The Year in Review: Best Papers 2014 Trish M. Perl, MD, MSc Professor of Medicine, Pathology and Epidemiology Johns Hopkins University Senior Epidemiologist Johns Hopkins Health.
Download ReportTranscript The Year in Review: Best Papers 2014 Trish M. Perl, MD, MSc Professor of Medicine, Pathology and Epidemiology Johns Hopkins University Senior Epidemiologist Johns Hopkins Health.
The Year in Review: Best Papers 2014 Trish M. Perl, MD, MSc Professor of Medicine, Pathology and Epidemiology Johns Hopkins University Senior Epidemiologist Johns Hopkins Health System [email protected] Disclosures • Disclosures: Pfizer (advisory board), Merck (grant), Medimmune (grant) C. difficile N Engl J Med 2015;372:825-34. C. difficile N Engl J Med 2015;372:825-34. Methods • Active population and laboratory based surveillance in 10 geographic areas across the US • Stools were positive for either antigen or PCR in persons > 1 year old • Cases classified as community or healthcare associated • A sample of cases were cultured and underwent molecular typing Findings • 15,461 cases identified • 65.8% healthcare associated; 24.2% had onset during hospitalization • Incident cases in the US is 453,000 with the rate higher in females (RR 1.26 95% CI 1.25-1.27); whites (RR 1.72 95% CI 1.56-2.0); > 65 years (RR 8.65 95% CI 8.16-9.31) • Estimated first occurrences was 83,000 and deaths--29,300 • NAP1 strain more prevalent in HCA (30.7%) than community infections (18.8%) Findings Findings: Burden of Disease Findings: Recurrences and Death Summary • C. difficile is more common than previously thought • Most cases are associated with medical care but do not manifest in the hospital—they are seen by you! • Almost 25% of the cases are recurrences • Certain populations of patients are at higher risk of recurrence and death Ebola What about the specifics Science 2014:345;1369 Luna et al. Crit Care Res Pract 2014: 480463 Methods • 1st case confirmed on May 25th in Sierra Leone • Sequenced 99 isolates from patients in Sierra Leone • Tests run on two different platforms History of Ebola Outbreaks Dating of the Outbreak Diversity of Mutations Person to Person Transmission: Using Genetic Clues Acquisition of Genetic Variation Over Time Overall Summary • The Ebola outbreak in Sierra Leone resulted from the simultaneous introduction of two different strains from Guinea, likely from funeral attendees • Intra and inter-host variation illucidates the epidemiology and transmission patterns • Substitution rate is twice as high during the outbreak as in between outbreaks • 5 authors died of Ebola while doing this important work N Engl J Med 2014;371:2083-91. Ebola Clinical Disease • • • • 7th Ebola outbreak in Congo btw July 26 and Oct 7, 2014 69 suspect or documented cases; 7 HCW 49 deaths Ebola Zaire Species, Genetic analysis demonstrated 99.2% similarity of the virus with that of the Kikwit outbreak; 96.8% similarity with virus circulating in West Africa Ebola Virus’s Named after the Ebola river in the Democratic Republic of Congo, it was first discovered in 1976. 5 species Ebola Zaire Ebola Sudan Ebola Ivory Coast Ebola Bundibugyp Ebola Reston Primarily found in Africa except E. Reston found in the Philippines (animal only) 24 DRC Epidemiology of the Outbreak Clinical Features: Ebola Mortality Clinical and laboratory features associated with non fatal disease • Respiratory rate < 25 • Lower temperature • Lower BUN • Lower creatinine • Alk Ptase • ALT • AST - Clinical Features: Ebola Chertow et al. NEJM 2014; 371:2054-7 Clinical Features: Ebola • Case finding and testing helped modulate the outbreak. • The virus has been relatively stable over the past 20 years. • Triphasic illness and clinical features are non specific; fatigue, myalgias and conjunctivitis were hallmarks. Although not asked hiccups are a feature. • Mortality remains high, although there are clinical and laboratory features that can be used to predict improved survival Clinical Trials The Ongoing Screening Question • 13 ICUs randomized to rapid or conventional screening for MRSA and resistant GNRs • 3 phases – Phase 1: 6 month--wash in of best practice – Phase 2: 6 months assessment of compliance with CHG bathing and hand hygiene – Phase 3: 12-15 month cluster randomized clinical trial of rapid (VRE, MRSA, resistant GNRs) versus conventional screening (VRE, MRSA) with contact precautions for carriers • Outcome: acquisition of MDROs Compliance with HH • 7 ICUs randomized to conventional; 6 to rapid screening • HH compliance increased from 52-69% from phase 1-2; and 77% in phase 3; CHG bathing increased from 0-100% between phase 1 and 2. MDRO Acquisition Impact of Interventions Summary • Impact of HH and CHG bathing on MDRO screening • No impact of screening although these finding may not impact areas where there is poor compliance with HH and the use of CHG bathing Mers CoV Al Hasa Intra-Hospital Outbreak Outbreak based in multiple hospitals in Al Hasa serving a governate of 1.1 million of rural and urban dwellers Initial focus was in two dialysis units and several ICUs Team performed chart review, survey collection to investigate hospital based outbreak Assiri et al, NEJM, 2013 Al Hasa Epidemic Curve: The Story of Intra-Hospital Transmission Assiri et al, NEJM, 2013 Cases • 21/23 (+2 probable cases) acquired by person-toperson transmission in HD units, ICUs, or in-patient units in 3 facilities • Among 217 household contacts and > 200 HCW contacts, MERS-CoV infection developed in • 5 family members (3 laboratory-confirmed) • 2 HCW (both laboratory-confirmed) Assiri et al, NEJM, 2013 Identifying Timing of Symptom Onset and Spatial Location Assiri et al, NEJM, 2013 Transmission Maps Assiri et al, NEJM, 2013 New York Times, 2013 Transmission Maps Estimated incubation Period to be 5.2 days (95% CI 2.2 to 12.4 days) (SARS 4.0 (95% CI 1.8, 10.6 days)) Estimated Serial Interval to 7.6 days (95% CI 3.0 to 19.4 days) (SARS Median 8.4 days) Assiri et al, NEJM, 2013 Genetic Mapping: Al Hasa Outbreak Genetic Distance of Al-Hasa Isolates from Other MERS CoV Isolates Cotten et al, Lancet, 2013 MERS-CoV Is Widespread Among Camels In The Arabian Peninsula • Neutralizing antibodies against MERS-CoV were found in all camel sera from Jordan (n=11) ; all samples from other livestock species were negative. Reusken C. Euro Surveill. 2013 Dec 12;18(50) • MERS-CoV neutralizing antibodies were present in all samples from 151 dromedary camels from the UAE in 2003 and 60% of 651 camels in 2013. Meyer B. Emerg Infect Dis 2014 Apr;20(4) • PCR testing and partial genomic sequencing confirmed the presence of MERS-COV in 3/14 camels with which 2 human cases in Qatar had contact. Haagmans BL Lancet Infect Dis. 2013 Dec 16 • Recently- likely proven transmission from pet camel to human Perera et al. Eurosurveillance 2013; 18 and Azhar NEJM 2014; 370 Azhar et al. NEJM 2014:DOI: 10.1056/NEJMoa1401505 Azhar et al. NEJM 2014:DOI: 10.1056/NEJMoa1401505 Azhar et al. NEJM 2014:DOI: 10.1056/NEJMoa1401505 Summary • All cases have been directly or indirectly linked through travel to or residence in the Arabian Gulf. • Among symptomatics respiratory symptoms almost universal; GI symptoms in ¼; most with comorbidities, age ~50. • Asymptomatic illness recognized. • Sequencing data suggests multiple, ongoing community introductions, and human-to-human spread especially in families and healthcare. • Camels may be an important link although a wide diversity in viral sequences noted.