients aren’t comfortable asking doctors challenging questions about their care.

British researchers gave surveys to about 80 surgical patients asking them how they would feel about asking doctors or nurses various questions. The questions ranged from simple factual questions like, “How long will I be in the hospital?” to more challenging questions such as, “Have you washed your hands?” The patients were asked to rate their level of willingness to ask the questions on a scale of 1 to 4, with 4 indicating they would be very willing to pose the question to their doctor or nurse.

Basic questions to doctors about length of hospital stay, time off work and details about the procedure were easy for patients to ask and received high marks, scoring on average 3.4 points, according to the report, which appeared in the journal Quality & Safety in Health Care.

But questions aimed at improving patient safety and reducing medical errors were far more difficult for patients to ask, receiving an average score of just 2.4 points. Questions that received low marks included:

“Who are you, and what is your job?”

“I don’t think that is the medication I am on. Can you check please?”

“Have you washed your hands?”

“How many times have you done this operation?”

Although patients were slightly more willing to ask challenging questions of nurses, scores remained low. However, the survey suggested that if a doctor instructs a surgical patient to be sure and ask about safety issues like hand washing and medication, patients found it far easier to ask challenging questions. Women also were more likely to ask challenging questions than men, the study showed.

The study authors said the findings suggest patients are worried about insulting their doctors by asking safety-oriented questions. For patient safety programs to be effective, doctors and nurses need to communicate to patients that challenging questions are a good thing.

“Patients need to feel they can ask questions that may be perceived as challenging without causing offense to those involved in their health care treatment,” the study authors wrote.

House Staffer Infected With MSRA

2009-04-27T08:10:00.001-05:00

ABC News, April 2009

Congressional staffers are privy to many Washington, D.C., insider perks -- but catching a bacterial infection at the House of Representatives gym is not one of them.

A House staffer reportedly has been infected with a drug-resistant superbug, possibly from a gym used by some members of Congress.

A House staffer reportedly has contracted the superbug known as Methicillin-resistant Staphylococcus Aureus (MRSA), and some who work in the Capitol have speculated that the origin of the infection was in a gym possibly used by some lawmakers, according to a report from the congressional newspaper, The Hill.

A statement The Hill received from the House chief administrative officer said that a House employee who is also a member of the House Staff Fitness Center (HSFC) reportedly contracted the common bacterium, which, in humans, is typically found on the skin and in the nose.

The identity of the infected staffer has not yet been released, nor have there been any further reports of infection.

Meanwhile, the HSFC reportedly has scrubbed down the gym with a germicidal cleaning product.

Interim Guidance for Swine influenza A (H1N1): Taking Care of a Sick Person in Your Home

2009-04-27T07:54:00.002-05:00

From the CDC
April 25, 2009 18:30 EDT
This document provides interim guidance and will be updated as needed.

Swine influenza A virus infection (swine flu) can cause a wide range of symptoms, including fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have reported diarrhea and vomiting associated with swine flu. People with swine flu also can have vomiting and diarrhea. Like seasonal flu, swine flu in humans can vary in severity from mild to severe.

Severe disease with pneumonia, respiratory failure and even death is possible with swine flu infection. Certain groups might be more likely to develop a severe illness from swine flu infection, such as persons with chronic medical conditions. Sometimes bacterial infections may occur at the same time as or after infection with influenza viruses and lead to pneumonias, ear infections, or sinus infections.

The following information can help you provide safer care at home for sick persons during a flu pandemic.

How Flu Spreads

The main way that influenza viruses are thought to spread is from person to person in respiratory droplets of coughs and sneezes. This can happen when droplets from a cough or sneeze of an infected person are propelled through the air and deposited on the mouth or nose of people nearby. Influenza viruses may also be spread when a person touches respiratory droplets on another person or an object and then touches their own mouth or nose (or someone else’s mouth or nose) before washing their hands.

People with swine flu who are cared for at home should:

Check with their health care provider about any special care they might need if they are pregnant or have a health condition such as diabetes, heart disease, asthma, or emphysema

Check with their health care provider about whether they should take antiviral medications

Stay home for 7 days after the start of illness and fever is gone

Get plenty of rest

Drink clear fluids (such as water, broth, sports drinks, electrolyte beverages for infants) to keep from being dehydrated

Cover coughs and sneezes.

Clean hands with soap and water or an alcohol-based hand rub often and especially after using tissues and after coughing or sneezing into hands.

Avoid close contact with others – do not go to work or school while ill

Be watchful for emergency warning signs (see below) that might indicate you need to seek medical attention

Medications to Help Lessen Symptoms of the Flu

Check with your healthcare provider or pharmacist for correct, safe use of medications. Antiviral medications can sometimes help lessen influenza symptoms, but require a prescription. Most people do not need these antiviral drugs to fully recover from the flu. However, persons at higher risk for severe flu complications, or those with severe flu illness who require hospitalization, might benefit from antiviral medications. Antiviral medications are available for persons 1 year of age and older. Ask your healthcare provider whether you need antiviral medication.

Influenza infections can lead to or occur with bacterial infections. Therefore, some people will also need to take antibiotics. More severe or prolonged illness or illness that seems to get better, but then gets worse again may be an indication that a person has a bacterial infection. Check with your healthcare provider if you have concerns.

Warning! Do not give aspirin (acetylsalicylic acid) to children or teenagers who have the flu; this can cause a rare but serious illness called Reye’s syndrome.

For more information about Reye’s syndrome, visit the National Institute of Health website at: http://www.ninds.nih.gov/disorders/reyes_syndrome/reyes_syndrome.htm

Check ingredient labels on over-the-counter cold and flu medications to see if they contain aspirin.

Teenagers with the flu can take medicines without aspirin, such as acetaminophen (Tylenol®) and ibuprofen (Advil®, Motrin®, Nuprin®), to relieve symptoms.

Children younger than 2 years of age should not be given over-the-counter cold medications without first speaking with a healthcare provider.

The safest care for flu symptoms in children younger than 2 years of age is using a cool-mist humidifier and a suction bulb to help clear away mucus.

Fevers and aches can be treated with acetaminophen (Tylenol®) or ibuprofen (Advil®, Motrin®, Nuprin®) or nonsteroidal anti-inflammatory drugs (NSAIDS). Examples of these kinds of medications include:

Acetaminophen
Tylenol®

Ibuprofen

Advil®, Motrin®, Nuprin®

Naproxen

Aleve

Over-the-counter cold and flu medications used according to the package instructions may help lessen some symptoms such as cough and congestion. Importantly, these medications will not lessen how infectious a person is.

Check the ingredients on the package label to see if the medication already contains acetaminophen or ibuprofen before taking additional doses of these medications—don’t double dose! Patients with kidney disease or stomach problems should check with their health care provider before taking any NSAIDS.

Check with your health care provider or pharmacist if you are taking other over-the-counter or prescription medications not related to the flu.For more information on products for treating flu symptoms, see the FDA website:

http://www.fda.gov/fdac/features/2005/105_buy.html.

When to Seek Emergency Medical Care

Get medical care right away if the sick person at home:

Has difficulty breathing or chest pain.

Has purple or blue discoloration of the lips.

Is vomiting and unable to keep liquids down.

Has signs of dehydration such as dizziness when standing, absence of urination, or in infants, a lack of tears when they cry
has seizures (for example, uncontrolled convulsions).

Is less responsive than normal or becomes confused.

Steps to Lessen the Spread of Flu in the Home

When providing care to a household member who is sick with influenza, the most important ways to protect yourself and others who are not sick are to:

Keep the sick person away from other people as much as possible (see “placement of the sick person at home”).

Remind the sick person to cover their coughs, and clean their hands with soap and water or an alcohol-based hand rub often, especially after coughing and/or sneezing.

Have everyone in the household clean their hands often, using soap and water or an alcohol-based hand rub.

Ask your healthcare provide if household contacts of the sick person, particularly those contacts that may have chronic health conditions, should take antiviral medications such as oseltemivir (Tamiflu®) or zanamivir (Relenza®) to prevent the flu.

Placement of the sick person

Keep the sick person in a room separate from the common areas of the house. (For example, a spare bedroom with its own bathroom, if that’s possible.) Keep the sickroom door closed.

Unless necessary for medical care, persons with the flu should not leave the home when they have a fever or during the time that they are most likely to spread their infection to others (7 days after onset of symptoms in adults, and 10 days after onset of symptoms in children).

If persons with the flu need to leave the home (for example, for medical care), they should cover their nose and mouth when coughing or sneezing and wear a loose-fitting (surgical) mask if available.

Have the sick person wear a surgical mask if they need to be in a common area of the house near other persons.

If possible, sick persons should use a separate bathroom. This bathroom should be cleaned daily with household disinfectant (see below).

Protect other persons in the home

The sick person should not have visitors other than caregivers. A phone call is safer than a visit.

If possible, have only one adult in the home take care of the sick person.

Avoid having pregnant women care for the sick person. (Pregnant women are at increased risk of influenza-related complications and immunity can be suppressed during pregnancy).

All persons in the household should clean their hands with soap and water or an alcohol-based hand rub frequently, including after every contact with the sick person or the person’s room or bathroom.

Use paper towels for drying hands after hand washing or dedicate cloth towels to each person in the household. For example, have different colored towels for each person.

If possible, consideration should be given to maintaining good ventilation in shared household areas (e.g., keeping windows open in restrooms, kitchen, bathroom, etc.).

Antivirals can be used to prevent the flu, so check with your healthcare provider to see if some persons in the home should use antiviral medications.

If you are the caregiver:

Avoid being face-to-face with the sick person.

When holding small children who are sick, place their chin on your shoulder so that they will not cough in your face.

Clean your hands with soap and water or use an alcohol-based hand rub after you touch the sick person or handle used tissues, or laundry.

Caregivers might catch flu from the person they are caring for and then the caregiver might be able to spread the flu to others before the caregiver shows symptoms. Therefore, the caregiver should wear a mask when they leave their home to keep from spreading flu to others in case they are in the early stages of infection.

Talk to your health care provider about taking antiviral medication to prevent the caregiver from getting the flu.

Monitor yourself and household members for flu symptoms and contact a telephone hotline or health care provider if symptoms occur.

Using Facemasks or Respirators

Avoid close contact (less than about 6 feet away) with the sick person as much as possible.

If you must have close contact with the sick person (for example, hold a sick infant), spend the least amount of time possible in close contact and try to wear a facemask (for example, surgical mask) or N95 disposable respirator.

An N95 respirator that fits snugly on your face can filter out small particles that can be inhaled around the edges of a facemask, but compared with a facemask it is harder to breathe through an N95 mask for long periods of time. More information on facemasks and respirators can be found at www.cdc.gov/swineflu

Facemasks and respirators may be purchased at a pharmacy, building supply or hardware store.

Wear an N95 respirator if you help a sick person with respiratory treatments using a nebulizer or inhaler, as directed by their doctor. Respiratory treatments should be performed in a separate room away from common areas of the house when at all possible.

Used facemasks and N95 respirators should be taken off and placed immediately in the regular trash so they don’t touch anything else.

Avoid re-using disposable facemasks and N95 respirators if possible. If a reusable fabric facemask is used, it should be laundered with normal laundry detergent and tumble-dried in a hot dryer.

After you take off a facemask or N95 respirator, clean your hands with soap and water or an alcohol-based hand sanitizer.

Household Cleaning, Laundry, and Waste Disposal

Throw away tissues and other disposable items used by the sick person in the trash. Wash your hands after touching used tissues and similar waste.

Keep surfaces (especially bedside tables, surfaces in the bathroom, and toys for children) clean by wiping them down with a household disinfectant according to directions on the product label.

Linens, eating utensils, and dishes belonging to those who are sick do not need to be cleaned separately, but importantly these items should not be shared without washing thoroughly first.

Wash linens (such as bed sheets and towels) by using household laundry soap and tumble dry on a hot setting. Avoid “hugging” laundry prior to washing it to prevent contaminating yourself. Clean your hands with soap and water or alcohol-based hand rub right after handling dirty laundry.

Eating utensils should be washed either in a dishwasher or by hand with water and soap.

For More Information: The Centers for Disease Control and Prevention (CDC) Hotline (1-800-CDC-INFO) is available in English and Spanish, 24 hours a day, 7 days a week.

CDC: Swine Flu Questions and Answers

2009-04-27T07:51:00.000-05:00

QUESTIONS & ANSWERS: Swine Influenza and You

What is swine flu?
Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza viruses that causes regular outbreaks in pigs. People do not normally get swine flu, but human infections can and do happen. Swine flu viruses have been reported to spread from person-to-person, but in the past, this transmission was limited and not sustained beyond three people.

Are there human infections with swine flu in the U.S.?
In late March and early April 2009, cases of human infection with swine influenza A (H1N1) viruses were first reported in Southern California and near San Antonio, Texas. Other U.S. states have reported cases of swine flu infection in humans and cases have been reported internationally as well. An updated case count of confirmed swine flu infections in the United States is kept at http://www.cdc.gov/swineflu/investigation.htm CDC and local and state health agencies are working together to investigate this situation.

Is this swine flu virus contagious?
CDC has determined that this swine influenza A (H1N1) virus is contagious and is spreading from human to human. However, at this time, it not known how easily the virus spreads between people.

What are the signs and symptoms of swine flu in people?
The symptoms of swine flu in people are similar to the symptoms of regular human flu and include fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have reported diarrhea and vomiting associated with swine flu. In the past, severe illness (pneumonia and respiratory failure) and deaths have been reported with swine flu infection in people. Like seasonal flu, swine flu may cause a worsening of underlying chronic medical conditions.

How does swine flu spread?
Spread of this swine influenza A (H1N1) virus is thought to be happening in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing of people with influenza. Sometimes people may become infected by touching something with flu viruses on it and then touching their mouth or nose.

How can someone with the flu infect someone else?
Infected people may be able to infect others beginning 1 day before symptoms develop and up to 7 or more days after becoming sick. That means that you may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick.

What should I do to keep from getting the flu?
First and most important: wash your hands. Try to stay in good general health. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food. Try not touch surfaces that may be contaminated with the flu virus. Avoid close contact with people who are sick.

Are there medicines to treat swine flu?
Yes. CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with these swine influenza viruses. Antiviral drugs are prescription medicines (pills, liquid or an inhaler) that fight against the flu by keeping flu viruses from reproducing in your body. If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious flu complications. For treatment, antiviral drugs work best if started soon after getting sick (within 2 days of symptoms).

How long can an infected person spread swine flu to others?
People with swine influenza virus infection should be considered potentially contagious as long as they are symptomatic and possible for up to 7 days following illness onset. Children, especially younger children, might potentially be contagious for longer periods.

What surfaces are most likely to be sources of contamination?
Germs can be spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth. Droplets from a cough or sneeze of an infected person move through the air. Germs can be spread when a person touches respiratory droplets from another person on a surface like a desk and then touches their own eyes, mouth or nose before washing their hands.

How long can viruses live outside the body?
We know that some viruses and bacteria can live 2 hours or longer on surfaces like cafeteria tables, doorknobs, and desks. Frequent handwashing will help you reduce the chance of getting contamination from these common surfaces.

What can I do to protect myself from getting sick?
There is no vaccine available right now to protect against swine flu. There are everyday actions that can help prevent the spread of germs that cause respiratory illnesses like influenza. Take these everyday steps to protect your health:

Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.

Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.

Avoid touching your eyes, nose or mouth. Germs spread this way.

Try to avoid close contact with sick people.

If you get sick with influenza, CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.

What is the best way to keep from spreading the virus through coughing or sneezing?
If you are sick, limit your contact with other people as much as possible. Do not go to work or school if ill. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick. Put your used tissue in the waste basket. Cover your cough or sneeze if you do not have a tissue. Then, clean your hands, and do so every time you cough or sneeze.

What is the best way to keep from spreading the virus through coughing or sneezing?
If you are sick, limit your contact with other people as much as possible. Do not go to work or school if ill. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick. Put your used tissue in the waste basket. Cover your cough or sneeze if you do not have a tissue. Then, clean your hands, and do so every time you cough or sneeze.

What is the best technique for washing my hands to avoid getting the flu?
Washing your hands often will help protect you from germs. Wash with soap and water. or clean with alcohol-based hand cleaner. we recommend that when you wash your hands -- with soap and warm water -- that you wash for 15 to 20 seconds. When soap and water are not available, alcohol-based disposable hand wipes or gel sanitizers may be used. You can find them in most supermarkets and drugstores. If using gel, rub your hands until the gel is dry. The gel doesn't need water to work; the alcohol in it kills the germs on your hands.

What should I do if I get sick?
If you live in areas where swine influenza cases have been identified and become ill with influenza-like symptoms, including fever, body aches, runny nose, sore throat, nausea, or vomiting or diarrhea, you may want to contact their health care provider, particularly if you are worried about your symptoms. Your health care provider will determine whether influenza testing or treatment is needed.

If you are sick, you should stay home and avoid contact with other people as much as possible to keep from spreading your illness to others.

If you become ill and experience any of the following warning signs, seek emergency medical care.

In children emergency warning signs that need urgent medical attention include:

Fast breathing or trouble breathing
Bluish skin color
Not drinking enough fluids
Not waking up or not interacting
Being so irritable that the child does not want to be held
Flu-like symptoms improve but then return with fever and worse cough
Fever with a rash
In adults, emergency warning signs that need urgent medical attention include:
Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen
Sudden dizziness
Confusion
Severe or persistent vomiting

How serious is swine flu infection?
Like seasonal flu, swine flu in humans can vary in severity from mild to severe. Between 2005 until January 2009, 12 human cases of swine flu were detected in the U.S. with no deaths occurring. However, swine flu infection can be serious. In September 1988, a previously healthy 32-year-old pregnant woman in Wisconsin was hospitalized for pneumonia after being infected with swine flu and died 8 days later. A swine flu outbreak in Fort Dix, New Jersey occurred in 1976 that caused more than 200 cases with serious illness in several people and one death.

Can I get swine influenza from eating or preparing pork?
No. Swine influenza viruses are not spread by food. You cannot get swine influenza from eating pork or pork products. Eating properly handled and cooked pork products is safe.

Hand Washing Helps to Prevent Swine Flu

2009-04-27T07:47:00.000-05:00

Monday, April 27, 2009

WASHINGTON — The acting head of the Centers for Disease Control said Monday that people can best protect themselves against the swine flu threat by taking precautions they were taught as kids, like frequently washing their hands.

Asked what individual steps should be taken, Richard Besser replied: "The things that we learned when we were little, covering a cough ... staying home when you have a fever, frequent hand-washing. If people do these things, it will decrease the spread in our communities."

Besser also said the U.S. government is being "extremely aggressive" in the steps it has taken, or is considering, to protect the American public. He said he didn't think he would personally recommend traveling to parts of Mexico where the new virus has taken hold, but noted that no decision has been made on a possible travel ban.

Besser said he was not reassured by the fact that so far in the U.S., no one has died from the disease.

"From what we understand in Mexico, I think people need to be ready for the idea that we could see more severe cases in this country and possibly deaths," Besser said. "That's something people have to be ready for and we're looking for that. So far, thankfully, we haven't seen that. But we're very concerned and that's why we're taking very aggressive measures."

Besser said there can be no one-size-fits-all approach when the severity of the problem varies from area to area. "You cannot see an outbreak occur at the same level in all places," he said.

He also said the government has worked hard to have the necessary medications in place in such a scenario and already has begun distributing them to states.

Asked in one interview why the United States was not issuing travel bans and quarantining passengers at airports, as some countries have done, Besser said: "We are being extremely aggressive in our approach to this outbreak and each day we're evaluating what we're undertaking and we'll make additional measures as necessary. What you're going to see in an outbreak like this is different things taking place in different parts of the country based on what's going on there."

He said that beginning Monday, screening for the illness would being at U.S. borders.

"What we're going to be doing at the borders, and that will be taking place starting today, is doing passive screening, asking people about fever and illness, looking for people who are ill and handing out cards that let people know what's going on in Mexico and what's going on here so people can take action to protect and prepare," Besser said.

The CDC was posting guidelines on its Web site Monday for health departments and members of the public to decide what to do in the event of illness.

The Next Flu Pandemic: What to Expect

2009-04-26T06:25:00.002-05:00

THE STAR PRESS • APRIL 25, 2009 (Background source: U.S. Health and Human Services)

A flu (influenza) pandemic is an outbreak caused by a new human flu virus that spreads around the world. Because the pandemic flu virus will be new to people, many people could get very sick or could die. Seasonal flu shots do not protect people from pandemic flu.

Flu pandemics have happened throughout history. They occur from time to time, and some are worse than others. Three flu pandemics happened in the 1900s. Near the end of World War I, the 1918 Flu Pandemic was the most severe flu pandemic of the century. It killed about 675,000 people in the United States and between 20 to 50 million people around the world.

If you check your family’s history, you may find how your family was affected at that time. Almost everyone was touched in some way by the 1918 Flu Pandemic. Other flu pandemics in the 1900s were less severe. Public health experts say it’s not a matter of IF a flu pandemic will happen, but WHEN. We cannot predict when the next flu pandemic will happen.

We have learned from past flu pandemics that during a pandemic, limiting contact among people helps to slow the spread of the virus and helps to save lives. Being around other people makes you more likely to get sick or to make others sick. The flu could spread and more people could get sick.

Until a vaccine can be made, limiting contact among people will be our main tool for helping to contain the disease and to prevent others from getting it. During a flu pandemic, health officials may ask you and your community to take actions to help limit contact among people. Your daily routines could change for several months. In all flu pandemics, sick people will be asked to stay home. Most people with pandemic flu can be cared for at home. During a flu pandemic, hospitals may only have room to care for patients who are the most ill or require special care.

Make plans now to be able to stay home for at least 10 days if you are sick with pandemic flu. Staying home will keep you from giving it to others. Make a plan for who will take care of you and your household if you get sick. In more severe flu pandemics, even people who are not sick may be asked to stay home.

Household members may be asked to stay home if a person in the household is sick with pandemic flu. This is because other household members may be infected but not sick yet. They could spread the pandemic flu virus to others. Household members may soon get sick, too. Make a plan for your household if everyone has to stay home.

In severe flu pandemics, students may be dismissed from school. Schools, after-school functions, and child-care programs may be closed. Parents may be asked to protect their children by keeping them from being with other children outside of school. Find out what your school or child-care program is planning to do in a pandemic. Plan how you will take care of your children if they need to stay home and how you would limit contact with others.

In severe flu pandemics, people may be asked to limit contact with others in the community and workplace. Places where people gather, such as theaters and places of worship, may be closed. Events such as sporting events or concerts may be delayed or cancelled. Businesses may allow some people to work from home or change work shifts to limit contact between workers. Ask your workplace or community groups what they plan to do.

You and your community need to start planning now while no flu pandemic exists. You need to be ready when the flu pandemic first arrives in your area. Information will be given on local TV, radio, websites, and in the newspaper. Limiting contact among people early will save more lives.

Making plans now will help you to be ready for the next flu pandemic, which could last up to several months. You can look at planning guides to help you, your family, your workplace, and your community at www.pandemicflu.gov.

* Make a list of important contacts for home, school, and work.

* Talk with your neighbors, workplace, and school about how to plan for staying home if you or your household members are sick.

* Think about services you may need and make plans with your service providers.

* Although the flu pandemic may last several months, buy and store at least 2-weeks supplies of food, water, medicine, and facemasks. (Food and supplies may be hard to get during a pandemic.) When you have to stay home, these supplies will support your family and pets.

Be aware, plan ahead, and share with others what you have learned. Together, we can help protect ourselves, our families, and our communities.

A new pandemic flu virus will spread easily from person to person, mostly through coughing and sneezing. When a sick person coughs or sneezes near you, you can breathe in droplets that have the virus. The droplets also could land on surfaces you may touch with your hands.

Get in the habit of washing your hands often and covering your coughs and sneezes. These actions can help you stay healthy now. They also may help protect you and your family during a flu pandemic.

Teach your family the importance of these habits and have them practice now:

* Wash your hands often with soap and water. If there is no soap and water, use an alcohol-based hand gel. Wash your hands before eating, drinking, or touching your face.

* Cover your mouth and nose when you cough or sneeze. Throw used tissues away in a trash can, and wash your hands. If you do not have a tissue, cough or sneeze into your sleeve and not into your hands.

For more information:

* Contact your local or state health department.
* Visit www.pandemicflu.gov.
* Call 1-800-CDC-INFO (232-4636).

(SOURCE: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES)