New CDC flu numbers: This may not go well

(Constant readers: Apologies for the slow blogging. Casa Superbug's little medical crisis from a week ago has recurred, and things are a bit distracting. Back to normal soon, I hope.)

In public health, one of the numbers you hear most often — and especially so the past few years — is 36,000. That's the number of deaths that the CDC estimates occur in an average year from influenza.

Or rather, estimated. Because today, in its weekly bulletin MMWR and also in a teleconference for the press, the CDC announced that it is discarding that widely used number, in favor of newer numbers from newer studies that take into account the wide variation in illness and death from one flu season to the next.

The new estimate is: 23,607. Or, a range that goes from 3,349 to 48,614. Or, in the language recommended by a CDC scientist and a communications specialist in the press call, "tens of thousands of people [who] may die each year in an average flu season."

If that sounds difficult to communicate in a concise manner, well, the reporters on the CDC call today clearly thought so too. And while reporting study results forthrightly is transparent, and more precise numbers are almost always better, I can't help but wonder whether this attempt at precision and transparency will not be received well. After all, we are only a few months (or a few weeks, depending whose end date you accept) away from the dribbling conclusion of a worldwide pandemic that was taken so not-seriously by the public that, in the US, 71 million doses of H1N1 vaccine went unused — and in Europe, some public representatives alleged that the entire emergency was a concoction by pharmaceutical companies.

Given that history, putting out a public message that flu kills fewer people than we thought — but is, still, a serious disease that should be planned for and vaccinated against — sounds like a hard sell.

Here's how today's new numbers came about:

The mortality rate from flu has always been difficult to assess: People die of influenza directly, but they also die of underlying conditions — heart disease or chronic obstructive pulmonary disease, among others — that might not kill the person if influenza were not putting an extra strain on the system. In either case, but especially in the latter, the death may not be attributed to flu, particularly if the victim has not been tested for the presence of the flu virus.

So, to arrive at an estimate, the CDC has used a statistical model. As explained in the briefing today by Dr. David Shay of the CDC's Influenza Division:

We have two categories that we look at... One is death certificates that have an underlying diagnosis of pneumonia or influenza. 99% of those deaths are actually coded as pneumonia. So, that's to make an estimate of deaths in a particular season from pneumonia that are associated with flu. And typically, that's about 8.5% of deaths over the time period that we looked at...  The broader category of respiratory and circulatory deaths we think encompasses the full picture of influenza-associated deaths, including things such as people who might die because of worsening chronic obstructive pulmonary disease or worsening congestive heart failure that results in death after an infection. And we estimate that about 2% of that broader category in any typical year is associated with influenza.

One other factor affects flu mortality: Which flu strain type is dominant in the season being measures. Flu is generally taken to cause the most severe disease, and the greatest number of deaths, in the elderly; but some strains cause more severe disease than others, and some (H1N1 "swine" flu, for instance) attack the young, who are healthier and less likely to die, more than they do the old. Again, Shay:

[I]t's important to keep in context, which we don't really describe in this article because of space, that there's at least four factors that affect sort of flu mortality in any particular year, and those four would be the specific strain or influenza strains that are in circulation, sort of the length of the season or how long influenza is circulating in the united states, how many people get sick, because of course, the more people get sick, there is more likely to be more serious outcomes, and finally, who gets sick.

In the study released today, the CDC did two things: It broadened the range of flu seasons from which it took data to feed into the statistical model, and it took a second look at the years on which the previous model, the one that produced the 36,000-death estimate, was based.

When the range of years was broadened to 31 flu seasons (1976-77 to 2006-07), here's what shook out:

• For deaths from influenza and pneumonia: from 961 in 1986-87 to 14,715 in 2003-04, an average of 6,309
• For deaths from respiratory and circulatory complications: from 3,349 in 1986-87 to 48,614 in 2003-04, an average of 23,607.

(When asked which number should be used for shorthand, Shay said: "The broader category of respiratory and circulatory deaths we think encompasses the full picture of influenza-associated deaths.")

When the 36,000-death estimate was re-examined, Shay said:

The 36,000 number that's often used pertains to a very specific time period from 1990 to 1999. And in that decade, where we had prominent circulation of H3N2 viruses, they were prominent in eight of the nine seasons that are contained within the data that were used to make that estimate, and those are, as you know, typically more severe seasons. We had a high mortality for that nine-year period.

According to the MMWR analysis, mortality rates in the H3N2 years were 2.7 times higher than in years when other types were dominant.

So that's the rationale behind today's dialed-down numbers. Here's the potential problem with it: It just took me about 1,000 words to (somewhat talkily) explain. It requires patience and detail to impart, which in the current media environment are in very short supply. As one of the participants on the call said today:

I'm really scratching my head here wondering what I'm going to use, because we really don't have a lot of time ... to present a lot of numbers, and I think in a sense to say that the range is 3,000 or 3,300 to 49,000 raises a lot of questions, and I think we don't have time to answer those questions in every report. And I also wonder if it's not a bit misleading to use 3,300 as the bottom number since it's been 20 years since it was that low, and even in the last 20 years, the mortality has never been much below 12,000.

You see the problem.

To repeat: This is an effort at transparency and accountability; those are worth applauding. But it's also a nuanced and difficult health-communication message, launched into a zeitgeist already tuned toward conspiracy theories and a media marketplace with little time or expertise to counter them.

Pessimistically, I wonder how long it will be before this message gets transformed into something like, "See? I told you so. Flu isn't that big a deal after all." I hope the CDC is prepared when it does.

(Here's today's MMWR article, the transcript of the press briefing, and a Q&A on the new calculation. The cite is: Morbidity and Mortality Weekly Report, "Estimates of Deaths Associated with Seasonal Influenza --- United States, 1976--2007." August 27, 2010. 59(33);1057-1062)

Quick alert: Congressional hearing Wednesday

Constant readers, I'm on the road again: Georgia Center for the Book tonight in Decatur, 7:15 p.m. But if you can't make that, take a look at this: The Energy and Commerce Subcommittee of the US House of Representatives has announced a hearing for Wednesday on "Antibiotic resistance and the threat to public health."

This is not a hearing on PAMTA, but apparently a broader hearing on the whole issue, featuring two VIPs: Dr. Anthony Fauci of NIH and Dr. Tom Frieden of the CDC. To my eye, this indicates that official, policy interest in this issue is (finally, at last) ramping up.

The hearing page is here and the preliminary memo on it is here.

Child deaths from flu + MRSA: CDC confirmation

Hello again, constant readers. It's been an exciting few weeks at Casa Superbug. I'll spare you the details — most of them are both grueling and trivial — but out of the murk, here is a piece of excellent news: SUPERBUG has been edited, revised and sent back to the publisher, who has sent it into production. Yes, it's actually beginning to become a book. There are many more steps to go, but it it is finally, really on its way.

Meanwhile, there is a ton of MRSA news to catch up on, which I will roll out over the next week or so. First: For those of you who don't read the CDC's weekly bulletin (called the MMWR, for Morbidity and Mortality Weekly Report. It's the best-read magazine you've never heard of. It's free. Go already), there was an important and disturbing report last Friday, reporting the case details of children who have died from H1N1 flu.

As of August 8, the CDC said, 477 people had died in the US from H1N1, and 36 of them were children and teenagers. Out of those 36:

• 7 were younger than 5
• 24 had at least one high-risk medical condition, many of them neurological (developmental delay, cerebral palsy) or pulmonary; 12, or one-third, did not
  
• 23 had some pathologic analysis done during their illness or after their deaths
• 10 had bacterial co-infections
• of those 10, 5 had staph infections
• 3 of the staph infections were MRSA.

Let's bring the first and last terms of that equation together: 36 children; 3 known MRSA infections. Though it could be an underestimate (because 13 children had no pathology done), that is a non-trivial 8%.

The report splits the data on the child deaths a number of different ways, and reveals details that are important to note. Six of the bacterial infections (four staph) were in children older than 5 who did not have any underlying conditions; they were healthy, normal kids before developing flu. Of the 7 kids younger than 5, 2 had a bacterial infection; again, neither child had a high-risk condition.

How worrisome are these numbers? It's hard to say with precision, but they are certainly not good news. The CDC has only been counting child deaths from flu for a few years, and the totals they have come up with are very variable: 153 in 2003-04, 47 in 2004-05, 46 in 2005-06 and 73 in 2006-07. But, important point: Those deaths were during the regular flu season, which goes from roughly October to March. These new deaths occurred between late April and early August, when there is not supposed to be any flu. What this will mean for this fall and winter, when H1N1 will still be around, and may co-circulate with seasonal flu, no one yet can say.

For our purposes, the most important point is that lethal MRSA co-infections are now confirmed to be happening in the setting of H1N1 flu. And, as the CDC paper notes, these infections happened in children who would not have been expected to have a tough course, because they had no underlying high-risk conditions:

This report also highlights the prominence of laboratory-confirmed bacterial coinfections, which were identified in 10 (43%) of the 23 children who had culture or pathology results reported. All six children who were aged ≥5 years, did not have a high-risk medical condition, and had culture or pathology results reported had an invasive bacterial coinfection, suggesting that bacterial infection, in combination with 2009 pandemic influenza A (H1N1) virus infection, can result in severe disease in children who might be otherwise healthy. Clinicians should be aware of the potential for severe bacterial coinfections among children diagnosed with influenza and treat accordingly.

Obviously those of us who are concerned about MRSA and the potential for MRSA pneumonia alongside flu have been worried about this (long archive of posts here). If there is any good news in the sad saga of these deaths, it is that the CDC has confirmed that MRSA pneumonia in H1N1 flu is a real and dangerous possibility.

So if you are concerned about this, first, bookmark the MMWR report, because it will be something to show to a physician if necessary. And second, keep in mind the potential for pneumonia if you have a young child who contracts H1N1. I am not suggesting being alarmist; if H1N1 circulates widely, doctors and ERs will be overwhelmed, and we should try not to add to their case load unless really necessary.

But on the other hand, if a child has chest pain or breathing difficulty, don't hold back. There are online tools such as this one by Children's Healthcare of Atlanta that can help a worried parent assess whether and when a child with flu should be taken to the ER. If you click through its steps, you'll see that breathing difficulties and the possibility of pneumonia are things that it takes seriously, and so should we.

Special extra for disease-detection wonks

Constant readers: Some of you know that my first book, published five years ago, was a narrative and history of the CDC's Epidemic Intelligence Service, the young, committed corps of MDs and PhDs who give up two years of their lives to serve on front-line outbreak SWAT teams.

The EIS are very important right now, because there are almost 100 CDC people in the field, in Mexico and in US cities and other countries where H1N1 swine flu is emerging.

My next book — the one for which this blog is the whiteboard — is being published by the same imprint, Free Press, part of Simon & Schuster. So because the EIS is so crucial to the outbreak investigation, FP has relaxed their rights and very graciously allowed me to fling up some parts of Beating Back the Devil on the web, for free, to my regular readers.

My web skills are not magnificent, and my site has outgrown the program I used to build it. However: If you go to this page, you'll see a section that announces Excerpts! And in it you'll find a prologue and two chapters in various formats. (We did this fast; it is messy. Sorry.)

I particularly recommend Chapter 13 [pdf], which is a narrative of the SARS outbreak in Asia, starting with an EIS officer named Dr. Joel Montgomery staring down a tray of blood samples in a laboratory in Vietnam. (I wrote about the importance of serology — blood-analysis — surveys to swine flu at CIDRAP tonight.) The description of that outbreak response should give you a good flavor of what the CDC investigators are doing and thinking about now. And, bonus, it talks about some little-known cases of avian flu H5N1; we did not know at the time how important those cases would turn out to be.

If you have time, there are also links to sections that FP has posted on their own site: Chapter 1, which will tell you who the EIS are and why the corps exists (Korean War veterans will know already); and the book's Prologue, which takes you inside the first bioterror-response training that EIS members ever endured.

I hope you enjoy.

For flu wonks: Hear from a CDC expert on novel H1N1 "swine" flu

Folks, I am a member of the Association of Health Care Journalists, a US-based organization of 1,100 journalists from North America and elsewhere committing to practicing science/health/medical journalism to a high standard. (No matter how much the collapse of the MSM undermines us. But that's a different blog post...)

One of the things the AHCJ tries to do is to get its membership in direct touch with newsmakers as much as possible. We have a conference, we have podcasts, we have newsmaker briefings. And on Tuesday, we had a live webcast/call-in with Dr. Carolyn Bridges, associate director for epidemiologic science in the influenza division of the CDC, taking questions for 45 minutes on aspects of the new flu.

Participation in the call was limited to AHCJ members, but the archived version is open to all on BlogTalkRadio. Link is here.

(And yes, the moderator/interviewer is, umm, me.)

Child deaths from flu + MRSA, an update

As predicted earlier this week: The Centers for Disease Control and Prevention (CDC) has announced more deaths of children from flu, and from flu followed by MRSA pneumonia.

My colleagues at the Center for Infectious Disease Research and Policy are tracking the case count, and here's what they said this evening:

The CDC received eight reports of influenza-related deaths in children during the week ending Feb 21, bringing the seasonal total to 17. Four of the deaths occurred in Texas, 2 in Colorado, and 1 each in Arizona and Massachusetts.
Bacterial coinfections have been confirmed in 10 (59%) of the 17 children. Staphylococcus aureus was identified in 8 of the 10 children—3 of the isolates were sensitive to methicillin, 4 were not, and results were not reported for 1. Eight of the 10 children who had coinfections were age 12 or older. (Byline: Lisa Schnirring)

Just to recap, that's four deaths so far this flu season from flu+MRSA, twice the number we knew of last week.

And just to remind: The CDC and its Advisory Committee on Immunization Practices now recommends flu shots for all children and adolescents, up through the age of 18. A flu shot is one defense against MRSA pneumonia. It is worth considering.

Child deaths from flu + MRSA, again

Folks, I am close to manuscript deadline and so keep disappearing down the rabbit hole; forgive me if I don't post as regularly as usual, I'll be back as soon as I can.

I wanted to point out the announcement by the Centers for Disease Control late Friday that we are starting to see children dying from MRSA this flu season. (The architecture of the linked page is unfortunately way clumsy; at the link, scroll down to the subhead "Influenza-Associated Pediatric Mortality.")

Since September 28, 2008, CDC has received nine reports of influenza-associated pediatric deaths that occurred during the current season.
Bacterial coinfections were confirmed in six (66.7%) of the nine children; Staphylococcus aureus was identified in four (66.7%) of the six children. Two of the S. aureus isolates were sensitive to methicillin and two were methicillin resistant. All six children with bacterial coinfections were five years of age or older.

We've talked before (here, here and here, among other posts) among the emerging understanding of the particular danger that MRSA poses during flu season, when (it is hypothesized) inflammation from flu infection makes the lungs more vulnerable to secondary bacterial infection.

(For those paying attention to the hospital v. community MRSA debate, this is a community-associated infection, not a hospital one.)

This current CDC bulletin underlines, just in case we have forgotten, that drug-sensitive S. aureus (MSSA) can be a serious foe as well. Let's remember, resistance makes MRSA less treatable than MSSA, but it does not change its virulence; MSSA by itself can be a very serious foe. Yes, there are other changes in some strains, especially the community ones, that do appear to increase virulence, but the original MSSA strain is nothing to trifle with.

Also, here's an important addition to this unfolding story: My colleagues at the Center for Infectious Disease Research and Policy are keeping track of kid deaths around the country. According to them, these CDC numbers are already out of date; they have uncovered more that the CDC has not yet posted, but may take note of in future weekly updates.

MRSA reductions in ICUs - good news, but qualified

Constant readers, you will no doubt have seen the overnight news about a paper by CDC authors in the Journal of the American Medical Association, reporting a significant decline in catheter-associated bloodstream infections (known by the uncatchy acronym CLABSIs, and yes, people pronounce it "klab-seez") in intensive care units.

Our results show that the 6 most common adult ICU types reporting central line–associated BSIs to the CDC, which together account for 96% of all reported MRSA central line–associated BSIs among studied ICU types, have experienced declines of 50% or more in the incidence of MRSA central line–associated BSI since 2001. This means that the risk of primary MRSA bloodstream infections among patients with central lines in these ICUs has substantially decreased in recent years.

First, let's stipulate that any reduction in healthcare-associated infections is good, good news.

Having said that, let's drill down into the paper a bit. Because in some of the coverage last night and this morning, this paper is being represented as "Hooray, the MRSA problem is over," and that's an over-reaction. Here are some reasons why.

The data come from several overlapping CDC databases: the National Nosocomial Infections Surveillance system (NNIS) and the National Healthcare Safety Network (NHSN). The NNIS existed from 1970 to 2004; there was a data gap in 2005, and the NHSN sprang up in 2006. There were 300 hospitals in 37 states reporting to the NNIS when it shut down, and in 2007 there were 518 reporting to the NHSN, many of which joined that year as a result of new mandatory HAI reporting in New York, Colorado and South Carolina. Participation in either database was/is voluntary.

The CDC analysis abstracts data from the reports to those systems for the years 1997-2007. But, as you can guess from those numbers above, the data does not cover all 7,500 US hospitals; and because it is more weighted to certain states, it does not represent a nationally representative sample. In addition, hospitals came into the system(s) during the study, and also dropped out; an accompanying editorial estimates that only 6% of the 599 hospitals in the study reported data for all 11 years.

Second, it's important to note that all CLABSIs went down: MRSA infections, drug-sensitive staph (MSSA) and other organisms. So something is going on — but it is not MRSA-specific. Optimistic interpretation: Enhanced infection control in hospitals is suppressing all HAIs. Pessimistic interpretation: Enhanced scrutiny, in the states that account for the most additional hospitals, is negatively affecting HAI reporting. Can we distinguish which? Probably not. On the one hand, CLABSIs started trending down in 2001, before the earliest mandatory reporting legislation became effective. On the other hand, the study doesn't/can't associate declines in CLABSIs with any specific interventions — so it is not possible to know from this study whether one particular strategy was responsible for this decline.

Third, to put the study focus in context, MRSA accounts for only about 7% of CLABSIs; according to the paper, it is not those infections' most common causative organism. And CLABSIs do not account for the largest proportion of MRSA HAIs; according to a 2007 paper, they fall third on the list behind nosocomial pneumonia and septicemia.

Fourth, since it is abstracted from a hospitals data base, this study doesn't address community MRSA infections — and there are some scientists in the family of MRSA researchers who would insist that it is the increasing prevalence of community infection that is the true driver of the MRSA epidemic.

So: Decreased MRSA HAIs, good news. Reasons, unfortunately unclear. Significance, possibly less than the headlines this morning maintain. But whatever it is that those hospitals were doing, let us hope they keep doing it.

The cite is: Burton, DC, Edwards, JR, Horan, TC et al. Methicillin-resistant Staphylococcus aureus Central Line-Associated Bloodstream Infections in US Intensive Care Units, 1997-2007. JAMA. 2009. 301(7): 727-36.
The accompanying editorial is: Climo, MW. Decreasing MRSA Infections: An End Met by Unclear Means. JAMA. 2009. 301(7)772-3.

MRSA in kid athletes - simple but not easy

It's been almost a week since this came out — told you there had been a lot of research released — but I wanted to make sure everyone saw it: The Centers for Disease Control and Prevention released results of an investigation into an outbreak of MRSA on a high school football team in Brooklyn, NY. (My home town, in case anyone cares. But it must have gotten gentrified, since the only organized activities I remember were somewhat less, umm, licit.)

Out of 59 players who attended a pre-season training camp where they practiced all day and bunked in the gym at night, 6 had MRSA skin abscesses (4 confirmed by culture, 2 suspected). The four confirmed cases all began as a pustule or blister that the kids ignored until the infections blew up; three of them subsequently needed the abscesses surgically incised and drained and also took antibiotics.

So, this will sound like not a big deal, right? Fifty-nine kids, 6 infections, attack rate of 11.8%, no one harmed in the long term. Well, in one sense, yes. On the other hand, without sounding like a Cassandra, there have been plenty of sports infections that did not turn out to be so minor: Kellen Winslow, Kenny George, Brandon Noble, Ricky Lannetti. (And if you'll stay tuned til this book is published, there will be an entire chapter on MRSA and sports, both amateur and pro, and the story of a teen athlete who almost died of invasive MRSA following what looked like an innocuous minor infection.)

The difficult thing here is that the steps for preventing such infections — or, at least, vastly reducing their likelihood — are simple: Washing hands, showering after practice, not sharing towels or razors, keeping uniforms and gear clean, and keeping on top of what look like minor abrasions and bug bites. But, as this investigation demonstrates, it's not so easy to get kids to take those things seriously:

The school had supplied antibacterial soap in pump dispensers in the showers; however, several players brought their own soap. Players supplied their own towels. Players reported that they usually left their towels on their cots or on the floor when not in use. The school offered a daily laundry service for uniforms and towels during the camp; however, most players did not have their towels washed and wore their uniforms two or three times between launderings. Players often remained in sweat-soaked clothes between the morning and afternoon practices. (MMWR Jan.30, 2009. 58(03);52-55)

As with hospital infections, where the simple act of handwashing remains one of the most difficult tasks to accomplish, the steps that could prevent MRSA among kid athletes are not complex. What is challenging is getting the kids to understand — over-against the hypermasculinity of sports, where it's cool to be sweaty, dirty and banged-up — how important it is to perform those steps: routinely, thoughtfully, time after time after time.

A timely reminder on using antibiotics well (and badly)

The Infectious Diseases Society of America, the professional organization for ID physicians, is criticizing large grocery store and pharmacy chains for giving antibiotics away for free. (Yes, you read that right: Not generic, not cheap, free. Here is a Wall Street Journal Health blog post explaining the practice, which has become quite common over the past two years.)

IDSA is concerned of course that these antibiotics will be used inappropriately because, being free, they will have a perceived lesser value. The Centers for Disease Control and Prevention has been campaigning for years against inappropriate antibiotic use, via its Get Smart: Keep Antibiotics Working campaign.

(Why is it important to use antibiotics only for the things they work against? All together now: Because if used inappropriately — in too-low doses, too-short courses, or against an illness where they are not useful — they will encourage the development of resistant bacteria, and also may kill your own commensal bacteria, clearing a niche that resistant ones can then occupy. Very good, class, early dismissal today.)

There's an additional, interesting twist to these campaigns, though, which IDSA very rightly raises: They are taking place now, in flu season. One of the most common inappropriate uses of antibiotics is against viral diseases such as flu; the CDC says:

Tens of millions of antibiotics prescribed in doctors' offices each year are for viral infections, which cannot effectively be treated with antibiotics. Doctors cite diagnostic uncertainty, time pressure on physicians, and patient demand as the primary reasons why antibiotics are over-prescribed.

IDSA is quite rightly concerned that the launch of these free-pill programs in flu season will reinforce the association between flu and antibiotics, which is precisely the association that causes antibiotics to be most overused. An excellent point.

Much new news on hospital-acquired infections

There's a ton of new, and conflicting, findings on prevention and detection of hospital-acquired MRSA and other infections.

First: Today, in the journal Infection Control and Hospital Epidemiology, three researchers from Virginia Commonwealth University add to the ferocious debate on "search and destroy," the colloquial name for active surveillance and testing: that is, checking admitted patients for MRSA, isolating them until you have a result, and and if they are positive, treating them while continuing to isolate them until they are clear. "Search and destroy" has kept in-hospital MRSA rates very low in Europe, and has proven successful in some hospitals in the United States; in addition, four states (Pennsylvania, Illinois, California and New Jersey) have mandated it for some admitted patients at least. Nevertheless, it remains a controversial tactic, with a variety of arguments levelled against it, many of them based on cost-benefit.

Comes now Richard P. Wenzel, M.D., Gonzalo Bearman, M.D., and Michael B. Edmond, M.D., of the VCU School of Medicine, to say that the moment for MRSA search and destroy has already passed, because hospitals are now dealing with so many highly resistant bugs (Acinetobacter, vancomycin-resistant enterococci (VRE), and so on). They contend that hospitals would do better to pour resources into aggressive infection-control programs that broadly target a spectrum of HAIs.

The abstract is here and the cite is: Richard P. Wenzel, MD, MSc; Gonzalo Bearman, MD, MPH; Michael B. Edmond, MD, MPH, MPA. Screening for MRSA: A Flawed Hospital Infection Control Intervention. Infection Control and Hospital Epidemiology 2008 29:11, 1012-1018.

Meanwhile, the US Government Accountability Office recently released a substantive examination of HAI surveillance and response programs, in states and in hospitals, that looks at:

• the design and implementation of state HAI public reporting systems,
• the initiatives hospitals have undertaken to reduce MRSA infections, and
• the experience of certain early-adopting hospitals in overcoming challenges to implement such initiatives. (from the cover letter)
  

The report is too thick to summarize here, but here are some key points:

• No two places are doing this the same way — which means that data still does not match state to state
• Experts are still divided about how much MRSA control is necessary
• Hospitals that have undertaken MRSA-reduction programs have taken different paths
• But MRSA control does work: It does reduce in-hospital infections, but at a cost.

This report is an important bookend to an earlier GAO report from last April that explored the poor state of MRSA surveillance nationwide. Read it if you wonder why we don't really know how much MRSA - in hospitals or in the community - we have.

I am stillworking my way through the new Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, released a week ago by a slew of health agencies (Joint Commission, CDC, et al.) and health organizations (American Hospital Association, ACIP, SHEA, IDSA et al.), to see how much the MRSA strategies have actually changed. If anyone has any comments, please weigh in!

MRSA in sports

I am possibly the most sports-impaired person on the planet (a consequence of growing up with the lovely but impenetrable game of cricket), but even I noticed these stories recently.

• University of North Carolina-Asheville basketball center Kenny George has lost part of his right foot to amputation as the result of a staph infection.
• Cleveland Browns tight end Kellen Winslow has emotionally gone public — to the displeasure of his coaches — with the news that he was hospitalized for three days for a staph infection. Winslow has been struggling with MRSA since 2005, when he had a motorbike accident, had surgery, and developed a post-surgical infection. Four other Browns players — Braylon Edwards, Joe Jurevicius, LeCharles Bentley and Brian Russell — have had MRSA as well.

MRSA in sports is not new news, but the prominence of some of its victims has brought great attention to the bug: For instance, Redskins defensive tackle Brandon Noble, who was sidelined for a season, and eventually ended his career, over a MRSA infection following arthroscopic knee surgery. And it is not limited to pro players: Lycoming College senior Ricky Lanetti died in 2003 from an overwhelming MRSA infection that began as a pimple-like "spider bite" lesion.

There has been so much concern about MRSA among schools and parents that the CDC has issued specific advice for sports programs. Some of the reasons why athletes may be vulnerable are well-understood: They work in crowded conditions, they undergo a lot of skin-to-skin contact, they are likely to get scraped and injured, and they may not get clean immediately (especially high school players — does anyone shower after high school sports any more?).

But some factors, such as the role of artificial turf, are still murky. An investigation of eight MRSA infections among the St. Louis Rams in the 2003 season (first author Sophia Kazakova) found that linemen and linebackers were more likely to develop MRSA, possibly because they ended up with more turf abrasions. On the other hand, an investigation of 10 infections among players at Sacred Heart University in Connecticut (first author Elizabeth Begier) found that, while turf burns played a role, a contaminated team whirlpool — and sharing razors for shaving body hair — did too.

Five-fold increase in flu+MRSA deaths in kids

I have a story up this evening at CIDRAP News about a new paper in the journal Pediatrics that analyzes the incidence of child deaths from pneumonia caused by the combination of MRSA and flu, a sad and scary development that we've talked about here, here and here.

(NB: CIDRAP News is the original-reporting and news-aggregation arm of the Center for Infectious Disease Research and Policy at the University of Minnesota, an infectious disease research center headed by noted epidemiologist Michael Osterholm, PhD. I have a part-time appointment there. CIDRAP News is the best-read infectious-disease website you have never heard of, with about 10 million visitors a year, and is a notable resource for news on seasonal and pandemic flu, select agents and bioterrorism, and foodborne disease.)

It is bad netiquette and not fair use to reproduce another publication's entire story here, even if I wrote it. Here though are the highlights:

• 166 children died of influenza in the past three seasons (2004-05, 2005-06, 2006-07) according to 39 states and 2 local health departments (86 this year in preliminary reporting)
• The proportion of deaths from bacterial co-infection rose each year, from 6% to 15% to 34%, a five-fold increase
• Almost all of the bacterial co-infections were staph; 64% of them MRSA
• The rapid rise in MRSA colonization (from 0.8% of the population in 2001 to 1.5% in 2004 — that's more than 4 million people) may be playing a role
• And, some of these deaths could have been avoided if children had had flu shots — but overall, only 21% of under-2s and 16% of 2- to 5-year-olds get the two shots they need to be fully protected against flu.
  

Please click through to CIDRAP for more.

The cite is: Finelli L, Fiore A, Dhara R, et al. Influenza-associated pediatric mortality in the United States: increase of Staphylococcus aureus coinfection. Pediatrics 2008;122:805-11.

CDC educational campaign on antimicrobial resistance

The Centers for Disease Control and Prevention has a long-running educational campaign called "Get Smart: Know When Antibiotics Work."

But with flu season starting, the agency has decided to make an extra push, hoping to prevent parents from asking pediatricians to prescribe antibiotics for colds and flu. (Which are, all together now: Viruses! And are not affected by: Antibiotics! Gold stars all 'round.) So it has named next week, Oct. 6-10, as "Get Smart About Antibiotics Week."

There's a website page specifically for the campaign, which seems to be aimed mostly at health-care institutions and public agencies — places that would mount campaigns and plan activities to reinforce the stewardship message. (The campaign has 14 health-agency and professional-association partners.) If you're in any of those roles, there are scripts, ads, PSAs, pre-written "articles" and web graphics and widgets. Find them here.

If you're looking for more general information that you can, for instance, share with friends, this page has explanations in everyday language.

Here's a question: Are there any readers who are health-care professionals (doctors, nurses, NPs, PAs etc.) who feel you are pressured to prescribe antibiotics? If so, please get in touch via the comments or the email address in the right-hand bio box. I would love to hear from you.

Disease-related Do Not Fly list?

This is not strictly MRSA-related, but it is so striking it's worth posting on. This morning, the Centers for Disease Control and Prevention, the US public health agency, revealed in its weekly bulletin that it has begun maintaining a "Do Not Board" list for people who are thought to be a communicable-disease risk to others.

In slightly more than a year, 33 people have been refused transportation because of the list, which is operated in conjunction with the Department of Homeland Security.

The CDC began operating the list in June 2007, shortly after tuberculosis patient Andrew Speaker flew to Europe and back despite requests by public-health authorities that he not fly; he returned via Canada, driving into the United States to evade an alert given to airlines to locate him. At the time, Speaker was thought to have extensively drug-resistant (XDR) TB, an extremely dangerous form of the disease. Later, his doctors asserted and the CDC agreed that his TB was multi-drug resistant (MDR) — still dangerous, but nowhere near as dangerous as the almost-untreatable XDR form.

Patients' names can be placed on the list by several entities though all requests are reviewed, the CDC says:

...state or local public health officials contact the CDC Quarantine Station for their region†; health-care providers make requests by contacting their state or local public health departments, and foreign and U.S. government agencies contact the Director's Emergency Operations Center (DEOC) at CDC in Atlanta.
To include someone on the list, CDC must determine that the person 1) likely is contagious with a communicable disease that would constitute a serious public health threat should the person be permitted to board a flight; 2) is unaware of or likely to be nonadherent with public health recommendations, including treatment; and 3) likely will attempt to board a commercial aircraft.
Once a person is placed on the list, airlines are instructed not to issue a boarding pass to the person for any commercial domestic flight or for any commercial international flight arriving in or departing from the United States. (MMWR 57(37);1009-1012)

An important point here is the phrase "would constitute a serious public health threat." Under US law (42 USC 264), most public health functions belong to the states, but the federal government is empowered to detain and isolate or quarantine people known or suspected to have a small list of communicable diseases: cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fevers (such as Ebola), SARS, and novel strains of flu. The Do Not Board list, however, reaches beyond that list, according to the CDC bulletin:

The public health DNB list is not limited to those communicable diseases for which the federal government can legally impose isolation and quarantine; the list can be used for other communicable diseases that would pose a serious health threat to air travelers. However, to date, the list has only been used for persons with suspected or confirmed pulmonary TB, which is transmitted via the respiratory route and which has had transmission documented during commercial air travel.

Detecting and protecting against disease threats to the US is well within the CDC's mandate. Still, this raises a huge list of questions, from how medical privacy is maintained when a patient's name is so widely circulated, to whether healthy people with similar names will be mistaken for sick ones, to how easily people get off the list once they are deemed well.

The CDC says that, of the 33 people placed on the list in the past 15 months, 18 already have been removed. But the persistent problems with the original No-Fly list — snagging air marshals and toddlers and causing passengers to change their names — suggests that this may not be as easy to manage as the CDC thinks. It would be good to hear more about what safeguards they propose — or whether they have left that part of the issue to be handled by DHS.

New CDC educational campaign on CA-MRSA, aimed at parents

This morning, the CDC is launching a "National MRSA Education Initiative" aimed at raising awareness among parents and average health-care professionals — not academic center researchers so much as front-line nurses, NPs, PAs and others who are likely to be the first set of eyes on a community MRSA infection.

The campaign's front door is a newly constructed page on the CDC's website that looks well-stocked with fact sheets for parents and for health-care workers; lots of informative photos, most of them taken by physicians, of what a MRSA skin infection looks like; specific information about MRSA infections in schools and in sports; and a free-of-charge radio PSA.

Especially useful, for those who might need it, is a copy of the CDC's recommended "treatment algorithm" for suspected MRSA — a flowchart or decision-tree for choosing antibiotics when MRSA is suspected. The algorithm was the result of a number of meetings of experts convened by the CDC and represents the best advice on what to take when. It's a useful thing to consult if you suspect you may be dealing with MRSA and wonder whether you have been given the appropriate drug. All of these materials are downloadable and printable; open-access/no copyright because they are government-produced.

From the agency's press release (not posted yetposted here):

The National MRSA Education Initiative is aimed at highlighting specific
actions parents can take to protect themselves and their families. CDC
estimates that Americans visit doctors more than 12 million times per
year for skin infections typical of those caused by staph bacteria. In
some areas of the country, more than half of the skin infections are
MRSA. ...
"Well-informed parents are a child's best defense against MRSA and other
skin infections," said Dr. Rachel Gorwitz, a pediatrician and medical
epidemiologist with CDC's Division of Healthcare Quality Promotion.
"Recognizing the signs and receiving treatment in the early stages of a
skin infection reduces the chances of the infection becoming severe or
spreading."

Hospital gives patient MRSA. Should Medicare reimburse?

You have until June 13th to tell the government what you think. Details of how to comment at the end of this post because they are complicated.

Here's the back-story: Until recently, hospitals were reimbursed by the Center for Medicare and Medicaid Services (part of the US Department of Health and Human Services) whenever they provided care to Medicare or Medicaid patients, even if that care included a mistake, error or hospital-acquired infection. Thankfully, that is beginning to change. Last December, CMS proposed a rule change. In the agency's language:

Beginning October 1, 2008, Medicare will no longer pay hospitals at a higher rate for the increased costs of care that result when a patient is harmed by one of several conditions they didn’t have when they were first admitted to the hospital and that have been determined to be reasonably preventable by following generally accepted guidelines. (Quoted from this press release.)

In other words: Hospitals, you break it, you bought it.

These are the conditions for which, as of Oct. 1, 2008 (the first day of federal fiscal year 2009), Medicare will not reimburse:

• Object inadvertently left in after surgery
• Air embolism
• Blood incompatibility
• Catheter associated urinary tract infection
• Pressure ulcer (decubitus ulcer)
• Vascular catheter associated infection
• Surgical site infection - Mediastinitis (infection in the chest) after coronary artery bypass graft surgery
• Certain types of falls and trauma.

Note: MRSA is not on that list. But: At the same time, CMS proposed a second set of error-related conditions for which it will consider not-reimbursing, based on public comment. Some of those conditions are MRSA-related. The conditions are:

• Surgical site infections following certain elective procedures.
• Legionnaires’ disease (a type of pneumonia caused by a specific bacterium)
• Extreme blood sugar derangement
• Iatrogenic pneumothorax (collapse of the lung)
• Delirium
• Ventilator-associated pneumonia
• Deep vein thrombosis/Pulmonary Embolism (formation/movement of a blood clot)
• Staphylococcus aureus septicemia (bloodstream infection)
• Clostridium difficile associated disease (a bacterium that causes severe diarrhea and more serious intestinal conditions such as colitis)

CMS will decide whether or not to include any or all of those additional events by Aug. 1. The non-reimbursement would start at a later date that the first list.

This a complex topic and there is a long paper trail attached to it. Fact sheets are here. Definitions of the conditions, as accepted by CMS and the CDC, are here. The records of the Dec. 17. 2007 hearing in which this was discussed, including complete transcripts, is here.

Directions for how to comment electronically and by mail and hand-delivery (faxes are not accepted) are contained in this long Federal Register entry. Here is how to do it electronically:

• Go to http://www.regulations.gov
• Under "Comment or Submission," enter this file-code: CMS–1390–P
• Click on "Send a comment or submission" in the left-middle of the page.
• Fill out the form that comes up (you may have to page-down to see the full form).

Child deaths from flu + MRSA

Steve Smith of the Boston Globe (who is really good, and I say that as someone who used to compete against him) has a story up regarding state and national concern over children's deaths from MRSA pneumonia. There have been two such deaths in Massachusetts this year. These are the sort of deaths that make headlines, as they did last October with the death of 17-year-old Ashton Bonds in Virginia: The pneumonia is very fast-moving and very destructive of lung tissue, and young children have died from it in less than 24 hours.

The CDC is concerned about this: Twice in two years (last May, blogged here, and last January), the agency pushed out an advisory to state health departments, asking them to report any children's deaths in which flu played a role. Surveillance for pediatric flu deaths is a relatively new thing for the CDC — the agency set up a system after the bad early flu season of 2003-04, in which more than 150 children died — so there is relatively little history to draw on. But MRSA has played a role in child deaths in each of the past three years, according to that January bulletin:

From October 1, 2006 through September 30, 2007, 73 deaths from influenza in children were reported to CDC from 39 state health departments and two city health departments. Data on the presence (or absence) of bacterial co-infections were recorded for 69 of these cases; 30 (44%) had a bacterial co-infection, and 22 (73%) of these 30 were infected with Staphylococcus aureus.

The number of pediatric influenza-associated deaths reported during 2006-07 was moderately higher than the number reported during the two previous surveillance years; the number of these deaths in which pneumonia or bacteremia due to S. aureus was noted represents a five-fold increase. Only one S. aureus co-infection among 47 influenza deaths was identified in 2004-2005, and 3 co-infections among 46 deaths were identified in 2005-2006. Of the 22 influenza deaths reported with S. aureus in 2006-2007, 15 children had infections with methicillin-resistant S. aureus (MRSA).

Among MRSA researchers, concern over these necrotizing pneumonia cases has been growing for a few years. Some surveillance suggests that such cases may be increasing, though that could be an issue of, "once you start looking for something, you find it." And the cases are undeniably severe: 56% of children with MRSA pneumonia die, according to a 2007 paper.

But at leaast some of those deaths may be avoisable — or would be if doctors in the community were more attuned to the possibility of MRSA. In a poster at last autumn's ICAAC meeting (first author AJ Kallen) CDC researchers reported thay reviewed charts of all the children admitted with a stah infection at Atlanta's three children's hospitals during the 2006-07 flu season. There were 53 cases of Staph aureus pneumonia; 22 of the children saw a physician an average of 3.5 days before being admitted to the hospital, and THREE of them got drugs that would work against staph.

And yes, you read that right: Active case-finding in Atlanta in 2006-07 found 53 cases of flu-related staph pneumonia; 22 of them, according to the paper, were MRSA. But from the entire country during 2006-07, according to the advisory quoted above, the CDC received reports of 22 flu/staph pneumonias, 15 of them MRSA. Which suggests that flu/MRSA pneumonias in children are more common than current surveillance reveals.

HAIs: Congress weighs in

Today, the House of Representatives Committee on Oversight and Government Reform held a hearing on hospital-acquired infections, led by committee Chairman Henry Waxman (D-Calif.).

The witness list is here. A Government Accountability Office report that was presented during the hearing is here. Its title captures the committee's point of view: "Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections."

In opening the hearing, Waxman said:

[HHS] is not providing the necessary leadership. It has not identified for hospitals the most important infection control practices, and it is not coordinating the collection of data from hospitals in order to avoid duplication and unnecessary burden.
The failure of HHS leadership is particularly regrettable because these illnesses, deaths, and costs are preventable. Moreover, the preventive measures don’t require new technologies or large investments.

The witness list includes links to testimony, including some very powerful remarks delivered by HA-MRSA survivor Edward F. Lawton:

We possess the knowledge and capabilities to fight this enemy; we possess the educational and professional expertise to overcome and destroy it. The only question is whether we have the will to fulfill the mission!

(And BTW, apologies to loyal readers for disappearing for a week. I was speaking at the American Society of Journalists and Authors, and doing book-related research in New York. Back now.)

A staph vaccine: How much would it help?

One more post on research from the meeting of the Society for Healthcare Epidemiology of America: Many MRSA researchers believe that the only way to truly control the pathogen — especially out in the community — will be through a vaccine.

Lay aside for the moment how problematic introducing a new vaccine can be these days, since the cost issues, along with shifts in the public's willingness to accept new vaccines, are ferocious hurdles. And lay aside also the difficulties that pharma companies have already faced in attempting to develop a staph vaccine.

But if such a vaccine were achieved, how many people could it help? Researchers from the Centers for Disease Control and Prevention attempted to answer that question in research presented at SHEA.

Background assumptions, part 1: The number of invasive MRSA infections now tops an estimated 105,000/year (a recalculation of the 94,000/year estimate from last October); more than 40% of invasive infections occur in those over 65; more than 50% are associated with a recent hospitalization; and 15% of MRSA infections recur at least once. And background assumptions part 2: A vaccine would have an efficacy rate of 40-75%, and an acceptance rate similar to flu-vaccine uptake: 20-50% among those 15-44, 35-70% among those 45-64, and 50-70% among those 65 and older.

Given those assumptions, Cynthia Lucero, MD and colleague predicted:

• If given only to those 65 and older, a vaccine would prevent from 12,720 to 32,270 invasive MRSA infections;
• If given to those over 65 and also those 15 and older who have already had an invasive infection, a vaccine would prevent 14,130 to 38,310 invasive MRSA infections;
• And if given to those over 65 and also anyone over 15 who is being discharged from a hospital, a vaccine would prevent from 17,240 to 49,940 invasive MRSA infections.

The best bang for the buck, the agency said, would be the middle strategy: It would prevent from 660 to 1,170 cases for every million doses of vaccine used. And since the vaccine would also cover methicillin-sensitive staph, it would likely prevent an equal number of serious MSSA cases as well.

The CDC is not by law allowed to lobby — or even, for the most part, allowed to offer a professional opinion unless Congress has asked it to do so. So these numbers are purely a thought experiment. But they're also a strong argument for the broad usefulness of a staph vaccine if one could be achieved.