As promised last month

Not MRSA but worth reading, I hope: My big project on post-Katrina New Orleans, a narrative profile of the leader of the city's "mental health SWAT team," has been published by MORE Magazine.

Read "After the Deluge" here, and then please take a moment to think what you might do to help the recovery of a fabled and shamefully abandoned city. New Orleans is not even close to being over Katrina. It needs all the help it can get.

MRSA and cats - an earlier paper

In journalism, there sometimes arises a situation in which a reporter for a major outlet writes a story that is very similar to one that has already been published by a minor outlet, without crediting the minor outlet. We call it "bigfooting." It's not a compliment.

The flurry of attention to the new letter in the New England Journal of Medicine about a pet cat harboring MRSA and reinfecting the cat's owner has a whiff of bigfooting about it. The letter describes a German family with MRSA that particularly persisted in the wife/mother despite treatment until one of their three pet cats was swabbed and decolonized.

The three authors from the Bavarian Food and Health Safety Authority write, "There is evidence that companion animals, mainly dogs, harbor MRSA, and interspecies transmission has been shown in the members of a family and their dog. This case illustrates that MRSA transmission also occurs between humans and cats." There are five cites appended to the letter, on MRSA epidemiology and sequencing and MRSA in dogs. The inference that this is the first recorded case of cat-human MRSA exchange was picked up by several media outlets: — Associated Press, Reuters — and explicitly stated by HealthDay. com, whose story was carried by the Washington Post.

So, the bigfooting: This isn't the first report of cat-human transmission at all. A very nice paper published in December 2006 in Emerging Infectious Diseases (not NEJM, but not exactly obscure as it is published by the CDC) reports the first isolation of the CA-MRSA strain USA300 from a California cat along with an identical strain in the cat's human. And it shows up close to the top of a Medline search, so it wasn't exactly hard to find.

(There is also a 2005 Veterinary Microbiology paper that reports a PVL+ strain in a cat along with several from dogs, but the researchers didn't type the strains and were unable to say whether they were CA or HA; and two letters in the Veterinary Record in 2004 and 2006 citing multiple MRSAs in cats. Neither draw a direct link to human illness.)

OK, enough truth-squadding. Back to HAI and search-and-destroy soon.

Cautionary tale: Unintended consequences, ripple effects

New story by me, up at the news website of the Center for Infectious Disease Research and Policy, where I am a contributing writer. It's on flu, not MRSA, but it contains lessons that apply to MRSA too.

Gist: This flu season turned out unexpectedly badly, with physicians across the country saying offices and ERs are overwhelmed with very sick patients. In ERs in particular, the dominos fall like this: More patients than usual come in for help; with some of them seriously sick, other patients get pushed further back in the triage queue; while the seriously sick wait in the ER for hospital admission, other patients back up in the waiting room; diversion (turning ambulances away) is called to relieve some of the pressure; and patients are taken instead to another ER, where the process begins again.

The irony here is that flu is an at least partially preventable disease: Under normal circumstances, get a flu shot, sharply reduce your chance of getting the flu. However, this year the flu vaccine and the circulating flu strains don't match well, and many people who stepped up and got the shot still developed flu. And why did the shot not match? It was partly a failure of luck — flu's perpetual genetic drift is unpredictable — but it was also a failure of infrastructure: Federal health planners knew a year ago that one strain was drifting, but that virus didn't grow well enough under lab conditions to get an isolate to vaccine manufacturers in time for it to be included in last fall's vaccine. (See Dr. Nancy Cox's comments in this CDC press briefing; the FDA discussions she refers to are archived here.)

And why did it have to be given to the manufacturers a year ago? Because it still takes 6 months to make commercial quantities of flu vaccine, using a technology that is essentially 50 years old. This despite either 10 years or 32 years of concern over the possibility of a flu pandemic (depending on whether you start counting from the appearance of avian flu H5N1 or the aftermath of the 1976 swine flu).

And why is any of this of concern for MRSA? Because many researchers and clinicians say that the only way to combat MRSA effectively is with a vaccine. Improving flu vaccination has been top of the public health wish-list, and a target of significant government funding, for years now, and yet it is still a disappointing mess. What chance for a lower-profile MRSA vaccine?

Typing and fingerprinting: Who pays?

More on the issue of doing more microbiology to track the epidemiology of CA-MRSA (raised in an exchange below between me and Medifix, to whom many thanks for being my first commenter!). In my slog through the endless and growing MRSA literature, I came across a paper that poses the problem much better than I did.

In Use of Routine Wound Cultures to Evaluate Cutaneous Abscesses for Community-Associated MRSA (Annals of Emergency Medicine, July 2007; cite here, no abstract), Fredrick Abrahamian and Sunil Shroff of UCLA School of Medicine say that cultures and susceptibility testing are not always necessary. The tests might not be needed, for instance, if a skin/soft-tissue infection suspected of being MRSA is going to be incised and drained without antibiotics being prescribed; or if antibiotics are going to be prescribed, but physicians already know local susceptibility patterns and plan to order a drug that will provide coverage. In both cases, having additional information about the strain infecting the patient is not going to make any difference to the patient's treatment.

That information will make a difference to understanding the local, regional, national epidemic. But as Abrahamian and Shroff say: "One must determine if it is ethical to make an individual pay the cost of a test for a perceived public health benefit."

The obvious answer is to say the CDC should do it — they are after all the arbiters of population-level public health. Only, you know, their budgets have been being cut...

And to Scott McPherson for the bloglove hat-trick!

Journalists aren't really accustomed to people liking us, so I'm a little dizzy. But huge thanks also to Scott McPherson, who was sweet enough to mention my first book, on the CDC's outbreak SWAT teams. Scott's day job is in the thick of politics — he's the chief information officer for the Florida House of Representatives — and he regularly nails the disconnect between public-health policy and the messy real world. Read him here.

And also to Crawford Kilian's readers!

Crof, dean of avian-flu bloggers and indefatigable proprietor of H5N1, very kindly called this "an excellent new site." To have the support of such experienced bloggers is a wonderful thing.

Big welcome to FLA_MEDIC's readers!

The energetic and always-thoughtful proprietor of Avian Flu Diary very kindly called out this blog today. (In the intro box over on the right, I invited reading by MRSA researchers, MRSA victims and major disease geeks — he says he's No. 3.) So welcome to anyone who found there way over here from there. And if you haven't been to his blog yet, go now: His essays and analyses on the possibility of pandemic flu are always worth reading.