Archive for November 15, 2016

Methicillin-Resistant Staphylococcus aureus CC398 in Humans and Pigs in Norway: A “One Health” Perspective on Introduction and Transmission

Clinical Infectious Diseases December 1, 2016 V.63 N.11 P.1431-1438

Carl Andreas Grøntvedt, Petter Elstrøm, Marc Stegger, Robert Leo Skov, Paal Skytt Andersen, Kjersti Wik Larssen, Anne Margrete Urdahl, Øystein Angen, Jesper Larsen, Solfrid Åmdal, Siri Margrete Løtvedt, Marianne Sunde, and Jørgen Vildershøj Bjørnholt

1The Norwegian Veterinary Institute

2The Norwegian Institute of Public Health, Oslo

3St Olavs Hospital, The Norwegian Reference Laboratory for MRSA, Trondheim

4The Norwegian Food Safety Authority, Brumunddal

5Statens Serum Institut, Copenhagen, Denmark

6Pathogen Genomics Division, Translational Genomics Research Institute (TGen), Flagstaff, Arizona


Emerging livestock-associated methicillin-resistant Staphylococcus aureus (MRSA) persist in livestock populations and represent a reservoir for transmission to humans. Understanding the routes of introduction and further transmission is crucial to control this threat to human health.


All reported cases of livestock-associated MRSA (CC398) in humans and pigs in Norway between 2008 and 2014 were included. Data were collected during an extensive outbreak investigation, including contact tracing and stringent surveillance. Whole-genome sequencing of isolates from all human cases and pig farms was performed to support and expand the epidemiological findings. The national strategy furthermore included a “search-and-destroy” policy at the pig farm level.


Three outbreak clusters were identified, including 26 pig farms, 2 slaughterhouses, and 36 humans. Primary introductions likely occurred by human transmission to 3 sow farms with secondary transmission to other pig farms, mainly through animal trade and to a lesser extent via humans or livestock trucks. All MRSA CC398 isolated from humans without an epidemiological link to the outbreaks were genetically distinct from isolates within the outbreak clusters indicating limited dissemination to the general population.


This study identified preventable routes of MRSA CC398 introduction and transmission: human occupational exposure, trade of pigs and livestock transport vehicles. These findings are essential for keeping pig populations MRSA free and, from a “One Health” perspective, preventing pig farms from becoming reservoirs for MRSA transmission to humans.



November 15, 2016 at 10:50 pm

Requirements for global elimination of hepatitis B: a modelling study

Lancet Infectious Diseases December 2016 V.16 N.12 P.1399–1408

Dr Shevanthi Nayagam, MBBS, Prof Mark Thursz, MD, Elisa Sicuri, PhD, Lesong Conteh, PhD, Stefan Wiktor, MD, Daniel Low-Beer, PhD, Prof Timothy B Hallett, PhD


Despite the existence of effective prevention and treatment interventions, hepatitis B virus (HBV) infection continues to cause nearly 1 million deaths each year. WHO aspires to global control and elimination of HBV infection. We aimed to evaluate the potential impact of public health interventions against HBV, propose targets for reducing incidence and mortality, and identify the key developments required to achieve them.


We developed a simulation model of the global HBV epidemic, incorporating data on the natural history of HBV, prevalence, mortality, vaccine coverage, treatment dynamics, and demographics. We estimate the impact of current interventions and scaling up of existing interventions for prevention of infection and introducing wide-scale population screening and treatment interventions on the worldwide epidemic.


Vaccination of infants and neonates is already driving a large decrease in new infections; vaccination has already prevented 210 million new chronic infections by 2015 and will have averted 1·1 million deaths by 2030. However, without scale-up of existing interventions, our model showed that there will be a cumulative 63 million new cases of chronic infection and 17 million HBV-related deaths between 2015 and 2030 because of ongoing transmission in some regions and poor access to treatment for people already infected. A target of a 90% reduction in new chronic infections and 65% reduction in mortality could be achieved by scaling up the coverage of infant vaccination (to 90% of infants), birth-dose vaccination (to 80% of neonates), use of peripartum antivirals (to 80% of hepatitis B e antigen-positive mothers), and population-wide testing and treatment (to 80% of eligible people). These interventions would avert 7·3 million deaths between 2015 and 2030, including 1·5 million cases of cancer deaths. An elimination threshold for incidence of new chronic infections would be reached by 2090 worldwide. The annual cost would peak at US$7·5 billion worldwide ($3·4 billion in low-income and lower-middle-income countries), but decrease rapidly and this would be accelerated if a cure is developed.


Scale-up of vaccination coverage, innovations in scalable options for prevention of mother-to-child transmission, and ambitious population-wide testing and treatment are needed to eliminate HBV as a major public health threat. Achievement of these targets could make a major contribution to one of the Sustainable Development Goals of combating hepatitis.


Medical Research Council.


November 15, 2016 at 12:19 pm

Association between Zika virus infection and microcephaly in Brazil, January to May, 2016: preliminary report of a case-control study

Lancet Infectious Diseases December 2016 V.16 N.12 P.1356–1363

Dr Thalia Velho Barreto de Araújo, PhD, Prof Laura Cunha Rodrigues, PhD, Prof Ricardo Arraes de Alencar Ximenes, PhD, Demócrito de Barros Miranda-Filho, PhD, Ulisses Ramos Montarroyos, PhD, Ana Paula Lopes de Melo, MSc, Sandra Valongueiro, PhD, Maria de Fátima Pessoa Militão de Albuquerque, PhD, Wayner Vieira Souza, PhD, Cynthia Braga, PhD, Sinval Pinto Brandão Filho, PhD, Marli Tenório Cordeiro, PhD, Enrique Vazquez, PhD, Danielle Di Cavalcanti Souza Cruz, MD, Cláudio Maierovitch Pessanha Henriques, MSc, Luciana Caroline Albuquerque Bezerra, MSc, Priscila Mayrelle da Silva Castanha, PhD, Rafael Dhalia, PhD, Ernesto Torres Azevedo Marques-Júnior, PhD, Prof Celina Maria Turchi Martelli, PhD on behalf of investigators from the Microcephaly Epidemic Research Group the Brazilian Ministry of Health the Pan American Health Organization Instituto de Medicina Integral Professor Fernando Figueira the State Health Department of Pernambuco†


The microcephaly epidemic, which started in Brazil in 2015, was declared a Public Health Emergency of International Concern by WHO in 2016. We report the preliminary results of a case-control study investigating the association between microcephaly and Zika virus infection during pregnancy.


We did this case-control study in eight public hospitals in Recife, Brazil. Cases were neonates with microcephaly. Two controls (neonates without microcephaly), matched by expected date of delivery and area of residence, were selected for each case. Serum samples of cases and controls and cerebrospinal fluid samples of cases were tested for Zika virus-specific IgM and by quantitative RT-PCR. Laboratory-confirmed Zika virus infection during pregnancy was defined as detection of Zika virus-specific IgM or a positive RT-PCR result in neonates. Maternal serum samples were tested by plaque reduction neutralisation assay for Zika virus and dengue virus. We estimated crude odds ratios (ORs) and 95% CIs using a median unbiased estimator for binary data in an unconditional logistic regression model. We estimated ORs separately for cases with and without radiological evidence of brain abnormalities.


Between Jan 15, 2016, and May 2, 2016, we prospectively recruited 32 cases and 62 controls. 24 (80%) of 30 mothers of cases had Zika virus infection compared with 39 (64%) of 61 mothers of controls (p=0·12). 13 (41%) of 32 cases and none of 62 controls had laboratory-confirmed Zika virus infection; crude overall OR 55·5 (95% CI 8·6–∞); OR 113·3 (95% CI 14·5–∞) for seven cases with brain abnormalities; and OR 24·7 (95% CI 2·9–∞) for four cases without brain abnormalities.


Our data suggest that the microcephaly epidemic is a result of congenital Zika virus infection. We await further data from this ongoing study to assess other potential risk factors and to confirm the strength of association in a larger sample size.


Brazilian Ministry of Health, Pan American Health Organization, and Enhancing Research Activity in Epidemic Situations.


November 15, 2016 at 12:16 pm

Comment – Eliminating hepatitis B virus as a global health threat

Lancet Infectious Diseases December 2016 V.16 N.12 P.1313–1314

Grace Lai-Hung Wong, Vincent Wai-Sun Wong

In The Lancet Infectious Diseases, Shevanthi Nayagam and colleagues1 report a modelling study on the effectiveness of different interventions on the incidence and mortality rate of chronic hepatitis B virus (HBV) infection. To appreciate the implications of this report, we need to understand the context. Chronic viral hepatitis is the seventh leading cause of death worldwide.2 Chronic HBV infection alone affects over 240 million people worldwide and is one of the most common causes of cirrhosis and liver cancer.3 In May, 2014, the World Health Assembly requested WHO to provide the necessary technical support to enable member states to develop robust national viral hepatitis prevention, diagnosis, and treatment strategies. In response, WHO set ambitious goals of reducing new cases of chronic viral hepatitis by 90%, and reducing mortality rates from these infections by 65% between 2015 and 2030.4 Achievement of these goals might at least eliminate chronic viral hepatitis as a major global health threat. What can we do to make this happen?


November 15, 2016 at 12:15 pm

Comment – More pieces to the microcephaly–Zika virus puzzle in Brazil

Lancet Infectious Diseases December 2016 V.16 N.12 P.1307–1309

Patricia Brasil, Karin Nielsen-Saines

By October, 2015, the Zika virus epidemic had grown substantially in Brazil with 14 states reporting autochthonous Zika virus transmission. Concurrently, concerns were raised regarding the discovery of a substantial increase in the number of microcephaly cases, particularly in the state of Pernambuco. The following month, a national public health emergency was declared in Brazil in response to growing concerns about the potential association between Zika virus and newborn microcephaly, with 1248 reported cases—20 times greater than the expected number.1 Following this announcement, additional progress was made in establishing more definitive associations between Zika virus and congenital anomalies, including microcephaly.2, 3

Studies in mouse models have addressed the causal relation between Zika virus infection in pregnancy and pathological changes in fetuses.4, 5 Although a growing body of evidence suggests that Zika virus causes brain anomalies and microcephaly, describing what has been identified as congenital Zika virus infection syndrome, there is a paucity of published prospective epidemiological studies.3 A study by Thalia Araújo and colleagues6 in The Lancet Infectious Diseases might be a missing piece to the puzzle, providing necessary epidemiological data to further advance our understanding of the association….


November 15, 2016 at 12:14 pm

Core Elements of Outpatient Antibiotic Stewardship

MMWR Recommendations and Reports November 2016 V.65 RR-6 P.1–12 

Guillermo V. Sanchez, MPH, MSHS; Katherine E. Fleming-Dutra, MD; Rebecca M. Roberts, MS; et al.

Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients.

Improving antibiotic prescribing involves implementing effective strategies to modify prescribing practices to align them with evidence-based recommendations for diagnosis and management.

This report provides a framework for antibiotic stewardship for outpatient clinicians and facilities that routinely provide antibiotic treatment.

Establishing effective antibiotic stewardship interventions can protect patients and improve clinical outcomes in outpatient health care settings….


November 15, 2016 at 7:58 am


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