The importance of MRSA in a flu pandemic

Constant readers will know that, in another part of my life, I write a great deal about seasonal and pandemic influenza, a subject I've been following since writing the first story in the American media about avian influenza H5N1 (in August 1997; find it on this page.)

And people concerned about MRSA realize that flu and MRSA have an important overlap: For decades, long before the emergence of MRSA, staph was one of the most important contributors to secondary bacterial pneumonia, which occurs after the flu virus has damaged the lung tissue and allows staph and other bacteria to take hold.

In the past few years, we've been reminded of this interaction because of the shocking rise in cases of necrotizing pneumonia caused by MRSA (blogged here and here). Twice in the past two years, the CDC has asked state health departments to report any cases of flu/MRSA co-infection; in the 2006-07 flu season, 22 children died from MRSA necrotizing pneumonia secondary to flu.

Comes now one of the giants of staph research to warn of an unconsidered danger of MRSA: as a contributor to deaths in a flu pandemic. Dr. Theodore Eickhoff, who wrote some of the earliest papers on hospital-acquired staph infections, has written an assessment in Infectious Disease News of two new pieces of research into deaths during the 1918 flu pandemic. Both papers contend that it was bacterial pneumonia that was the major killer in that global storm of death, and not the novel flu virus itself.

Eickhoff looks forward from those findings to consider what havoc a new pandemic could wreak in this era of massive MRSA transmission. He contends that national planning for pandemics — a huge effort and expense for the US and other governments over the past few years — has paid insufficient attention to the possibility that bacterial infection will be as significant a danger as whatever new flu has emerged:

Authors of both of these reports point out that their findings have important implications for pandemic preparedness today. U.S. preparedness policy, and indeed that of almost all other countries, has been focused on preventing or modifying influenza virus infection itself. Thus, vaccine development and anti-viral drugs (eg, neuraminidase inhibitors) have been the major efforts, and a great deal of stockpiling has already taken place. Clearly it is equally necessary to stockpile antibiotics effective against primarily community-acquired organisms causing post-influenza pneumonia today, including both MSSA and MRSA. Much more consideration needs to be given to the possible role of pneumococcal and possibly other bacterial vaccines as part of pandemic preparedness.

Good news from California

Last night, California Gov. Arnold Schwarzenegger signed an extremely important bill, California SB 1058. The new law, formally called the Medical Facility Infection Control and Prevention Act, requires California hospitals to do MRSA screening on high-risk patients (such as in ICUs, admitted from long-term care facilities, or known to have a previous MRSA infection) and to report their rates for hospital-acquired infections including MRSA to a newly created body with the state Department of Public Health.

This new law puts California in the vanguard of states who are requiring healthcare institutions to count and track MRSA infections. (For a complete list, visit the database maintained by Consumers' Union's Stop Hospital Infections project.) This is vital not only for controlling MRSA, but also simply for helping us to understand how much MRSA is out there. Because MRSA has not been a reportable disease, and is not subject to any national surveillance, state counts like these are one of the best ways of assembling a fuller picture of the bug's spread.

The most important reason to hail the passage of this law, though, is that it represents a memorial to a MRSA victim, and a determination by his survivors that no one else should meet the same fate. SB 1058 is also known as "Nile's Law." Nile is Nile Calvin Moss, who died in 2006. In response, his parents Carole and Ty Moss founded Nile's Project and became tireless advocates for MRSA surveillance and screening. Among other efforts, Carole was appointed by Schwarzenegger to a state commission on hospital-acquired infections, where she is the sole voting member representing health-care consumers.

It is no small thing to step out of your grief and make your loss into a force for change. Carole and Ty Moss deserve congratulations.

A small self-promotion

I have a long story in the new (October) SELF Magazine: Morgellons mystery.

It is not about MRSA; it's about Morgellons, a syndrome which approximately 12,000 sufferers claim is a new, unrecognized disease, but which medical authorities say is a delusion. The story is a look at the experience of several people who identify themselves as having the disease, contrasted with the efforts of several researchers — including the head of a new CDC investigation — to figure out what exactly is going on.

It's a medical mystery story, and a meditation on the nature of evidence and belief.

And it raises the question: When something arises that fits no past pattern, how do we recognize it, describe it and prove its existence to others? It's a question that should resonate with advocates for MRSA - especially community MRSA infection.

Lotrs more MRSA news coming this week.

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.

UK grapples with community MRSA

Regular readers in the US will have noticed that the MRSA situation here is quite different from Europe. In the UK, for instance, hospital MRSA has been an enormous scandal, but community MRSA — both skin and soft-tissue infections, and fatal invasive infections such as necrotizing pneumonia — has been much less of a concern.

That appears to be changing. Today, the BBC's Radio 4 broadcast a documentary, "The Bug That Can Kill Within Hours," that focuses on fears of a dramatic rise in the UK of cases of serious community MRSA. According to the UK's Health Protection Agency, lab-confirmed cases of community MRSA strains hit 1,361 in 2007, three times what they were the year before. (Soundfile here, starts automatically.)

The documentary refers to CA-MRSA as "PVL-MRSA," a recognition of the fact that most of the community strains produce the toxin Panton-Valentine leukocidin, or PVL. (PVL is known to destroy white blood cells, but whether it is responsible for the virulence of CA-MRSA is a hotly disputed question in MRSA research.) Aside from the difference in terminology, any of the statements from the accompanying BBC website story could have been said here any time in the past 10 years:

Professor Brian Duerdan, the Inspector of Infection Control at the Department of Health, admits however that many aspects of this virulent bug are a mystery.
"We do know that it spreads in the community amongst close contacts, families, people who share the same sporting events. But we still need to know a lot more about its exact prevalence in the community," he said.

People who have been tracking the relentless expansion of CA-MRSA, espeially its dominant clone USA 300, are likely to find some of the statements in the documentary both troubling and poignant. The UK is beginning to deal with some of the wuestiosn that the US has struggled with: how much surveillance to do, how to spend scarce research dollars, and what the consequences may be if CA-MRSA is not focused on now.

Hugh Pennington, Emeritus Professor at the University of Aberdeen, and President of MRSA Action, told the BBC that the HPA lacks the resources to keep proper surveillance on outbreaks of infection from this strain of bugs.
"The scandal here is that we know what to do, the technology's there to spot these things as they are appearing and we know how to react to them.
"It would be quite wrong if we allow these things to develop and of course history tells us that it we do neglect these bugs, we neglect them at our peril."

Indeed.

A plea (and, if you need relevance, an example of the failure of US healthcare)

Constant readers will know that I keep the personal buzz on this blog to a low rumble, so as to stay out of the way of the news about MRSA, which affects hundreds of thousands of people beyond n=me. Today, though, I'm going to break my own rule, tell you a story, and launch a personal plea. Readers outside the US will be astounded such things can happen. Readers in the US will recognize how sadly common to our fractured system stories like this are. And they will be right. And yet, this one has particularly touched me.

So: Lori Hall Steele, of Traverse City, Mich., is a prolific freelance writer and blogger and the divorced mother of a 7-year-old son. She is also newly diagnosed with amyotrophic lateral sclerosis. She is bedridden and using breathing support and is unable to work. As a freelancer, she no doubt has not-excellent health insurance. Her bills are extraordinary. And, to add insult to grave injury, she is about to lose her house to foreclosure.

Before she became ill — her first symptoms appeared a year ago — Lori wrote an essay for the Washington Post, about watching Bambi with her son and trying to explain, yes, the death of Bambi's mother. As often happens, they held the essay for months, and it was published in June. It is extraordinarily resonant. Please consider reading it. Tissues will help.

Let us be candid with each other: ALS is a one-way trip. People who support Lori are not expecting miracles; they are asking only for compassion, and for the ability to keep an ill young mother and her child together in the home they love for whatever time she has left.

If you are touched by Lori's story, please consider visiting Save Lori's House, which details fundraising efforts to help her, including a PayPal account.

Writers around the US are rallying to offer what support we can, via a blogathon of which this post is one entry. Lori's friends are attempting to log the blogathon here.

(And because we always worry about such things on the intertubes: This has been vetted by many eyes. The chair of the Writers' Emergency Assistance Fund, an arm of the American Society of Journalists and Authors, has been in contact with the family since the spring and has spoken by phone with family and friends. If you Google Lori's hometown newspaper, the Traverse City (MI) Record-Eagle, and put her name in the search box, you will see notices of fund-raisers for her dating back early this year. So there is no evidence this is a scam.)

I appreciate your indulgence and support, all of you. We'll get back to MRSA tomorrow.

Gram-negatives need love too

Britain's Health Protection Agency warns today that the supply of new drugs for resistant Gram-negative infections — Acinetobacter, Pseudomonas, Burkholderia — is in even worse shape that the drug pipeline for MRSA and other Gram-positives.

"Over the last ten years the pharmaceutical industry has significantly invested in antibiotic treatments for bacteria such as Staphylococcus aureus (including MRSA). There is however a big public health threat posed today by multi-resistant gram-negative bacteria and therefore there is an urgent need for the pharmaceutical industry to work towards developing new treatment options to tackle infections caused by these bacteria, in the same way as they did for bacteria like MRSA." (Dr. David Livermore, HPA press release)

The announcement comes between two important events: the release of the HPA's annual survey of antibiotic prescribing patterns in England, Wales and Northern Ireland (report .pdf here, 2mb); and the start next week of the HPA's annual scientific conference, which will have a full-day symposium on resistant infections (agenda here).

Interesting: The meme "MRSA's taken care of, let's get on to the gnarly Gram-negatives" has picked up traction in the past few months. While I'd certainly agree with the second proposition — pharmaceuticals for resistant Gram-negatives are the next big task — I reject the first, that the MRSA problem is solved and all we have to do is wait for the drugs to roll down the pipeline. Doesn't exactly square with all those posters at the last ICAAC and IDSA exploring emerging resistance to daptomycin and other new compounds.

For a full and thoughtful exploration of the Gram-negatives problem, see this recent New Yorker article, written by the inestimable Dr. Jerome Groopman. (True story: When Groopman's first book came out, I interviewed him by phone - I was working in Atlanta - and wrote a complimentary piece about it. Fast-forward several years, he has at least one more book out, has become a writing rockstar - in addition to being a hugely respected Harvard clinician and professor — and I am doing a journalism fellowship on genomics at Harvard Medical School. I'm standing in line at the Longwood area Starbucks, and I spy Groopman about four people ahead of me. And I'm too shy to say anything. So much for reportorial moxie.)