Coronavirus - Photo Credit WHO
# 7552
This morning Dr. Ian Mackay writes on his Virology Down Under blog about acute respiratory infection (ARI) prevention & control protocols discussed in a recent article in the EMRO Journal, and this morning’s MERS-specific home care advice published by the World Health Organization (see WHO: Homecare Advice For Mild MERS-CoV Cases).
Follow the link to read:
Infection Prevention and Control measures for MERS..mostly as per other ARIs
Credit CDC Get Smart Campaign
# 7021
One of the most common ailments seen by family physicians and emergency departments is the ARI, or acute respiratory infection.
Typically the result of a viral infection (e.g. influenza, rhinovirus, adenovirus, coronavirus, parainfluenzavirus, etc.) – conditions that do not respond to antibiotics – they can occasionally progress into a life threatening bacterial pneumonia.
For that reason many patients insist on having a round of antibiotics `just in case’. A practice of long-standing that has been linked to the rapidly growing problem of increased antibiotic resistance.
Caught in between are busy doctors who must quickly balance each individual patient’s needs (based on patient age, history, frailty - and sometimes - just how `sick’ they look), against prudent public health policy.
To avoid a protracted discussion, all-but-predictable disgruntled patient returns – and the remote, but real possibility of a patient progressing to a bacterial pneumonia – doctors will often oblige and prescribe a course of prophylactic antibiotics.
Today, we’ve a reassuring study appearing in the Annals of Family Medicine, that helps to quantify the risks of not prescribing antibiotics for acute nonspecific respiratory infections (ARIs).
Researchers in the UK used cohort of more than 1.5 million adult patient visits with ARI visits to their primary care provider over a 20 year period (1986-2006). Of these 65% received antibiotics.
Patients receiving antibiotics saw an overall small decrease in the rate of bacterial pneumonia hospitalizations – roughly 8.16 fewer per 100,000 (95% CI, –13.24 to –3.08; P = .002) than those not prescribed antibiotics.
First a link to the study and then a Reuters report, after which I’ll be back with more.
Risks and Benefits Associated With Antibiotic Use for Acute Respiratory Infections: A Cohort Study
Sharon B. Meropol, MD, PhD, A. Russell Localio, PhD and Joshua P. Metlay, MD, PhD
RESULTS The cohort included 1,531,019 visits with an ARI diagnosis; prescriptions for antibiotics were given in 65% of cases.
The adjusted risk difference for treated vs untreated patients per 100,000 visits was 1.07 fewer adverse events (95% CI, −4.52 to 2.38; P = .54) and 8.16 fewer pneumonia hospitalizations (95% CI, −13.24 to −3.08; P = .002).
The number needed to treat to prevent 1 hospitalization for pneumonia was 12,255.
And this report from Reuters Health.
Antibiotics not worth risk in most chest colds: study
By Andrew M. Seaman
NEW YORK | Thu Mar 21, 2013 4:12pm EDT
(Reuters Health) - Doctors need to give antibiotics to more than 12,000 people with acute respiratory infections to prevent just one of them from being hospitalized with pneumonia, according to a new study.
And that small benefit is outweighed by the very real risks that go along with antibiotics - both from serious side effects and the promotion of resistant "superbugs," researchers say.
The practice of medicine is still very much an art, dependent upon the skill and yes, the intuition, of the health care provider. Patients are not statistics, and a one size-fits-all policy for dispensing antibiotics is neither practical or desirable.
But despite decades of warnings, the persistent overuse of antibiotics has led us to the precipice, and we now face an uncertain and potentially frightening future where previously curable infections may run rampant.
A few recent warnings include:
UK CMO: Antimicrobial Resistance Poses `Catastrophic Threat’
MMWR Vital Signs: Carbapenem-Resistant Enterobacteriaceae (CRE)
CDC HAN Advisory: Increase In CRE Reports In The United States
PNAS: Abundant Antibiotic Resistance Genes In Chinese Swine Farms
The bottom line is that our antibiotic development pipeline is pathetically inadequate, and that bacteria are rapidly learning to evade our current arsenal.
If we fail to control the rise in antibiotic resistance, and our current antimicrobial armamentarium fails, the decision whether to give – or not give – antibiotics will eventually become moot.
While it is unlikely to sway many patient’s opinions, hopefully today’s study will provide doctors with a little more reassurance when they opt not to prescribe antibiotics for routine ARIs.
For a more complete look at the complex issues of antibiotic resistance, and the dearth of new drugs on the horizon, I can think of no resource better than Maryn McKenna’s superb book (and recent winner of the 2013 June Roth Memorial Book Award, American Society of Journalists and Authors) Superbug: The Fatal Menace of MRSA.
And while I dabble in the issues of antibiotic resistance, undoubtedly the best coverage can be found on Maryn’s Superbug blog.
# 5244
In March of 2008 I flew from Orlando to Washington D.C. (changing planes in Atlanta) to attend an HHS sponsored Flu conference. As this was prime cold & flu season, passengers on all 4 legs of this trip were sneezing and coughing around me.
And as is appropriate for returning from an influenza conference, two days later I came down with the the `flu’ (actually an Influenza-like Illness).
I’ve no idea exactly where I picked up this nasty viral hitchhiker. It could have been aboard the planes, or it may well have been at the conference (a lot of conversational huddles and handshaking going on), or at the hotel, or during the several hours of waiting in the airport terminals.
Surprisingly, during the 2009 influenza pandemic I made two similar airline trips (to Washington D.C. & Minneapolis) to flu conferences, and managed to evade illness both times.
Go figure.
Which brings us to a study that recently appeared in BMC Infectious Diseases, that looked at the incidence of ARI (Acute Respiratory Infection) presenting within 5 days of train or tram travel in the UK.
First a link, and some excerpts from the abstract, then some discussion on why this is interesting on several levels.
Is public transport a risk factor for acute respiratory infection?
BMC Infectious Diseases 2011, 11:16 doi:10.1186/1471-2334-11-16
Joy Troko, Puja Myles, Jack Gibson, Ahmed Hashim, Joanne Enstone, Susan Kingdon, Chris Packham, Shahid Amin, Andrew Hayward, Jonathan Nguyen-Van-Tam
ABSTRACT
Background:
The relationship between public transport use and acquisition of acute respiratory infection (ARI) is not well understood but potentially important during epidemics and pandemics.
Methods:
A case-control study performed during the 2008/09 influenza season. Cases (n=72) consulted a General Practitioner with ARI, and controls with another non-respiratory acute condition (n=66). Data were obtained on bus or tram usage in the five days preceding illness onset (cases) or the five days before consultation (controls) alongside demographic details. Multiple logistic regression modelling was used to investigate the association between bus or tram use and ARI, adjusting for potential confounders.
Results:
Recent bus or tram use within five days of symptom onset was associated with an almost six-fold increased risk of consulting for ARI (adjusted OR=5.94 95% CI 1.33- 26.5).
The risk of ARI appeared to be modified according to the degree of habitual bus and tram use, but this was not statistically significant (1-3 times/week: adjusted OR=0.54 (95% CI 0.15-1.95; >3 times/week: 0.37 (95% CI 0.13-1.06).
Conclusions:
We found a statistically significant association between ARI and bus or tram use in the five days before symptom onset. The risk appeared greatest among occasional bus or tram users, but this trend was not statistically significant. However, these data are plausible in relation to the greater likelihood of developing protective antibodies to common respiratory viruses if repeatedly exposed. The findings have differing implications for the control of seasonal acute respiratory infections and for pandemic influenza.
The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.
One of the difficult questions that public health officials must contend with are what precautions they should recommend to the public during an epidemic.
As we saw early in the 2009 pandemic, before the risks of the newly emerged H1N1 virus were well established, the CDC was quick to recommend the closing of schools when cases appeared, and a 7-day period of home isolation for infected cases.
Once it became apparent that the virus wasn’t as virulent as first feared - in order to reduce their impact on society - many of those recommendations were relaxed.
In order to make these determinations, much depends on the type and severity of an outbreak, its rate of spread (R0), and the manner in which it is transmitted (ie. aerosolized, large droplet, fomites, orofecal route).
And those are factors that must be established for every novel illness.
Because, if you’ve seen one pandemic . . . you’ve seen one pandemic.
The authors of this BMC study point out that the UK pandemic plan is disrupt the continuity of society as little as possible during a pandemic.
The current UK National Framework for Pandemic Influenza states that during a pandemic, domestic travel should continue to operate normally but users should adopt good hygiene measures, stagger journeys where possible to reduce overcrowding; and stay at home altogether if symptomatic with pandemic influenza [1].
This advice reflects the need to maintain, as far as possible, business continuity and near normal functioning of society, but acknowledges that some data exist about the transmission of influenza on board public transport, notably commercial airliners [2].
Not every country is on the same page with this.
In Japan - prior to the 2009 pandemic outbreak - we saw a different tactic being tested; the enforced separation (by 1 to 2 meters) of passengers on public transportation (see Japan: Social Distancing Test On Commuter Trains).
Granted, these Japanese drills were based on an extremely virulent `bird flu’ type virus.
Understanding how readily viruses may be transmitted in an enclosed environment (like a train, plane, or tram) can help pandemic planners better make crucial decisions.
Interestingly, those who were frequent users of public transportation were slightly less likely to consult their GP for an ARI during this study period, than those who were only occasional users.
Since this study was conducted in the month of December, it is possible that more frequent users of public transportation had already been exposed to the `flu’ earlier in the season, although the authors suggest further study on this finding is warranted.
While a six-fold increase in ARI consultations among recent public transport users is compelling, these results must be accepted with caution.
Among other factors: the size of this observational study was small, it was conducted in a single location (Nottingham, UK), and it was conducted during a normal flu season, not a pandemic.
The authors conclude that while the use of public transport is associated with a significant individual risk for acquiring an ARI during the winter, the UK’s current pandemic policy on public transportation during an epidemic is sound.
The findings support current public advice to exercise good respiratory hygiene and existing pandemic guidance to refrain from making unnecessary journeys by public transport when symptomatic.
The findings do not support the effectiveness of suspending mass urban transport systems as a pandemic countermeasure aimed at reducing or slowing population spread because, whatever the relevance of public transport is to individual-level risk, household exposure most likely poses a greater threat [3].
Coincidentally, we are once again about to witness the busiest travel period of the year; Chunyun, or the Spring Festival Travel Season (of which Chinese New Years is a central part)
It is, quite rightfully, billed as the largest annual migration of humans on the planet. Chunyun begins about 15 days before the Lunar New Year and runs for about 40 days total.
This year, the Lunar New year falls on February 3rd, and with it comes a cultural ethic for millions who have moved to the big cities to return home to visit with their families for a few days.
During this time, it has been estimated that well over 2 billion passenger journeys are taken, mostly by bus and train, across Asia.
With H1N1 still making the rounds, epidemiologists will no doubt be watching to see if a post-Chunyun increase in influenza cases is observed during February across Asia.
# 4681
We’ve a little more information this morning about the events in Tripura, India where 20 or more people have recently died from a `mysterious illness’ (see Newshounds Watching Tripura).
According to a news report today, Tripura’s Health Minister Tapan Chakraborty is describing this as an ARI (Acute Respiratory Infection), and giving the number of deaths as approximately 24 (with 17 of them children).
The cause of the respiratory infection isn’t stated, although an investigation is promised.
For now, the debate seems to have centered around political infighting and affixing blame for the spread of the illness.
Which leaves us – for the time being - not knowing whether this outbreak is due to a pneumonia, an influenza, or perhaps some other respiratory pathogen (RSV, Parainfluenza, metapneumovirus, etc.).
These reports come via Alert on FluTrackers.
ARI claims 24 lives in Tripura
Agartala | Tuesday, Jun 29 2010 ISTAt least 24 people have lost their lives since the past fortnight following sudden spread of acute respiratory infection (ARI) in remote Kangrai hamlet under North Tripura along Tripura-Mizoram border.
Health Minister Tapan Chakraborty said according to hospital records, 24 people had died so far and 50 others were admitted with ARI complications, adding that there was a possibility of few more unrecorded deaths outside the hospital. Unofficial reports said 28 people, including 17 children, had died.
The minister said initial investigation revealed that the deaths occurred due to failure of the health officials to contain the disease in the area and village panchayats were also to be blamed for their careless attitude.
''We are giving our best efforts to control the situation and we have launched investigation into the cause of spread of the disease and all the accused authorities will be dealt with as per law,'' Mr Chakraborty said.
And this from the Tripura Times.
Health Minister holds meeting with officials
Kangrai incident to rock Assembly today
Times News(EXCERPT)
Mr. Nath has already demanded resignation of Health Minister for his alleged failure to check the outbreak of the mysterious disease.The outbreak of mysterious disease that has so far claimed 26 lives has pushed the government in an awaked situation keeping in view of the Assembly session.
The deaths of mysterious disease have exposed the poor health service in the rural areas like Kangrai. Sources said, the treasury bench has also envisaged strategy on how the tackle the opposition members in the Assembly tomorrow.It has been learnt that Health Minister held a meeting with senior Health department officials where he was briefed about the steps taken by the department to tackle the situation.The steps include setting up of a special sub-centre, engagement of a paediatrician at Kanchanpur hospital and house to house surveillance in the entire subdivision.
The government today formally informed the Ministry of Health and Family Welfare about the outbreak of Respiratory Tract Infection (RTI) at Kangrai in Kanchanpur subdivision. The outbreak of RTI has claimed 14 lives, according to an official of Health department.
Obviously, we’ll watch with interest to see what is determined to be the infectious agent in this case.
