What to do next to control the 2019-nCoV epidemic?

The 2019 novel coronavirus (2019-nCoV) infection can lead to acute resolved or fatal pneumonia. On the basis of knowledge of other coronaviruses, the main route of human-to-human transmission of 2019-nCoV is probably through respiratory droplets. As of Feb 4, 2020, statistical data show that the outbreak constitutes an epidemic threat in China, where the exponential increase in patients has reached 20438 confirmed cases, with 2788 (13·64%) patients in critical condition and 425 (2·08%) deaths; 23214 additional suspected cases have also been identified so far. The most affected city, Wuhan, and related regions in Hubei province of China have reported 13522 confirmed patients (66·16% of total cases) and 414 deaths from 2019 nCoV infection (97·41%of total deaths in China). 632 patients with confirmed infection have recovered and have been discharged from hospital. However, the downward turning point for new cases of infection has not been observed yet (figure). Notably, 159 confirmed cases have been reported in 23 other countries beyond China, including Japan, Thailand, Singapore, South Korea, Australia, the USA, Malaysia, and Germany. Because of the seriousness of this outbreak, WHO declared it a public health emergency of international concern on Jan 30, 2020, followed by the USA announcing a public health emergency on Jan 31, 2020.

During the epidemic, rapid and robust research is important to help guide clinical practices and public health policies. Zhu and colleagues sampled bronchoalveolar-lavage fluid from three patients and used next-generation sequencing and PCR to characterise the virus, and they identified the pathogen of this outbreak as a novel coronavirus that falls within the subgenus Sarbecovirus of the genus Betacoronavirus and confirmed the cytopathic effects (structural changes in host cells) of this virus.1 Their achievement not only improves methods of diagnosis confirmation in clinics but also promotes the study of the underlying mechanisms of viral infection.2 Subsequently, collaborations between Chinese and international scientists have rapidly unmasked some additional virological features of 2019-nCoV. A specific viral nucleic acid assay using RT-PCR was quickly developed for the diagnosis of 2019-nCoV infection.3,4Additionally, human angiotensin-converting enzyme 2 has been shown to be the putative receptor for the entry into host cells by use of bioinformatic prediction methods and in-vitro testing.2,5,6 Furthermore, bats are speculated to be the original host of this zoonotic virus, but whether an intermediate host facilitated the viral infection in humans is still unknown.7 Lastly, evidence of person-to-person transmission is accumulating,8,9 with an estimated R0 of 2·2 (95% CI 1·4–3·9),10 and the assessment of the full extent of this mode of transmission is urgently needed.

In The Lancet, two retrospective studies from Wuhan Jin Yin-tan Hospital have recently provided the first-hand evidence of epidemiological, clinical, laboratory, radiological imaging, and outcomes among 41 patients11 and 99 patients.12 Of 99 patients with 2019-nCoV pneumonia,12 the average age was 55·5 years (SD 13·1) and 50 (51%) patients had chronic diseases. Clinical manifestations were fever (82 [83%] patients), cough (81 [82%] patients), shortness of breath (31 [31%] patients), muscle ache (11 [11%] patients), confusion (nine [9%] patients), headache (eight [8%] patients), sore throat (five [5%] patients), rhinorrhoea (four [4%] patients), chest pain (two [2%] patients), diarrhoea (two [2%] patients), and nausea and vomiting (one [1%] patient). In view of the findings from both studies, as well as accumulated clinical experience, the next crucial step would be to identify the proper treatment for patients infected with 2019-nCoV.

No fully proven and specific antiviral treatment for the coronavirus exists. Guidance from China’s National Health Commission suggests taking an anti-HIV drug combination of lopinavir and ritonavir and inhaling a dose of nebulised interferon α for the antiviral therapy.13Many efforts, including several clinical trials, such as NCT04246242 and NCT04252664, are in progress to screen existing antiviral drugs to identify those that could be specific and efficient against 2019-nCoV. Notably, the first reported use of remdesivir, in the first diagnosed patient with 2019-nCoV infection in the USA,14 has encouraged additional clinical study of this medication.

More importantly, patients in critical conditions often develop serious complications, such as acute respiratory distress syndrome (17 [17%] of 99 patients),12and thus medical groups should include physicians with expertise in both infectious diseases and critical care. It is noteworthy that patients in critical condition often show a reduction in peripheral blood lymphocytes.11,12 Whether immune cells infiltrate into the lungs and then cause serious lung lesions (as occurred in patients with severe acute respiratory syndrome [SARS])15 is not clear. Therefore, it is important to understand the lung microenvironment and the map of immune responses against 2019-nCoV infection, which might help to define clinical stages and uncover the pathogenesis of the disease. Recent data showed that mostdeaths were due to respiratory failure;11,12 however, no reports of lung pathology in patients who died from 2019-nCoV infection have been reported so far. Notably, elderly men with 2019-nCoV infection and other underlying diseases often have a higher fatality rate than that of elderly women or younger and more healthy patients;11,12more studies are needed to determine the associated influencing factors underlying this finding.

The development of more efficient and quicker methods for the detection of viral nucleic acids is needed to ensure the accuracy of diagnosis. Several challenges remain for basic research, including viral mutation rateand transmission, infectivity dynamics, and viral infection-associated pathogenicity in vivo. Some evidence has suggested that the virus can spread during the incubation period9,16 and is detectable during the convalescent period.16 Notably, the virus was found in the loose stool of a patient in the USA,14 suggesting potential transmission through the faecal–oral route. It is of high priority to ascertain whether persistent asymptomatic carriers of 2019-nCoV exist and to reach an accurate definition of when a patient can be considered cured. Moreover, no certainty exists about the source of the outbreak, and a prophylactic vaccine is still under development.

WHO has acknowledged the efforts made by the Chinese Government to investigate and contain the outbreak.17 For example, authorities rapidly initiated the first measures to isolate Wuhan, which were then extended to the whole Hubei province, stranding 35 million residents during the heavy-travel Chinese Spring Festival holidays. At the same time, the two new-built hospitals in Wuhan have been put into use, with 2600 beds for the confirmed and suspected patients with pneumonia. The decision makers also extended the holiday period and postponed school openings. Additionally, at least 68 medical teams, including more than 8000 physicians and nurses, from other provinces and cities went to the most affected Hubei province to fight against the disease side by side with the local medical staff.18 The Chinese Government has initiated at least 13 research programmes as an emergency measure to study the different aspects of the outbreak such as the diagnosis, treatment, and prevention of 2019-nCoV-associated disease.19 Novel therapeutic approaches, including treatment with allogeneic mesenchymal stem cells, are expected to progress to clinical trials involving patients with 2019-nCoV infection in a critical condition when the projects meet both ethical requirements and the principle of informed consent (eg, NCT04252118). Furthermore, therapeutic drugs, protective equipment, and charitable funds from inside and outside of China are transported to the epidemic area to support the response. All these measures are aimed to maximise prevention and minimise the occurrence of new infections, which will help the in-time diagnosis and treatment of patients and protect the healthy population against viral infection not only in China but also in the rest of the world. China also faces other challenges, including asymptomatic carriers with 2019-nCoV might be a new potential source of infection; there will be a huge increase in people returning from trips after the Chinese Spring Festival vacation; and it may be difficult to control the outbreak due to the lack of adequate medical resources in epidemic communities and rural areas of Hubei province.

First-line medical staff and scientists in China have had a leading role in fighting the outbreak of 2019-nCoV-associated pneumonia. The basic and essential strategies that we should stick to remain the early detection, early diagnosis, early isolation, and early treatment of the disease. With the huge efforts from medical professionals to treat patients, substantial public health prevention measures, and accelerated research, we hope the downward turning points for both new cases of 2019-nCoV and the resulting fatal events might come soon.

We declare no competing interests.

*Fu-Sheng Wang, Chao Zhang
fswang302@163.com

www.thelancet.comVol 395 February 8, 2020

Treatment and Research Center for Infectious Diseases, The Fifth Medical Center of PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing 100039, China

1
Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020; published online Jan 24. DOI:10.1056/NEJMoa2001017.

2
Zhou P, Yang X, Wang X, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020; published online Feb 3. DOI:10.1038/s41586-020-2012-7.

3
Corman VM, Landt O, Kaiser M, et al. Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Euro Surveill 2020; 25: 2000045.

4
WHO. Laboratory testing of human suspected cases of novel coronavirus (nCoV) infection: interim guidance, 10 January 2020. Geneva: World Health Organization, 2020.

5
Xu X, Chen P, Wang J, et al. Evolution of the novel coronavirus from the ongoing Wuhan outbreak and modeling of its spike protein for risk of human transmission. Sci China Life Sci 2020; published online Jan 21. DOI:10.1007/s11427-020-1637-5.

6
Letko MC, Munster V. Functional assessment of cell entry and receptor usage for lineage B β-coronaviruses, including 2019-nCoV. bioRxiv 2020; published online Jan 22. DOI:10.1101/2020.01.22.915660 (preprint).

7
Lu R, Zhao X, Li J, et al. Genomic characterisation and epidemiology of 2019novel coronavirus: implications for virus origins and receptor binding. Lancet2020; published online Jan 30. https://doi.org/10.1016/S0140-6736(20)30251-8.

8
Phan LT, Nguyen TV, Luong QC, et al. Importation and human-to-human transmission of a novel coronavirus in Vietnam. N Engl J Med 2020; published online Jan 28. DOI:10.1056/NEJMc2001272.

9
Chan JF, Yuan S, Kok KH, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet 2020; published online Jan 24. https://doi.org/10.1016/S0140-6736(20)30154-9.

10
Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020; published online Jan 29. DOI:10.1056/NEJMoa2001316.

11
Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; published online Jan 24. https://doi.org/10.1016/S0140-6736(20)30183-5.

12
Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; published online Jan 29. https://doi.org/10.1016/S0140-6736(20)30211-7.

13
Chu CM. Role of lopinavir/ritonavir in the treatment of SARS: initial virological and clinical findings. Thorax 2004; 59: 252–56.

14
Holshue ML, DeBolt C, Lindquist S, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med 2020; published online Jan 31. DOI:10.1056/NEJMoa2001191.

15
de Wit E, van Doremalen N, Falzarano D, Munster VJ. SARS and MERS: recentinsights into emerging coronaviruses. Nat Rev Microbiol 2016; 14: 523–34.

16
Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-nCoV infection from an asymptomatic contact in Germany. N Engl J Med 2020; published online Jan 30. DOI:10.1056/NEJMc2001468.

17
Wang W, Tang J, Wei F. Updated understanding of the outbreak of 2019 novel coronavirus (2019-nCoV) in Wuhan, China. J Med Virol 202; published online Jan 29. DOI:10.1002/jmv.25689.

18
Huaxia. 68 medical teams sent to Hubei to aid coronavirus control. 2020.Xinhuanet, Feb 3, 2020. http://www.xinhuanet.com/english/2020-02/03/c_138752003.htm (accessed Feb 4, 2020).

19
Ministry of Science and Technology of the People’s Republic of China. Emergency scientific programs on prevention and control of the novel coronavirus-induced pneumonia. Jan 25, 2020. http://www.most.gov.cn/kjbgz/202001/t20200125_151233.htm (accessed Feb 4, 2020).


Hand Hygiene Day: It’s in your hands – prevent sepsis in health care

Sepsis is a life-threatening complication from infection that arises when an infection alters the body’s normal response, causing injury to tissues and organs. Each year, sepsis can cause up to 6 million deaths globally – most of which are preventable.

Sepsis is the most preventable cause of death and disability in Europe. According to the Global Sepsis Alliance, more than 3.4 million individuals develop sepsis every year in the WHO European Region, and 700 000 of these patients do not survive. An additional one third of survivors die within the following year, and many face lifelong consequences, such as physical, psychological and cognitive challenges.

The financial burden due to sepsis has been calculated to be more than US$ 24 billion, representing 6.2% of total hospital costs in 2013. Studies in Europe and Canada estimated the daily costs of hospital care of a septic patient to be between €710 and €1033 in 2000 (equivalent to about US$ 645 and US$ 939, respectively).

On Hand Hygiene Day, observed annually on 5 May, WHO calls on health facilities to prevent health care-associated sepsis through hand hygiene and infection prevention and control (IPC) action. By working together to each play our part, we can prevent sepsis and save millions of lives every year.

To stop sepsis, prevent infection

The first step to stopping sepsis is implementing measures that prevent infections from occurring. The second is preventing infections from evolving into sepsis. In both communities and health-care facilities, this requires early detection of sepsis signs and symptoms and appropriate antibiotic treatment.

In health-care settings, sepsis may result from health care-associated infections. This makes it all the more important for health workers to practise good IPC measures, including effective hand hygiene. Washing hands properly prevents infections and, in turn, reduces the risk of sepsis in health-care facilities.

This year’s Hand Hygiene Day campaign follows a resolution, adopted in May 2017 by the Seventieth World Health Assembly, recognizing sepsis as a global health priority and calling for improved prevention, diagnosis and clinical management of sepsis. It emphasizes 5 calls to action for 5 target audiences:

• health workers: “Take 5 moments to clean your hands to prevent sepsis in health care”;
• IPC leaders: “Be a champion in promoting hand hygiene to prevent sepsis in health care”;
• health facility leaders: “Prevent sepsis in health care, make hand hygiene a quality indicator in your hospital”;
• ministries of health: “Implement the 2017 WHA sepsis resolution. Make hand hygiene a national marker of health care quality”; and
• patient advocacy groups: “Ask for 5 moments of clean hands to prevent sepsis in health care”.

It is also vital to ensure that health workers can recognize, diagnose and rapidly treat sepsis. Despite its tragic impact, sepsis is frequently underdiagnosed at an early stage when it is still potentially reversible.

The evolution of an infection to sepsis can be prevented through early detection of the signs and symptoms, followed by prompt medical care and especially treatment with appropriate antimicrobials. This is crucial to increasing the chances of surviving sepsis. In the case of antimicrobial-resistant infections, which are becoming increasingly common, a patient’s condition can deteriorate rapidly, further underscoring the need for early diagnosis.

Working towards a sepsis-free world

It is possible to envision a world free from sepsis, but this vision will only become a reality through concerted action taken by a range of actors. On Hand Hygiene Day, it is time to collectively commit to raising awareness about the proven approaches to preventing infection, and to encourage everyone – particularly health workers – to recognize that stopping sepsis is in their hands.

WHO/Europe


Ecoli rates soaring despite ministers' pledges to wage war on superbugs

The number of people contracting potentially deadly E.coli infections has risen sharply, despite a Government pledge to wage “war on superbugs”.

Official figures show the number of infections have risen by more than a third since 2013.

Experts said shortages of nurses could be fuelling the trend, with rushed staff paying insufficient attention to infection control.

In 2016, then-health secretary Jeremy Hunt promised to halve so-called gram-negative bloodstream infections – two thirds of which are E. coli cases – by 2020.

But the figures show that since then, E. coli infections have actually increased by nearly 5,000 cases per year.

In 2018/19, 43,242 cases of E. coli infection were recorded – a 34 per cent rise from 32,309 cases six years before.

The figure is a 13 per cent increase since Mr Hunt pledged to crack down on the problem.

And overall rates, compared with the population, have risen by 29 per cent since 2012/13, from 60.4 cases per 100,000 people to 77.7 cases per 100,000.

“Superbug” versions of the bacteria, which are hard to treat because they are resistant to antibiotics, have also seen “consecutive increases” every year, a report found.

The reports, from Public Health England (PHE), show infections were most common in people over the age of 85 and around one in six cases took hold while the patient was in hospital.

Officials warned up to half of patients with E. coli infections had recently interacted with healthcare workers, including in care homes.

E. coli (or Escherichia coli) bacteria are common and mostly live harmlessly in the bowel but can cause infections like food poisoning or cystitis.

Some strains produce toxins which can trigger serious illness if they get into the bloodstream, potentially causing kidney failure or death.

Infections can be spread through contact with contaminated food or water, unhygienic facilities or a lack of personal hygiene.

The PHE report says: “In order to reduce infection rates further, control efforts in the hospital setting must be maintained or strengthened, while increasing focus on interventions in the community and the interface between hospital and community infection control teams improved.”

In his November 2016 announcement, Mr Hunt revealed plans to “dramatically reduce” infections in the NHS to save lives, saying: “Like a many-headed hydra the curse of dangerous infections comes back to haunt us in different ways despite our progress since 2010.”

At the time, E. coli infections killed more than 5,500 patients a year and cost the NHS around £2billion annually.

Prof Hugh Pennington, Emeritus professor of bacteriology at the University of Aberdeen, said most hospital-acquired infections entered the bloodstream through intravenous (IV) lines – tubes used to carry medicines or fluids into the body – which needed to be carefully looked after to prevent infection.

He said shortages of nurses could be fuelling the problem, with too few staff to attend to increasingly unwell elderly patients.

“Common sense says that the fewer nurses you have per patient the more likely it is that something like an IV line will not be as well looked after as it should be,” he said.

The Government has pledged to increase nursing numbers by 50,000, amid warnings of widespread shortages.

In November a survey of more than 8,000 nurses found six in ten felt too busy to provide the level of care to patient that they want to give.

The figure is up from 43 per cent, when the Royal College of Nursing asked the question a decade ago.

Prof Mark Enright, professor of medical microbiology at Manchester Metropolitan University, said Mr Hunt’s target had been “ambitious”.

“Failure to meet these targets could be due to a lack of effective social care in the elderly and inappropriate antibiotic prescribing both in and out of hospital,” he said.

Some E. coli bacteria have evolved to become “superbugs” which are resistant to at least two forms of commonly-used antibiotics. Antibiotic resistance has been named by the World Health Organisation as one of the biggest threats to global health.

Bacteria in up to one in seven E. coli cases recorded in 2018 were resistant to a combination of two common antibiotics, a separate PHE report found.

And 0.04 per cent – around a dozen cases – were resistant to all four known drugs to treat the infection.

“While this proportion is small, patients who fall into this category will have very limited treatment options available,” the report warns.

Dr Susan Hopkins, deputy director, national infection service, at PHE, said:“Our data monitoring in support of the UK’s National Action Plan on Antimicrobial Resistance shows cases of MRSA and C. difficile bloodstream infections are low and cases of E.coli infections have remained stable in the most recent year.

“Inappropriate GP prescribing has reduced, but there can be no complacency and we continue to support the NHS and the government’s effort to cut gram negative infections.”

By Laura Donnelly, Health Editor Rosie Taylor

Published 29. December 2019  telegraph.co.uk/news/2019/12/29


Patient safety: too little, but not too late

The first-ever World Patient Safety Day is taking place on Sept 17, 2019. Every day, countless patients worldwide are put at risk by unsafe care and end up requiring treatment for ailments caused by the very system that was supposed to help them get better. Protecting patients from errors, injuries, accidents, and infections is an essential goal for every health system, but no health system has so far successfully addressed patient safety.

Some of the statistics proffered by WHO to high-light patient safety are striking. In low-income and middle-income countries (LMICs), 134 million adverse events per year are directly attributable to unsafe care. These adverse events—including misdiagnosis, hospital-acquired infections, and medical errors—lead to 2·6 million unnecessary deaths. Worldwide, the risk of patient death because of a preventable medical accident is one in 300. One in ten patients suffer injury while receiving health care, and 15% of all hospital expenses are incurred as a result of treating failures in patient safety.

Patient safety hinges on quality of care. The Lancet Global Health’s 2018 Commission highlighted the need for “high-quality health systems that optimise health care in each context by consistently delivering care that improves or maintains health”. It feels obvious to state that a health-care system should aim to improve the health of those accessing it. Similarly, all health professionals expect that patients will have their condition improved by health care. However, the data compiled by WHO should be a wake-up call as they would be in any other industry. So what can be done?

First, do no harm. The safety of patients must be the paramount concern of professionals and the systems they work in. Rather than a platitude, this ask is an exhortation to strengthen systems, build better infrastructure, and value strong leadership. Reporting in US hospitals shows some health-care-associated infections can be reduced by as much as 70% with proper patient safety interventions that include stan-dardised clinician education, proper notification processes, and strict hand hygiene procedures. However, the WHO hand hygiene guidelines sug-gest compliance with proper hygiene can be as low s 40%. Hence, a greater effort needs to be made in monitoring and ensuring that basic practices of patient safety are strong and robust across all institutions, no matter how obvious the need for such procedures.

Second, health professionals must recognise that patient safety is a two-way partnership. Patients must be involved—indeed be central—in their own care. The myriad ways inadvertent harm can be done to patients indicate that everyone, from policy maker and health advocate to caregiver and health worker, holds a vital stake in patient safety. Indeed, evidence suggests that involving patients, service users, and carers in important decisions relating to care and treatment strengthens patient safety and is the best way for patients to achieve a positive outcome. As WHO comments, “safe health care starts with good communication”.

Finally, awareness of the burden that patient safety requirements place on LMICs is needed: addressing all improvements necessary for increased patient safety require resources. Two-thirds of all adverse events resulting from unsafe care occur in LMICs. Health professionals in high-income countries must ask themselves what they can do, not just to promote patient safety in their own system but also to offer outreach, support, resources, and expertise to LMICs bearing the burden of raised patient safety standards, rapidly changing disease patterns, and expectations of achieving the same development goals.

Recognising the importance of patient safety world wide is something that strikes right at the philosophical heart of health care. A Comment in this issue highlights how patient safety is now a core part of the move towards universal health coverage and states, importantly, that “addressing systemic, organisational, cultural and behavioural drivers of patient harm remains extremely challenging and a lot of known problems remain unsolved”. World Patient Safety Day is a prompt to everyone involved in care to examine their role in contributing to these drivers. In the treatment of immediate illness, health-care systems must offer best practice and consistent treatment for all patients, and at all levels, to ensure further damage is prevented.

The Lancet
www.thelancet.com Vol 394 September 14, 2019


Antibiotics cannot treat the flu or the common cold

The only common illness that affects children and requires an antibiotic every time is strep throat. Doctors won’t prescribe antibiotics if your child is sick with the flu or a cold because the treatment would be useless for those conditions.

Taking antibiotics when they’re not necessary can lead to antibiotic resistance in the body, one of the most urgent threats to public health, according to the Centers for Disease Control and Prevention (CDC).

“Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die as a direct result,” according to the CDC. “Many more die from complications from antibiotic-resistant infections.”

Antibiotics are used to treat serious infections such as pneumonia and life-threatening conditions such as sepsis. Sometimes people at high risk for developing infections also need antibiotics, such as patients who have end-stage kidney disease, patients undergoing surgery or those receiving chemotherapy treatment, according to the CDC.

But viruses that cause colds, the flu, bronchitis or runny noses cannot be treated with antibiotics.

When are antibiotics appropriate?

In short, antibiotics only work on bacteria and not on viruses.

“Using an antibiotic when you don’t need it is a problem because these drugs don’t just kill off harmful bacteria; they also take a toll on the beneficial bacteria inside your body that help to help keep you healthy,” according to Harvard Medical School.

But even some bacterial infections get better without antibiotics, according to the CDC. “Antibiotics aren’t needed for many sinus infections and some ear infections,” reports the CDC. “Antibiotics save lives, and when a patient needs antibiotics, the benefits usually outweigh the risk of side effects and antibiotic resistance. When antibiotics aren’t needed, they won’t help you, and the side effects could still cause harm.”

When children need antibiotics

For children with the common cold, the flu or an upset stomach, antibiotics are not the answer. In fact, they could cause more harm than good down the road when the body actually does need these life-saving drugs.

According to Memorial Regional Health, strep throat is really the only common illness that affects kids that requires an antibiotic every single time. For other illnesses, MRH doctors will likely tell you to keep your child home from school to rest and drink plenty of fluids.

Taking unnecessary antibiotics doesn’t just affect the person taking them — including raising the risks of side effects that could cause harm such as nausea, dizziness, rash, diarrhea and yeast infections — but they also could cause harm to the community at large. When people become resistant to these drugs, the risk of the spread of certain diseases increases, such as tuberculosis, gonorrhea, typhoid fever and Group B streptococcus, reports the World Health Organization.

So, how do you avoid getting bacterial infections in the first place? Practice good hygiene, make sure you and your children receive recommended vaccinations, reduce your risk of foodborne illness by cooking foods properly and washing your hands. And finally, don’t take antibiotics when you don’t need them.


November 13, 2019

By Lauren Glendenning/
Brought to you by Memorial Regional Health
Link to article


Hand Sanitizer Won't Kill Norovirus?

Hand sanitizer is a daily staple for parents on diaper duty, commuters who hold those rarely-cleaned handle bars on buses and subways, and many other people in between. In fact, according to global information company NPD Group, hand sanitizer sales in the United States shot up 37 percent from 2017 to 2018 alone. And while it’s perfectly fine to turn to this bottled product as a last resort, you shouldn’t opt for hand sanitizer over washing your hands in the sink if there’s clean water and soap available to you.

As it turns out, there’s a reason why most hand sanitizer companies don’t claim to kill 100 percent of germs and bacteria: Because they don’t. Some of the viruses and germs you’re leaving on your hands every time you opt for hand sanitizer instead of soap and water.

According to the Centers for Disease Control and Prevention (CDC), norovirus is a “very contagious virus” that can be spread via direct contact, contaminated food or drinks, and contaminated surfaces. And while thoroughly washing your hands (and your produce) is a good way to ensure your safety, using alcohol-based hand sanitizer isn’t quite as effective.

In one 2011 study published in the American Journal of Infection Control, researchers analyzed data from health departments in three states and found that the facilities that relied on hand sanitizer were more likely to experience a norovirus outbreak than those that favored hand-washing.


Epidemiology and impact of norovirus outbreaks in Norwegian healthcare institutions, 2005–2018

Outbreaks in healthcare settings affect vulnerable populations, disrupt normal routines and may spread to other healthcare institutions (HCIs). Outbreaks can be limited in extent by good routines for detection, management of cases and other infection-control measures [1]. Norovirus infection is most often seen in the winter months and is a common cause of outbreaks in HCIs [2] as it has a low infectious dose, short incubation period, and symptoms such as diarrhoea and vomiting which facilitate spread. Symptoms normally lasts around one to three days, but can be longer in hospital patients [3]; and in this type of setting, infection can lead to slower recovery from other illness and even death [4]. Norovirus can be divided into several genogroups and genotypes [5]. Genogroup II genotype 4 is the most prevalent genotype globally [6] as well as in the Nordic countries [6]. There is no vaccine and immunity is not well understood; at best it is strain-specific but probably only partial and shortlived as the virus readily undergoes mutation [7, 8]. Humans are the only reservoir of the virus and spread of the infection in outbreaks is particularly difficult to control because of the low infectious dose, its stability in the environment and efficient transmission by person-to-person contact and exposure through contaminated surfaces [9]. Norway has national recommendations on norovirus infection in long-term-care facilities (LTCFs) in which the most important measure is isolation or cohort nursing of sick residents. Exclusion of sick staff until 48 h after they are symptom free is also recommended [10]. In a hospital setting, the infection-prevention-control unit will have local procedures. There are around 60 hospitals and 950 LTCFs in Norway [11]. The responsibility for management of local outbreaks lies within the hospital or with the community medical officer (one in each of the 422 municipalities) for outbreaks in LTCFs. All suspected outbreaks in Norwegian HCIs, regardless of the causative pathogen, should be alerted by law to relevant actors, including the Norwegian Insititute of Public Health (NIPH), to facilitate communication and response [12, 13]. The aim of this study was to describe, for the first time, the epidemiology and impact of these outbreaks in order to identify areas which may improve outbreak response.

This study shows that norovirus outbreaks pose an important burden for HCIs all over Norway, especially in the winter months. In addition to affecting an already vulnerable population, this study shows that these outbreaks indeed also impact on the internal workflow and resources, with a conservative estimate of around 1800 days of absenteeism per year due to these outbreaks, during which staff would have to be covered for by other internal or external healthcare staff.

Surveillance of norovirus outbreaks exists in Germany and Scotland. In Germany, reporting of norovirus outbreaks in HCIs has been mandatory since 2001. In contrast to what is seen in Norway, outbreaks were smaller (median nine cases vs 15 in this study) and around 80% of norovirus outbreaks were reported from hospitals (vs 23% in this study) during the first 12 months after introduction of the system [15]. Varying ways of counting interdepartmental outbreaks, better collaboration with the local level or under-reporting from hospitals may explain this. In Scotland, surveillance of ward closures due to norovirus infection has been in place since October 2017. From then until week 26, 2018, 219 wards or bays have been closed due to confirmed or suspected norovirus [16]. This is markedly more than the 16 reported outbreaks in hospitals in Norway 2017/18, in a population of similar size. The occurrence of norovirus outbreaks has also been studied prospectively; Curran et al. [17] aimed to identify the index cases of norovirus outbreaks in the UK and Ireland in 54 acute and non-acute healthcare centres; only five out of the 54 included centres did not experience any outbreak during one winter. Also, Lopman et al. found that 171 inpatients units, had on average 1.3 gastroenteritis outbreaks in the 1-year follow-up period. Of these, 63%were caused by norovirus [2].

It was seen that a small proportion of residents at LTCFs were admitted to hospital during norovirus outbreaks. This may be necessary in severe cases despite the risk of spread from one institution to the next. Our results suggest that hospitals are affected by norovirus outbreaks earlier in the epidemiological year than LTCFs. Potentially because there is a greater influx of patients from the community, where norovirus circulates, to and from hospital than between the community and LTCFs as also suggested by Sadique et al. [18]. This finding, however, could only be evaluated on the national level, as the number of reported outbreaks is low. That the start of the outbreak season seemed to start earlier in hospitals than in LTCFs, at least at the national level, suggests an opportunity that with improved communication, hospitals could alert LTCFs within the same area in order to prepare for the outbreak season and limit the extent of further outbreaks.

Slightly more cases were seen amongst healthcare staff in hospitals compared to LTCFs, though no information about the number of healthcare staff at risk during the outbreaks is available. The patient or resident:healthcare-staff ratio varies with the level of care needed and type of department and will most often be higher in hospitals. Whether this explains the slightly higher proportion of staff affected in hospital outbreaks is unknown. Nevertheless, healthcare staff do represent a big proportion of cases in the reported outbreaks, indicating a need for improved compliance with infection prevention and control measures. Outbreaks are an economic burden for HCIs, both as infected staff need to be covered for during illness and ‘quarantine’ and cohort nursing may require extra staff.

The relatively high number of people infected during an outbreak underscores the infectiousness of norovirus and norovirus can serve as a worst-case scenario for introduction of other, more virulent, person-to-person transmitted pathogens into HCIs. With the current information captured in the alert system, it was not possible to assess the extent to which national recommendations were followed and/or which infection prevention control procedures are in place locally. But the high number of people infected do suggest a potential for limiting spread, for example by having systems and routines in place before outbreaks happen, as advised in the national recommendations.

Even though NIPH routinely promotes the web-based outbreak alert system and teaches outbreak management, both at the regional and national level, in order to strengthen local capacity and encourage the use of the alert system, under-reporting is still apparent. If the under-reporting of outbreaks reflects a lack of awareness concerning outbreak management, or a lack of communication between the LTCF and the municipal doctors about ongoing outbreaks, it is worrying. The alert system serves to alert relevant stakeholders so that outbreak support and advice can be given in an early phase. The alert system can also be used for statistical purposes to get a national overview of outbreaks which will facilitate targeted capacity building, guideline development and communication messages in order to increase awareness and investigate whether there are any changes in trends.

Limitations
This study has three main limitations: the sensitivity of the norovirus outbreak definition and under-reporting of number of outbreaks and number of cases in each outbreak. Classification as a norovirus outbreak is dependent on local definitions. The infection prevention measures for diarrhoea and vomiting are the same for all the common pathogens in this setting. Samples were submitted for testing in two thirds of the outbreaks and most were confirmed as norovirus at the time of reporting or updating. Information about the genotypes of the isolated strains from each outbreak or of dominant strain of the season was not available. For this reason, it was not possible to evaluate the effect of the genotype.

Concerning under-reporting, the number of outbreaks notified through the outbreak alert system and reported here, most likely represent only a proportion of all norovirus outbreaks occurring in Norwegian HCIs. Although outbreaks were reported from all parts of Norway, some areas had not reported any outbreaks of any kind during the 13-year study-period.

The alert system is used for the mandatory alerting of suspected outbreaks. Reporting should happen as soon as the outbreak is suspected and before the full extent of the outbreak is known. Even though the system sends a reminder to update the details about the outbreak, including the case numbers, three weeks after the initial alert, some under-reporting of the extent of each outbreak is expected.

This is the first comprehensive description of norovirus outbreaks in HCIs in Norway. Even though the analyses revealed under-reporting that is unlikely to reflect the real epidemiology, this study clearly shows that these outbreaks affect both hospital and LTCFs all over Norway. Norovirus infection may delay medically important procedures and recovery, but also presents a major challenge to the functional ability of an HCI and its resources as up to one-half of cases were healthcare personnel.

It is recommended that NIPH promotes the outbreak alert system to increase reporting and improve the quality of the data and strengthen local capacity for outbreak management and general infection control. It is also recommended to investigate possibilities for improving communication between hospitals and LTCFs regarding when the norovirus season starts and progresses, for hospitals and LTCFs to be prepared and to take early action to prevent and limit further spread.

Read full article: https://www.journalofhospitalinfection.com/article/S0195-6701(19)30268-3/fulltext?dgcid=raven_jbs_etoc_email

© 2019 The Authors. Published by Elsevier Ltd on behalf of The Healthcare Infection Society.


A Breeding Ground for a Fatal Scourge: Nursing Homes

From The New York Times:

Drug-resistant germs, including Candida auris, prey on severely ill patients in skilled nursing facilities, a problem sometimes amplified by poor care and low staffing.

https://www.nytimes.com/2019/09/11/health/nursing-homes-fungus.html

“They are caldrons that are constantly seeding and reseeding hospitals with increasingly dangerous bacteria,” said Betsy McCaughey, a former lieutenant governor of New York who leads the nonprofit Committee to Reduce Infection Deaths. “You’ll never protect hospital patients until the nursing homes are forced to clean up.”

Resistant germs can then move from bed to bed, or from patient to family or staff, and then to hospitals and the public because of lax hygiene and poor staffing.

A recent inquiry by the New York State Department of Health found that some long-term hospitals grappling with C. auris were failing to take basic measures, such as using disposable gowns and latex gloves, or to post warning signs outside the rooms of infected patients. At one unnamed facility, it said, “hand sanitizers were completely absent.”

https://www.ncbi.nlm.nih.gov/pubmed/30753383


Antibiotic Resistance and the Importance of Hand Hygiene | Infection Control Today

The increasing risk of antibiotic-resistant infections is a threat in todayʼs world but can be reduced through key interventions such as hand hygiene. Better hand hygiene cannot eliminate all infections, but because of the central role contaminated hands play in a large number of infections, better hand hygiene practices used broadly in society would help to reduce the risk of infections in general and for those that are antibiotic resistant as well.

Read more about it here: https://www.infectioncontroltoday.com/hand-hygiene/antibiotic-resistance-and-importance-hand-hygiene


Historical perspective on hand hygiene in health care

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. Geneva: World Health Organization; 2009.

Handwashing with soap and water has been considered a measure of personal hygiene for centuries48,49 and has been generally embedded in religious and cultural habits (see Part I, Section 17). Nevertheless, the link between handwashing and the spread of disease was established only two centuries ago, although this can be considered as relatively early with respect to the discoveries of Pasteur and Lister that occurred decades later.

In the mid-1800s, studies by Ignaz Semmelweis in Vienna, Austria, and Oliver Wendell Holmes in Boston, USA, established that hospital-acquired diseases were transmitted via the hands of HCWs. In 1847, Semmelweiss was appointed as a house officer in one of the two obstetric clinics at the University of Vienna Allgemeine Krankenhaus (General Hospital). He observed that maternal mortality rates, mostly attributable to puerperal fever, were substantially higher in one clinic compared with the other (16% versus 7%).50 He also noted that doctors and medical students often went directly to the delivery suite after performing autopsies and had a disagreeable odour on their hands despite handwashing with soap and water before entering the clinic. He hypothesized therefore that “cadaverous particles” were transmitted via the hands of doctors and students from the autopsy room to the delivery theatre and caused the puerperal fever. As a consequence, Semmelweis recommended that hands be scrubbed in a chlorinated lime solution before every patient contact and particularly after leaving the autopsy room. Following the implementation of this measure, the mortality rate fell dramatically to 3% in the clinic most affected and remained low thereafter.

Apart from providing the first evidence that cleansing heavily contaminated hands with an antiseptic agent can reduce nosocomial transmission of germs more effectively than handwashing with plain soap and water, this approach includes all the essential elements for a successful infection control intervention: “recognize-explain-act”.51 Unfortunately, both Holmes and Semmelweis failed to observe a sustained change in their colleagues’ behaviour. In particular, Semmelweis experienced great difficulties in convincing his colleagues and administrators of the benefits of this procedure. In the light of the principles of social marketing today, his major error was that he imposed a system change (the use of the chlorinated lime solution) without consulting the opinion of his collaborators. Despite these drawbacks, many lessons have been learnt from the Semmelweis intervention; the “recognize-explain-act” approach has driven many investigators and practitioners since then and has also been replicated in different fields and settings. Semmelweis is considered not only the father of hand hygiene, but his intervention is also a model of epidemiologically driven strategies to prevent A prospective controlled trial conducted in a hospital nursery and many other investigations conducted over the past 40 years have confirmed the important role that contaminated HCWs’ hands play in the transmission of health care-associated pathogens (see Part I, Sections 7–9).

The 1980s represented a landmark in the evolution of concepts of hand hygiene in health care.infection. The first national hand hygiene guidelines were published in the 1980s,53–55 followed by several others in more recent years in different countries. In 1995 and 1996, the CDC/Healthcare Infection Control Practices Advisory Committee (HICPAC) in the USA recommended that either antimicrobial soap or a waterless antiseptic agent be used56,57 the rooms of patients with multidrug-resistant pathogens. More recently, the HICPAC guidelines issued in 200258 defined alcohol-based handrubbing, where available, as the standard of care for situations only. The present guidelines are based on this previous document and represent the most extensive review of the evidence related to hand hygiene in the literature. They aim to expand the scope of recommendations to a global perspective, foster discussion and expert consultation on controversial issues related to hand hygiene in health care, and to propose a practical approach for successful implementation (see also Part VI).

As far as the implementation of recommendations on hand hygiene improvement is concerned, very significant progress has been achieved since the introduction and validation of the concept that promotional strategies must be multimodal to achieve any degree of success. In 2000, Pittet et al. reported the experience of the Geneva’s University Hospitals with the implementation of a strategy based on several essential components and not only the introduction of an alcohol-based handrub. The study showed remarkable results in terms of an improvement in hand hygiene compliance improvement and HCAI reduction.60 Taking inspiration from this innovative approach, the results of which were also demonstrated to be long-lasting,61 many other studies including further original aspects have enriched the scientific literature (see Table I.22.1). Given its very solid evidence base, this model has been adopted by the First Global Patient Safety Challenge to develop the WHO Hand Hygiene Improvement Strategy aimed at translating into practice the recommendations included in the present guidelines. In this final version of the guidelines, evidence generated from the pilot testing of the strategy during 2007–2008 is included (see also Part I, Section 21.5).62

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hand hygiene practices in health-care settings, whereas handwashing is reserved for particular