MDedge Infectious Disease

The World Health Organization and United Nations International Children’s Emergency Fund are warning about a heightened risk of measles spreading and triggering larger outbreaks in 2022.

Worldwide cases are up nearly 80% so far over 2021, the groups reported. More than 17,300 measles cases were reported worldwide in January and February, compared with 9,600 cases at the beginning of 2021.

In the last 12 months, there have been 21 “large and disruptive” measles outbreaks, particularly in Africa and the East Mediterranean region. The actual numbers are likely higher because of underreporting and disruptions to surveillance systems.

“Pandemic-related disruptions, increasing inequalities in access to vaccines, and the diversion of resources from routine immunization are leaving too many children without protection against measles and other vaccine-preventable diseases,” the organizations said.

As cities and countries relax COVID-19 restrictions, measles outbreaks are becoming more likely, they noted.

“It is encouraging that people in many communities are beginning to feel protected enough from COVID-19 to return to more social activities. But doing so in places where children are not receiving routine vaccination creates the perfect storm for the spread of a disease like measles,” Catherine Russell, executive director for UNICEF, said in the statement.

In the past year, the largest measles outbreaks have occurred in Somalia, Yemen, Nigeria, Afghanistan, and Ethiopia. The main reason for outbreaks is a lack measles vaccine coverage, the organizations said.

About 23 million children missed childhood vaccinations in 2020, the groups said. Childhood vaccination campaigns were hindered because of the COVID-19 pandemic and conflicts in Ukraine, Ethiopia, Somalia, and Afghanistan.

Overall, 57 campaigns targeting vaccine-preventable diseases across 43 countries that were scheduled to take place since the beginning of the COVID-19 pandemic are still postponed, the groups said, which could affect 203 million people. Among those, 19 are measles campaigns, which could put 73 million children at risk of measles because of missed vaccinations.

Vaccine coverage of 95% or higher with two doses of the measles vaccine can provide protection, according to the organizations. But the five countries that had the highest measles cases in the last year had first-dose coverage between 46% and 68%.

In the United States, measles vaccinations in kindergarten students dropped from about 95% to 93.9% for the 2020-2021 school year, according to CNN.

Vaccination coverage also dropped from 95% to 93.6% for diphtheria, tetanus, acellular pertussis, and varicella. Even though the decreases appear small, it means tens of thousands of children across the United States started school without their common childhood vaccinations, the Centers for Disease Control and Prevention said.

“We are concerned that missed routine vaccinations could leave children vulnerable to preventable diseases like measles and whooping cough, which are extremely contagious and can be very serious, especially for babies and young children,” Shannon Stokley, DrPH, deputy director of the CDC’s immunization services division, told CNN.

The numbers show a “concerning decline in childhood immunizations that began in March 2020,” she said.

A version of this article first appeared on WebMD.com.

The World Health Organization and United Nations International Children’s Emergency Fund are warning about a heightened risk of measles spreading and triggering larger outbreaks in 2022.

Worldwide cases are up nearly 80% so far over 2021, the groups reported. More than 17,300 measles cases were reported worldwide in January and February, compared with 9,600 cases at the beginning of 2021.

In the last 12 months, there have been 21 “large and disruptive” measles outbreaks, particularly in Africa and the East Mediterranean region. The actual numbers are likely higher because of underreporting and disruptions to surveillance systems.

“Pandemic-related disruptions, increasing inequalities in access to vaccines, and the diversion of resources from routine immunization are leaving too many children without protection against measles and other vaccine-preventable diseases,” the organizations said.

As cities and countries relax COVID-19 restrictions, measles outbreaks are becoming more likely, they noted.

“It is encouraging that people in many communities are beginning to feel protected enough from COVID-19 to return to more social activities. But doing so in places where children are not receiving routine vaccination creates the perfect storm for the spread of a disease like measles,” Catherine Russell, executive director for UNICEF, said in the statement.

In the past year, the largest measles outbreaks have occurred in Somalia, Yemen, Nigeria, Afghanistan, and Ethiopia. The main reason for outbreaks is a lack measles vaccine coverage, the organizations said.

About 23 million children missed childhood vaccinations in 2020, the groups said. Childhood vaccination campaigns were hindered because of the COVID-19 pandemic and conflicts in Ukraine, Ethiopia, Somalia, and Afghanistan.

Overall, 57 campaigns targeting vaccine-preventable diseases across 43 countries that were scheduled to take place since the beginning of the COVID-19 pandemic are still postponed, the groups said, which could affect 203 million people. Among those, 19 are measles campaigns, which could put 73 million children at risk of measles because of missed vaccinations.

Vaccine coverage of 95% or higher with two doses of the measles vaccine can provide protection, according to the organizations. But the five countries that had the highest measles cases in the last year had first-dose coverage between 46% and 68%.

In the United States, measles vaccinations in kindergarten students dropped from about 95% to 93.9% for the 2020-2021 school year, according to CNN.

Vaccination coverage also dropped from 95% to 93.6% for diphtheria, tetanus, acellular pertussis, and varicella. Even though the decreases appear small, it means tens of thousands of children across the United States started school without their common childhood vaccinations, the Centers for Disease Control and Prevention said.

“We are concerned that missed routine vaccinations could leave children vulnerable to preventable diseases like measles and whooping cough, which are extremely contagious and can be very serious, especially for babies and young children,” Shannon Stokley, DrPH, deputy director of the CDC’s immunization services division, told CNN.

The numbers show a “concerning decline in childhood immunizations that began in March 2020,” she said.

A version of this article first appeared on WebMD.com.

The World Health Organization and United Nations International Children’s Emergency Fund are warning about a heightened risk of measles spreading and triggering larger outbreaks in 2022.

Worldwide cases are up nearly 80% so far over 2021, the groups reported. More than 17,300 measles cases were reported worldwide in January and February, compared with 9,600 cases at the beginning of 2021.

In the last 12 months, there have been 21 “large and disruptive” measles outbreaks, particularly in Africa and the East Mediterranean region. The actual numbers are likely higher because of underreporting and disruptions to surveillance systems.

“Pandemic-related disruptions, increasing inequalities in access to vaccines, and the diversion of resources from routine immunization are leaving too many children without protection against measles and other vaccine-preventable diseases,” the organizations said.

As cities and countries relax COVID-19 restrictions, measles outbreaks are becoming more likely, they noted.

“It is encouraging that people in many communities are beginning to feel protected enough from COVID-19 to return to more social activities. But doing so in places where children are not receiving routine vaccination creates the perfect storm for the spread of a disease like measles,” Catherine Russell, executive director for UNICEF, said in the statement.

In the past year, the largest measles outbreaks have occurred in Somalia, Yemen, Nigeria, Afghanistan, and Ethiopia. The main reason for outbreaks is a lack measles vaccine coverage, the organizations said.

About 23 million children missed childhood vaccinations in 2020, the groups said. Childhood vaccination campaigns were hindered because of the COVID-19 pandemic and conflicts in Ukraine, Ethiopia, Somalia, and Afghanistan.

Overall, 57 campaigns targeting vaccine-preventable diseases across 43 countries that were scheduled to take place since the beginning of the COVID-19 pandemic are still postponed, the groups said, which could affect 203 million people. Among those, 19 are measles campaigns, which could put 73 million children at risk of measles because of missed vaccinations.

Vaccine coverage of 95% or higher with two doses of the measles vaccine can provide protection, according to the organizations. But the five countries that had the highest measles cases in the last year had first-dose coverage between 46% and 68%.

In the United States, measles vaccinations in kindergarten students dropped from about 95% to 93.9% for the 2020-2021 school year, according to CNN.

Vaccination coverage also dropped from 95% to 93.6% for diphtheria, tetanus, acellular pertussis, and varicella. Even though the decreases appear small, it means tens of thousands of children across the United States started school without their common childhood vaccinations, the Centers for Disease Control and Prevention said.

“We are concerned that missed routine vaccinations could leave children vulnerable to preventable diseases like measles and whooping cough, which are extremely contagious and can be very serious, especially for babies and young children,” Shannon Stokley, DrPH, deputy director of the CDC’s immunization services division, told CNN.

The numbers show a “concerning decline in childhood immunizations that began in March 2020,” she said.

A version of this article first appeared on WebMD.com.

Health officials are investigating at least 30 cases of severe hepatitis in children across 10 U.S. states. The Minnesota Department of Health received two reports of severe hepatitis, one in an infant and another in a 2-year-old, the Associated Press reported on April 30. One child was treated “several months ago” and required a liver transplant, according to the article. 

Worldwide cases surpass 200, including 34 cases in the United Kingdom, the U.K. Health Security Agency announced on April 29. Most cases have occurred in the United Kingdom, but there have been more than 55 probable and confirmed hepatitis cases in children in 12 countries in the European Union or the European Economic Area. Cases have also been identified in Asia, with both Japan and Singapore reporting one case each of acute hepatitis, Bloomberg reported. Additionally, three children in Indonesia died from acute hepatitis in April, but the total number of cases in that country was not available.

Although the total number of worldwide cases remains small, the severity of the cases – as well as their unexplained cause – have health officials on alert, said David Lee Thomas, MD, MPH, of the Viral Hepatitis Center at Johns Hopkins Medicine in Baltimore. “There are some kids who would have died if not for liver transplants.”

In the United States, the only confirmed cases are in Alabama, where nine patients were admitted for severe hepatitis between October 2021 and February 2022. Beyond the two suspected cases in Minnesota, health officials are investigating at least 19 other potential cases in eight states, according to NBC News: Delaware (1), Georgia, Illinois (3), Louisiana (1), New York, North Carolina (2), Tennessee (6), and Wisconsin (4). (New York and Georgia did not specify the number of cases being investigated.)

Reported cases have occurred in patients aged between 1 month and 16 years old. Globally, at least 17 patients have needed liver transplants, according to a World Health Organization alert on April 23. While WHO officials said there has been at least one death globally linked to hepatitis, that does not include the three deaths in Indonesia. One death has also been reported in Wisconsin, but the state’s Department of Health Services did not confirm whether this death was included in the WHO announcement.

The cause of these severe hepatitis cases has yet to be identified, but these cases have tested negative for more common viruses that can cause hepatitis in children. There is no link between these cases and COVID-19 vaccination, according to WHO, because most affected children have not been vaccinated.

Adenovirus is a possible contributing factor in these cases, as many of the cases in Europe tested positive for the virus. In an analysis of the nine Alabama cases released by the Centers for Disease Control and Prevention, adenovirus was detected in the blood samples of all nine children. Five of the nine children tested positive for adenovirus type 41, which is a common cause of acute gastroenteritis in children. While the six liver biopsies performed showed varying degrees of hepatitis, there were “no viral inclusions observed, no immunohistochemical evidence of adenovirus, or no viral particles identified by electron microscopy,” according to the report. None of the children tested positive for COVID-19 or had a documented history of previous COVID-19 infection.

“At this time, we believe that adenovirus may be the cause for these reported cases, but other potential environmental and situational factors are still being investigated,” the CDC said in a media statement. The CDC added that the report was specific to the nine Alabama cases, and that the agency is working to investigate other potential cases with state and local public health officials.

While the “growing consensus” among experts is that adenovirus could be behind these severe cases, there are many unanswered questions, Dr. Thomas added, such as why this strain of adenovirus causes such severe hepatitis, and why the liver biopsies do not show classic signs of viral infection. That information will come as investigations continue.

“From a provider point of view, if you have a child with an unexplained liver problem, report it to the CDC,” he advised. “Right now, we have to learn more about [these cases],” and that requires more research like the investigations in Alabama, he noted.

A version of this article first appeared on Medscape.com.

Health officials are investigating at least 30 cases of severe hepatitis in children across 10 U.S. states. The Minnesota Department of Health received two reports of severe hepatitis, one in an infant and another in a 2-year-old, the Associated Press reported on April 30. One child was treated “several months ago” and required a liver transplant, according to the article. 

Worldwide cases surpass 200, including 34 cases in the United Kingdom, the U.K. Health Security Agency announced on April 29. Most cases have occurred in the United Kingdom, but there have been more than 55 probable and confirmed hepatitis cases in children in 12 countries in the European Union or the European Economic Area. Cases have also been identified in Asia, with both Japan and Singapore reporting one case each of acute hepatitis, Bloomberg reported. Additionally, three children in Indonesia died from acute hepatitis in April, but the total number of cases in that country was not available.

Although the total number of worldwide cases remains small, the severity of the cases – as well as their unexplained cause – have health officials on alert, said David Lee Thomas, MD, MPH, of the Viral Hepatitis Center at Johns Hopkins Medicine in Baltimore. “There are some kids who would have died if not for liver transplants.”

In the United States, the only confirmed cases are in Alabama, where nine patients were admitted for severe hepatitis between October 2021 and February 2022. Beyond the two suspected cases in Minnesota, health officials are investigating at least 19 other potential cases in eight states, according to NBC News: Delaware (1), Georgia, Illinois (3), Louisiana (1), New York, North Carolina (2), Tennessee (6), and Wisconsin (4). (New York and Georgia did not specify the number of cases being investigated.)

Reported cases have occurred in patients aged between 1 month and 16 years old. Globally, at least 17 patients have needed liver transplants, according to a World Health Organization alert on April 23. While WHO officials said there has been at least one death globally linked to hepatitis, that does not include the three deaths in Indonesia. One death has also been reported in Wisconsin, but the state’s Department of Health Services did not confirm whether this death was included in the WHO announcement.

The cause of these severe hepatitis cases has yet to be identified, but these cases have tested negative for more common viruses that can cause hepatitis in children. There is no link between these cases and COVID-19 vaccination, according to WHO, because most affected children have not been vaccinated.

Adenovirus is a possible contributing factor in these cases, as many of the cases in Europe tested positive for the virus. In an analysis of the nine Alabama cases released by the Centers for Disease Control and Prevention, adenovirus was detected in the blood samples of all nine children. Five of the nine children tested positive for adenovirus type 41, which is a common cause of acute gastroenteritis in children. While the six liver biopsies performed showed varying degrees of hepatitis, there were “no viral inclusions observed, no immunohistochemical evidence of adenovirus, or no viral particles identified by electron microscopy,” according to the report. None of the children tested positive for COVID-19 or had a documented history of previous COVID-19 infection.

“At this time, we believe that adenovirus may be the cause for these reported cases, but other potential environmental and situational factors are still being investigated,” the CDC said in a media statement. The CDC added that the report was specific to the nine Alabama cases, and that the agency is working to investigate other potential cases with state and local public health officials.

While the “growing consensus” among experts is that adenovirus could be behind these severe cases, there are many unanswered questions, Dr. Thomas added, such as why this strain of adenovirus causes such severe hepatitis, and why the liver biopsies do not show classic signs of viral infection. That information will come as investigations continue.

“From a provider point of view, if you have a child with an unexplained liver problem, report it to the CDC,” he advised. “Right now, we have to learn more about [these cases],” and that requires more research like the investigations in Alabama, he noted.

A version of this article first appeared on Medscape.com.

Health officials are investigating at least 30 cases of severe hepatitis in children across 10 U.S. states. The Minnesota Department of Health received two reports of severe hepatitis, one in an infant and another in a 2-year-old, the Associated Press reported on April 30. One child was treated “several months ago” and required a liver transplant, according to the article. 

Worldwide cases surpass 200, including 34 cases in the United Kingdom, the U.K. Health Security Agency announced on April 29. Most cases have occurred in the United Kingdom, but there have been more than 55 probable and confirmed hepatitis cases in children in 12 countries in the European Union or the European Economic Area. Cases have also been identified in Asia, with both Japan and Singapore reporting one case each of acute hepatitis, Bloomberg reported. Additionally, three children in Indonesia died from acute hepatitis in April, but the total number of cases in that country was not available.

Although the total number of worldwide cases remains small, the severity of the cases – as well as their unexplained cause – have health officials on alert, said David Lee Thomas, MD, MPH, of the Viral Hepatitis Center at Johns Hopkins Medicine in Baltimore. “There are some kids who would have died if not for liver transplants.”

In the United States, the only confirmed cases are in Alabama, where nine patients were admitted for severe hepatitis between October 2021 and February 2022. Beyond the two suspected cases in Minnesota, health officials are investigating at least 19 other potential cases in eight states, according to NBC News: Delaware (1), Georgia, Illinois (3), Louisiana (1), New York, North Carolina (2), Tennessee (6), and Wisconsin (4). (New York and Georgia did not specify the number of cases being investigated.)

Reported cases have occurred in patients aged between 1 month and 16 years old. Globally, at least 17 patients have needed liver transplants, according to a World Health Organization alert on April 23. While WHO officials said there has been at least one death globally linked to hepatitis, that does not include the three deaths in Indonesia. One death has also been reported in Wisconsin, but the state’s Department of Health Services did not confirm whether this death was included in the WHO announcement.

The cause of these severe hepatitis cases has yet to be identified, but these cases have tested negative for more common viruses that can cause hepatitis in children. There is no link between these cases and COVID-19 vaccination, according to WHO, because most affected children have not been vaccinated.

Adenovirus is a possible contributing factor in these cases, as many of the cases in Europe tested positive for the virus. In an analysis of the nine Alabama cases released by the Centers for Disease Control and Prevention, adenovirus was detected in the blood samples of all nine children. Five of the nine children tested positive for adenovirus type 41, which is a common cause of acute gastroenteritis in children. While the six liver biopsies performed showed varying degrees of hepatitis, there were “no viral inclusions observed, no immunohistochemical evidence of adenovirus, or no viral particles identified by electron microscopy,” according to the report. None of the children tested positive for COVID-19 or had a documented history of previous COVID-19 infection.

“At this time, we believe that adenovirus may be the cause for these reported cases, but other potential environmental and situational factors are still being investigated,” the CDC said in a media statement. The CDC added that the report was specific to the nine Alabama cases, and that the agency is working to investigate other potential cases with state and local public health officials.

While the “growing consensus” among experts is that adenovirus could be behind these severe cases, there are many unanswered questions, Dr. Thomas added, such as why this strain of adenovirus causes such severe hepatitis, and why the liver biopsies do not show classic signs of viral infection. That information will come as investigations continue.

“From a provider point of view, if you have a child with an unexplained liver problem, report it to the CDC,” he advised. “Right now, we have to learn more about [these cases],” and that requires more research like the investigations in Alabama, he noted.

A version of this article first appeared on Medscape.com.

Paxlovid works as a treatment for COVID-19 but not as a preventive measure, particularly if you’ve been exposed to the coronavirus through a household member who is infected, according to a new announcement from Pfizer.

In a clinical trial, the oral antiviral tablets were tested for postexposure prophylactic use, or tested for how well they prevented a coronavirus infection in people exposed to the virus. Paxlovid somewhat reduced the risk of infection, but the results weren’t statistically significant.

“We designed the clinical development program for Paxlovid to be comprehensive and ambitious with the aim of being able to help combat COVID-19 in a very broad population of patients,” Albert Bourla, PhD, Pfizer’s chairman and CEO, said in the announcement.

“While we are disappointed in the outcome of this particular study, these results do not impact the strong efficacy and safety data we’ve observed in our earlier trial for the treatment of COVID-19 patients at high risk of developing severe illness,” he said.

The trial included nearly 3,000 adults who were living with someone who recently tested positive for COVID-19 and had symptoms. The people in the trial, who tested negative and didn’t have symptoms, were given either Paxlovid twice daily for 5 or 10 days or a placebo. The study recruitment began in September 2021 and was completed during the peak of the Omicron wave.

Those who took the 5-day course of Paxlovid were found to be 32% less likely to become infected than the placebo group. Those who took the 10-day treatment had a 37% risk reduction. But the results weren’t statistically significant and may have been because of chance.

“Traditionally, it’s been difficult to use small-molecule antivirals for true prophylaxis because the biology of treating infection is different from the biology of preventing infection,” Daniel Barouch, MD, director of the Center for Virology and Vaccine Research at Beth Israel Deaconess Medical Center, told STAT News.

He also noted that the Omicron variant could have played a role.

“That hyperinfectiousness probably makes it more difficult to prevent infections,” Dr. Barouch said.

The safety data was consistent with that of previous studies, Pfizer said, which found that the treatment was about 90% effective at preventing hospitalization or death in COVID-19 patients with a high risk of severe illness if the pills were taken for 5 days soon after symptoms started.

Paxlovid is approved or authorized for conditional or emergency use in more than 60 countries to treat high-risk COVID-19 patients, Pfizer said. In the United States, the drug is authorized for emergency use for the treatment of mild to moderate COVID-19 in those aged 12 and older who face high risks for severe disease, hospitalization, or death.

The full study data will be released in coming months and submitted to a peer-reviewed publication, the company said. More details are on the ClinicalTrials.gov website (NCT05047601).

A version of this article first appeared on WebMD.com.

Paxlovid works as a treatment for COVID-19 but not as a preventive measure, particularly if you’ve been exposed to the coronavirus through a household member who is infected, according to a new announcement from Pfizer.

In a clinical trial, the oral antiviral tablets were tested for postexposure prophylactic use, or tested for how well they prevented a coronavirus infection in people exposed to the virus. Paxlovid somewhat reduced the risk of infection, but the results weren’t statistically significant.

“We designed the clinical development program for Paxlovid to be comprehensive and ambitious with the aim of being able to help combat COVID-19 in a very broad population of patients,” Albert Bourla, PhD, Pfizer’s chairman and CEO, said in the announcement.

“While we are disappointed in the outcome of this particular study, these results do not impact the strong efficacy and safety data we’ve observed in our earlier trial for the treatment of COVID-19 patients at high risk of developing severe illness,” he said.

The trial included nearly 3,000 adults who were living with someone who recently tested positive for COVID-19 and had symptoms. The people in the trial, who tested negative and didn’t have symptoms, were given either Paxlovid twice daily for 5 or 10 days or a placebo. The study recruitment began in September 2021 and was completed during the peak of the Omicron wave.

Those who took the 5-day course of Paxlovid were found to be 32% less likely to become infected than the placebo group. Those who took the 10-day treatment had a 37% risk reduction. But the results weren’t statistically significant and may have been because of chance.

“Traditionally, it’s been difficult to use small-molecule antivirals for true prophylaxis because the biology of treating infection is different from the biology of preventing infection,” Daniel Barouch, MD, director of the Center for Virology and Vaccine Research at Beth Israel Deaconess Medical Center, told STAT News.

He also noted that the Omicron variant could have played a role.

“That hyperinfectiousness probably makes it more difficult to prevent infections,” Dr. Barouch said.

The safety data was consistent with that of previous studies, Pfizer said, which found that the treatment was about 90% effective at preventing hospitalization or death in COVID-19 patients with a high risk of severe illness if the pills were taken for 5 days soon after symptoms started.

Paxlovid is approved or authorized for conditional or emergency use in more than 60 countries to treat high-risk COVID-19 patients, Pfizer said. In the United States, the drug is authorized for emergency use for the treatment of mild to moderate COVID-19 in those aged 12 and older who face high risks for severe disease, hospitalization, or death.

The full study data will be released in coming months and submitted to a peer-reviewed publication, the company said. More details are on the ClinicalTrials.gov website (NCT05047601).

A version of this article first appeared on WebMD.com.

Paxlovid works as a treatment for COVID-19 but not as a preventive measure, particularly if you’ve been exposed to the coronavirus through a household member who is infected, according to a new announcement from Pfizer.

In a clinical trial, the oral antiviral tablets were tested for postexposure prophylactic use, or tested for how well they prevented a coronavirus infection in people exposed to the virus. Paxlovid somewhat reduced the risk of infection, but the results weren’t statistically significant.

“We designed the clinical development program for Paxlovid to be comprehensive and ambitious with the aim of being able to help combat COVID-19 in a very broad population of patients,” Albert Bourla, PhD, Pfizer’s chairman and CEO, said in the announcement.

“While we are disappointed in the outcome of this particular study, these results do not impact the strong efficacy and safety data we’ve observed in our earlier trial for the treatment of COVID-19 patients at high risk of developing severe illness,” he said.

The trial included nearly 3,000 adults who were living with someone who recently tested positive for COVID-19 and had symptoms. The people in the trial, who tested negative and didn’t have symptoms, were given either Paxlovid twice daily for 5 or 10 days or a placebo. The study recruitment began in September 2021 and was completed during the peak of the Omicron wave.

Those who took the 5-day course of Paxlovid were found to be 32% less likely to become infected than the placebo group. Those who took the 10-day treatment had a 37% risk reduction. But the results weren’t statistically significant and may have been because of chance.

“Traditionally, it’s been difficult to use small-molecule antivirals for true prophylaxis because the biology of treating infection is different from the biology of preventing infection,” Daniel Barouch, MD, director of the Center for Virology and Vaccine Research at Beth Israel Deaconess Medical Center, told STAT News.

He also noted that the Omicron variant could have played a role.

“That hyperinfectiousness probably makes it more difficult to prevent infections,” Dr. Barouch said.

The safety data was consistent with that of previous studies, Pfizer said, which found that the treatment was about 90% effective at preventing hospitalization or death in COVID-19 patients with a high risk of severe illness if the pills were taken for 5 days soon after symptoms started.

Paxlovid is approved or authorized for conditional or emergency use in more than 60 countries to treat high-risk COVID-19 patients, Pfizer said. In the United States, the drug is authorized for emergency use for the treatment of mild to moderate COVID-19 in those aged 12 and older who face high risks for severe disease, hospitalization, or death.

The full study data will be released in coming months and submitted to a peer-reviewed publication, the company said. More details are on the ClinicalTrials.gov website (NCT05047601).

A version of this article first appeared on WebMD.com.

A man who worked on a commercial poultry farm in Colorado has tested positive for avian influenza A(H5) virus, better known as H5 bird flu, the CDC announced on April 28.

This is the first case of H5 bird flu in humans in the United States and only the second case in the world, the CDC said in a news release. The first case was detected last December in a man who raised birds in the United Kingdom. That man had no symptoms.

The only symptom the man in Colorado reported was fatigue, the Colorado Department of Public Health and Environment (CDPHE) reported. He has recovered and is isolating and being treated with oseltamivir, an antiviral drug.

The CDC said the man was helping kill poultry that likely had the H5N1 bird flu.

He is a state prison inmate who was working on a commercial poultry farm in Montrose County in a prerelease employment program, the CDPHE said. The flock he was working with has been euthanized, and the response team and other inmates working on the farm were given protective equipment, the CDPHE said.

“Repeat testing on the person was negative for influenza,” the department said. “Because the person was in close contact with infected poultry, the virus may have been in the person’s nose without causing infection.”

This CDC said the case does not change the risk of bird flu for the general public, which is considered low. People who work with birds should continue to take safety precautions, such as wearing gloves when handling birds and avoiding birds that appear to be dead or ill, the CDC said.

“We want to reassure Coloradans that the risk to them is low,” said Rachel Herlihy, MD, state epidemiologist with the CDPHE. “I am grateful for the seamless collaboration between CDC, Department of Corrections, Department of Agriculture, and CDPHE, as we continue to monitor this virus and protect all Coloradans.”

The federal government says the H5N1 virus has been found in commercial and backyard birds in 29 states and in wild birds in 34 states since the first cases were detected in late 2021.

The CDC says it has tracked the health of 2,500 people exposed to birds infected with H5N1 and only found one case of human infection, in Colorado.

A version of this article first appeared on WebMD.com.

A man who worked on a commercial poultry farm in Colorado has tested positive for avian influenza A(H5) virus, better known as H5 bird flu, the CDC announced on April 28.

This is the first case of H5 bird flu in humans in the United States and only the second case in the world, the CDC said in a news release. The first case was detected last December in a man who raised birds in the United Kingdom. That man had no symptoms.

The only symptom the man in Colorado reported was fatigue, the Colorado Department of Public Health and Environment (CDPHE) reported. He has recovered and is isolating and being treated with oseltamivir, an antiviral drug.

The CDC said the man was helping kill poultry that likely had the H5N1 bird flu.

He is a state prison inmate who was working on a commercial poultry farm in Montrose County in a prerelease employment program, the CDPHE said. The flock he was working with has been euthanized, and the response team and other inmates working on the farm were given protective equipment, the CDPHE said.

“Repeat testing on the person was negative for influenza,” the department said. “Because the person was in close contact with infected poultry, the virus may have been in the person’s nose without causing infection.”

This CDC said the case does not change the risk of bird flu for the general public, which is considered low. People who work with birds should continue to take safety precautions, such as wearing gloves when handling birds and avoiding birds that appear to be dead or ill, the CDC said.

“We want to reassure Coloradans that the risk to them is low,” said Rachel Herlihy, MD, state epidemiologist with the CDPHE. “I am grateful for the seamless collaboration between CDC, Department of Corrections, Department of Agriculture, and CDPHE, as we continue to monitor this virus and protect all Coloradans.”

The federal government says the H5N1 virus has been found in commercial and backyard birds in 29 states and in wild birds in 34 states since the first cases were detected in late 2021.

The CDC says it has tracked the health of 2,500 people exposed to birds infected with H5N1 and only found one case of human infection, in Colorado.

A version of this article first appeared on WebMD.com.

A man who worked on a commercial poultry farm in Colorado has tested positive for avian influenza A(H5) virus, better known as H5 bird flu, the CDC announced on April 28.

This is the first case of H5 bird flu in humans in the United States and only the second case in the world, the CDC said in a news release. The first case was detected last December in a man who raised birds in the United Kingdom. That man had no symptoms.

The only symptom the man in Colorado reported was fatigue, the Colorado Department of Public Health and Environment (CDPHE) reported. He has recovered and is isolating and being treated with oseltamivir, an antiviral drug.

The CDC said the man was helping kill poultry that likely had the H5N1 bird flu.

He is a state prison inmate who was working on a commercial poultry farm in Montrose County in a prerelease employment program, the CDPHE said. The flock he was working with has been euthanized, and the response team and other inmates working on the farm were given protective equipment, the CDPHE said.

“Repeat testing on the person was negative for influenza,” the department said. “Because the person was in close contact with infected poultry, the virus may have been in the person’s nose without causing infection.”

This CDC said the case does not change the risk of bird flu for the general public, which is considered low. People who work with birds should continue to take safety precautions, such as wearing gloves when handling birds and avoiding birds that appear to be dead or ill, the CDC said.

“We want to reassure Coloradans that the risk to them is low,” said Rachel Herlihy, MD, state epidemiologist with the CDPHE. “I am grateful for the seamless collaboration between CDC, Department of Corrections, Department of Agriculture, and CDPHE, as we continue to monitor this virus and protect all Coloradans.”

The federal government says the H5N1 virus has been found in commercial and backyard birds in 29 states and in wild birds in 34 states since the first cases were detected in late 2021.

The CDC says it has tracked the health of 2,500 people exposed to birds infected with H5N1 and only found one case of human infection, in Colorado.

A version of this article first appeared on WebMD.com.

The incidence of sexually transmitted infection (STI) as well as disability-adjusted life-years (DALYs) increased worldwide over 30 years, according to an observational trend study from China.

“Most countries had a decrease in age-standardized rates of incidence and DALY for STIs, whereas the absolute incident cases and DALYs increased from 1990 to 2019,” the authors write in The Lancet Infectious Diseases. “Therefore, STIs still represent a global public health challenge, especially in sub-Saharan Africa and Latin America, where more attention and health prevention services are warranted.”

“Our study also suggested an upward trend of age-standardized incidence rates among young populations, especially for syphilis, after 2010,” they add.
 

STIs are a major worldwide public health challenge

To assess global STI burden and trends, co–lead study author Yang Zheng, MD, of Zhejiang University School of Medicine in Hangzhou, China, and colleagues analyzed data from the Global Burden of Disease (GBD) study 2019.

They calculated incidence and DALYs of STIs in the general population at national, regional, and global levels over 30 years. They also calculated annual percentage changes in the age-standardized incidence rate and the age-standardized DALY rate of the five STIs included in the GBD study.

Of 204 countries in GBD 2019, 161 provided data on syphilis, 64 on gonorrhea, 94 on chlamydia, 56 on trichomonas, and 77 on genital herpes. The authors included 95% uncertainty intervals (UIs) and used Bayesian meta-regression to model the data.

• Overall, they found that the global age-standardized incidence rate of STIs trended downward, with an estimated annual percentage change of –0.04 (95% UI, –0.08 to 0.00) from 1990 to 2019, reaching 9,535.71 per 100,000 person-years (8,169.73-11,054.76) in 2019.
• The age-standardized DALY rate decreased with an estimated annual percentage change of –0.92 (–1.01 to –0.84) and reached 22.74 per 100,000 person-years (14.37-37.11) in 2019.
• Sub-Saharan Africa, one of the hotspots, had the highest age-standardized incidence rate (19,973.12 per 100,000 person-years, 17,382.69-23,001.57) and age-standardized DALY rate (389.32 per 100,000 person-years, 154.27-769.74).
• The highest incidence rate was among adolescents (18,377.82 per 100,000 person-years, 14,040.38-23,443.31), with stable total STI trends except for an increase in syphilis between 2010 (347.65 per 100,000 person-years, 203.58-590.69) and 2019 (423.16 per 100,000 person-years, 235.70-659.01).
• The age-standardized incidence rate was higher among males (10,471.63 per 100,000 person-years, 8,892.20-12,176.10) than females (8,602.40 per 100,000 person-years, 7,358.00-10,001.18), whereas the age-standardized DALY rate was higher among females (33.31 per 100,000 person-years, 21.05-55.25) than males (12.11 per 100,000 person-years, 7.63-18.93).

The authors deliver a call to action

“This paper is a call to action to focus on the STI pandemic with granular data on key target populations,” Yukari C. Manabe, MD, FIDSA, FRCP, who was not involved in the study, told this news organization. “If behavioral messaging and testing in adolescents is not improved, HIV incidence rates will be impacted, and the gains that have been made in this area will be threatened.”

“Although the number of countries from which data could be culled was limited, the change in incident cases is particularly striking, with most countries showing an increase and with African countries showing the largest rise,” said Dr. Manabe, professor of medicine, international health, and molecular microbiology and immunology at Johns Hopkins Medicine and director of the Johns Hopkins Center for Innovative Diagnostics for Infectious Diseases, Baltimore.

“The increase in syphilis incidence rates, particularly in younger people, including men who have sex with men, is also alarming,” she added in an email. “It is interesting to see the gender gap grow as more countries adopt antenatal syphilis screening.”

Ken S. Ho, MD, MPH, infectious diseases specialist and medical director of the Pitt Men’s Study at the University of Pittsburgh School of Medicine, Pennsylvania, called the study’s findings a wake-up call for clinicians to discuss sexual health and wellness with their patients, to increase STI screening, and to address STI stigma.

“Overall, STI rates in most countries have trended down, but paradoxically, the number of cases may be going up, because we have more younger, sexually actively people,” Dr. Ho said in an email.

“The study helps us understand the populations most impacted by STIs and allows us to design and create public health interventions that target the most impacted communities and demographic groups,” Dr. Ho, who also was not involved in the study, added. “It allows us to reflect on how we address disparities. For example, the greater burden of disease seen in women may be due to the fact that women may not be screened and are diagnosed later.”

Dr. Ho explained that the high STI rates in sub-Saharan Africa and Latin America are thought to be due to factors such as poverty and limited access to health care, known drivers of health care disparities.

The 2016 global incidence of common STIs was estimated to be up to 563.3 million, including 6.3 million cases of syphilis, 86.9 million cases of gonorrhea, 127.2 million cases of chlamydia, 156.0 million cases of trichomonas, and 186.9 million cases of genital herpes, the authors write.

The World Health Organization aims to end the STI epidemic by 2030, they note.

The study was funded by Mega-Project of National Science and Technology for the 13th Five-Year Plan of China and the National Natural Science Foundation of China. The authors, Dr. Manabe, and Dr. Ho have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The incidence of sexually transmitted infection (STI) as well as disability-adjusted life-years (DALYs) increased worldwide over 30 years, according to an observational trend study from China.

“Most countries had a decrease in age-standardized rates of incidence and DALY for STIs, whereas the absolute incident cases and DALYs increased from 1990 to 2019,” the authors write in The Lancet Infectious Diseases. “Therefore, STIs still represent a global public health challenge, especially in sub-Saharan Africa and Latin America, where more attention and health prevention services are warranted.”

“Our study also suggested an upward trend of age-standardized incidence rates among young populations, especially for syphilis, after 2010,” they add.
 

STIs are a major worldwide public health challenge

To assess global STI burden and trends, co–lead study author Yang Zheng, MD, of Zhejiang University School of Medicine in Hangzhou, China, and colleagues analyzed data from the Global Burden of Disease (GBD) study 2019.

They calculated incidence and DALYs of STIs in the general population at national, regional, and global levels over 30 years. They also calculated annual percentage changes in the age-standardized incidence rate and the age-standardized DALY rate of the five STIs included in the GBD study.

Of 204 countries in GBD 2019, 161 provided data on syphilis, 64 on gonorrhea, 94 on chlamydia, 56 on trichomonas, and 77 on genital herpes. The authors included 95% uncertainty intervals (UIs) and used Bayesian meta-regression to model the data.

• Overall, they found that the global age-standardized incidence rate of STIs trended downward, with an estimated annual percentage change of –0.04 (95% UI, –0.08 to 0.00) from 1990 to 2019, reaching 9,535.71 per 100,000 person-years (8,169.73-11,054.76) in 2019.
• The age-standardized DALY rate decreased with an estimated annual percentage change of –0.92 (–1.01 to –0.84) and reached 22.74 per 100,000 person-years (14.37-37.11) in 2019.
• Sub-Saharan Africa, one of the hotspots, had the highest age-standardized incidence rate (19,973.12 per 100,000 person-years, 17,382.69-23,001.57) and age-standardized DALY rate (389.32 per 100,000 person-years, 154.27-769.74).
• The highest incidence rate was among adolescents (18,377.82 per 100,000 person-years, 14,040.38-23,443.31), with stable total STI trends except for an increase in syphilis between 2010 (347.65 per 100,000 person-years, 203.58-590.69) and 2019 (423.16 per 100,000 person-years, 235.70-659.01).
• The age-standardized incidence rate was higher among males (10,471.63 per 100,000 person-years, 8,892.20-12,176.10) than females (8,602.40 per 100,000 person-years, 7,358.00-10,001.18), whereas the age-standardized DALY rate was higher among females (33.31 per 100,000 person-years, 21.05-55.25) than males (12.11 per 100,000 person-years, 7.63-18.93).

The authors deliver a call to action

“This paper is a call to action to focus on the STI pandemic with granular data on key target populations,” Yukari C. Manabe, MD, FIDSA, FRCP, who was not involved in the study, told this news organization. “If behavioral messaging and testing in adolescents is not improved, HIV incidence rates will be impacted, and the gains that have been made in this area will be threatened.”

“Although the number of countries from which data could be culled was limited, the change in incident cases is particularly striking, with most countries showing an increase and with African countries showing the largest rise,” said Dr. Manabe, professor of medicine, international health, and molecular microbiology and immunology at Johns Hopkins Medicine and director of the Johns Hopkins Center for Innovative Diagnostics for Infectious Diseases, Baltimore.

“The increase in syphilis incidence rates, particularly in younger people, including men who have sex with men, is also alarming,” she added in an email. “It is interesting to see the gender gap grow as more countries adopt antenatal syphilis screening.”

Ken S. Ho, MD, MPH, infectious diseases specialist and medical director of the Pitt Men’s Study at the University of Pittsburgh School of Medicine, Pennsylvania, called the study’s findings a wake-up call for clinicians to discuss sexual health and wellness with their patients, to increase STI screening, and to address STI stigma.

“Overall, STI rates in most countries have trended down, but paradoxically, the number of cases may be going up, because we have more younger, sexually actively people,” Dr. Ho said in an email.

“The study helps us understand the populations most impacted by STIs and allows us to design and create public health interventions that target the most impacted communities and demographic groups,” Dr. Ho, who also was not involved in the study, added. “It allows us to reflect on how we address disparities. For example, the greater burden of disease seen in women may be due to the fact that women may not be screened and are diagnosed later.”

Dr. Ho explained that the high STI rates in sub-Saharan Africa and Latin America are thought to be due to factors such as poverty and limited access to health care, known drivers of health care disparities.

The 2016 global incidence of common STIs was estimated to be up to 563.3 million, including 6.3 million cases of syphilis, 86.9 million cases of gonorrhea, 127.2 million cases of chlamydia, 156.0 million cases of trichomonas, and 186.9 million cases of genital herpes, the authors write.

The World Health Organization aims to end the STI epidemic by 2030, they note.

The study was funded by Mega-Project of National Science and Technology for the 13th Five-Year Plan of China and the National Natural Science Foundation of China. The authors, Dr. Manabe, and Dr. Ho have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The incidence of sexually transmitted infection (STI) as well as disability-adjusted life-years (DALYs) increased worldwide over 30 years, according to an observational trend study from China.

“Most countries had a decrease in age-standardized rates of incidence and DALY for STIs, whereas the absolute incident cases and DALYs increased from 1990 to 2019,” the authors write in The Lancet Infectious Diseases. “Therefore, STIs still represent a global public health challenge, especially in sub-Saharan Africa and Latin America, where more attention and health prevention services are warranted.”

“Our study also suggested an upward trend of age-standardized incidence rates among young populations, especially for syphilis, after 2010,” they add.
 

STIs are a major worldwide public health challenge

To assess global STI burden and trends, co–lead study author Yang Zheng, MD, of Zhejiang University School of Medicine in Hangzhou, China, and colleagues analyzed data from the Global Burden of Disease (GBD) study 2019.

They calculated incidence and DALYs of STIs in the general population at national, regional, and global levels over 30 years. They also calculated annual percentage changes in the age-standardized incidence rate and the age-standardized DALY rate of the five STIs included in the GBD study.

Of 204 countries in GBD 2019, 161 provided data on syphilis, 64 on gonorrhea, 94 on chlamydia, 56 on trichomonas, and 77 on genital herpes. The authors included 95% uncertainty intervals (UIs) and used Bayesian meta-regression to model the data.

• Overall, they found that the global age-standardized incidence rate of STIs trended downward, with an estimated annual percentage change of –0.04 (95% UI, –0.08 to 0.00) from 1990 to 2019, reaching 9,535.71 per 100,000 person-years (8,169.73-11,054.76) in 2019.
• The age-standardized DALY rate decreased with an estimated annual percentage change of –0.92 (–1.01 to –0.84) and reached 22.74 per 100,000 person-years (14.37-37.11) in 2019.
• Sub-Saharan Africa, one of the hotspots, had the highest age-standardized incidence rate (19,973.12 per 100,000 person-years, 17,382.69-23,001.57) and age-standardized DALY rate (389.32 per 100,000 person-years, 154.27-769.74).
• The highest incidence rate was among adolescents (18,377.82 per 100,000 person-years, 14,040.38-23,443.31), with stable total STI trends except for an increase in syphilis between 2010 (347.65 per 100,000 person-years, 203.58-590.69) and 2019 (423.16 per 100,000 person-years, 235.70-659.01).
• The age-standardized incidence rate was higher among males (10,471.63 per 100,000 person-years, 8,892.20-12,176.10) than females (8,602.40 per 100,000 person-years, 7,358.00-10,001.18), whereas the age-standardized DALY rate was higher among females (33.31 per 100,000 person-years, 21.05-55.25) than males (12.11 per 100,000 person-years, 7.63-18.93).

The authors deliver a call to action

“This paper is a call to action to focus on the STI pandemic with granular data on key target populations,” Yukari C. Manabe, MD, FIDSA, FRCP, who was not involved in the study, told this news organization. “If behavioral messaging and testing in adolescents is not improved, HIV incidence rates will be impacted, and the gains that have been made in this area will be threatened.”

“Although the number of countries from which data could be culled was limited, the change in incident cases is particularly striking, with most countries showing an increase and with African countries showing the largest rise,” said Dr. Manabe, professor of medicine, international health, and molecular microbiology and immunology at Johns Hopkins Medicine and director of the Johns Hopkins Center for Innovative Diagnostics for Infectious Diseases, Baltimore.

“The increase in syphilis incidence rates, particularly in younger people, including men who have sex with men, is also alarming,” she added in an email. “It is interesting to see the gender gap grow as more countries adopt antenatal syphilis screening.”

Ken S. Ho, MD, MPH, infectious diseases specialist and medical director of the Pitt Men’s Study at the University of Pittsburgh School of Medicine, Pennsylvania, called the study’s findings a wake-up call for clinicians to discuss sexual health and wellness with their patients, to increase STI screening, and to address STI stigma.

“Overall, STI rates in most countries have trended down, but paradoxically, the number of cases may be going up, because we have more younger, sexually actively people,” Dr. Ho said in an email.

“The study helps us understand the populations most impacted by STIs and allows us to design and create public health interventions that target the most impacted communities and demographic groups,” Dr. Ho, who also was not involved in the study, added. “It allows us to reflect on how we address disparities. For example, the greater burden of disease seen in women may be due to the fact that women may not be screened and are diagnosed later.”

Dr. Ho explained that the high STI rates in sub-Saharan Africa and Latin America are thought to be due to factors such as poverty and limited access to health care, known drivers of health care disparities.

The 2016 global incidence of common STIs was estimated to be up to 563.3 million, including 6.3 million cases of syphilis, 86.9 million cases of gonorrhea, 127.2 million cases of chlamydia, 156.0 million cases of trichomonas, and 186.9 million cases of genital herpes, the authors write.

The World Health Organization aims to end the STI epidemic by 2030, they note.

The study was funded by Mega-Project of National Science and Technology for the 13th Five-Year Plan of China and the National Natural Science Foundation of China. The authors, Dr. Manabe, and Dr. Ho have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

After several cases of acute hepatitis of unknown origin in children in the United Kingdom were reported, further cases have now been reported in France (two cases), Denmark, Ireland, the Netherlands, and Spain. More than 80 cases have been reported overall, raising fears of an epidemic, according to a press release from the European Centre for Disease Prevention and Control (ECDC).

Furthermore, nine cases have allegedly been reported since last autumn in Alabama in the United States. These cases have mainly been in children aged 1-6 years.

Investigations are ongoing in all these countries, particularly as the “exact causes of these cases of acute hepatitis remain unknown.” Nevertheless, the team working on these cases in the United Kingdom believes that, based on clinical and epidemiologic data, the cause is probably infectious in origin.

Coordinated by the ECDC, European medical societies such as the European Association for the Study of the Liver and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) are working together to promote information sharing, according to the European agency.
 

Potential infectious agent

For context, on April 5, the United Kingdom reported about 10 cases of acute hepatitis of unknown origin in children younger than 10 in Scotland with no underlying conditions. Seven days later, the UK reported that 61 additional cases were under investigation in England, Wales, and Northern Ireland, the majority of which were in children aged 2-5 years.

The cases in the United Kingdom presented with severe acute hepatitis, with increased liver enzyme levels (aspartate aminotransferase [AST] and alanine aminotransferase [ALT] levels above 500 IU/L), and most presented with jaundice. Some reported gastrointestinal symptoms such as abdominal pain, diarrhea, and vomiting in the previous weeks.

The majority had no fever.

Although no deaths had been reported at press time, some cases needed to be seen by a liver specialist in the hospital, and others had to undergo transplantation (six transplants in Europe and two in the United States).

Initial hypotheses have focused on a potential infectious agent or exposure to a toxin. No link to COVID-19 vaccination has been established.
 

Which type of hepatitis?

The ECDC reports that laboratory tests have ruled out the possibility of attributing the cases to type A, B, C, D, and E viral hepatitis. Of the 13 cases in Scotland, 3 tested positive for SARS-CoV-2, 5 were negative, and 2 had contracted COVID-19 over the course of the last 3 months.

One positive test for adenovirus was found in 5 of the 13 Scottish cases, out of the 11 that were tested. All the cases reported in the United States tested positive for an adenovirus, five of which were for adenovirus type 41, which is responsible for inflammation of the bowel. Investigations are ongoing to assess any possible involvement of this virus in other cases. It should be noted that adenoviruses can cause hepatitis in children, but generally only in those who are immunosuppressed.

The pandemic could be another possible explanation, Nancy Reau, MD, head of the hepatology department at Rush University, Chicago, told this news organization. “The possibility that these cases are linked to COVID still exists,” she said. Some cases in the United Kingdom tested positive for COVID-19; none of these children had received the COVID-19 vaccine.

“COVID has been regularly seen to raise liver markers. It has also been shown to affect organs other than the lungs,” she stated. “It could be the case that, as it evolves, this virus has the potential to cause hepatitis in children.”

A version of this article first appeared on Medscape.com.

After several cases of acute hepatitis of unknown origin in children in the United Kingdom were reported, further cases have now been reported in France (two cases), Denmark, Ireland, the Netherlands, and Spain. More than 80 cases have been reported overall, raising fears of an epidemic, according to a press release from the European Centre for Disease Prevention and Control (ECDC).

Furthermore, nine cases have allegedly been reported since last autumn in Alabama in the United States. These cases have mainly been in children aged 1-6 years.

Investigations are ongoing in all these countries, particularly as the “exact causes of these cases of acute hepatitis remain unknown.” Nevertheless, the team working on these cases in the United Kingdom believes that, based on clinical and epidemiologic data, the cause is probably infectious in origin.

Coordinated by the ECDC, European medical societies such as the European Association for the Study of the Liver and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) are working together to promote information sharing, according to the European agency.
 

Potential infectious agent

For context, on April 5, the United Kingdom reported about 10 cases of acute hepatitis of unknown origin in children younger than 10 in Scotland with no underlying conditions. Seven days later, the UK reported that 61 additional cases were under investigation in England, Wales, and Northern Ireland, the majority of which were in children aged 2-5 years.

The cases in the United Kingdom presented with severe acute hepatitis, with increased liver enzyme levels (aspartate aminotransferase [AST] and alanine aminotransferase [ALT] levels above 500 IU/L), and most presented with jaundice. Some reported gastrointestinal symptoms such as abdominal pain, diarrhea, and vomiting in the previous weeks.

The majority had no fever.

Although no deaths had been reported at press time, some cases needed to be seen by a liver specialist in the hospital, and others had to undergo transplantation (six transplants in Europe and two in the United States).

Initial hypotheses have focused on a potential infectious agent or exposure to a toxin. No link to COVID-19 vaccination has been established.
 

Which type of hepatitis?

The ECDC reports that laboratory tests have ruled out the possibility of attributing the cases to type A, B, C, D, and E viral hepatitis. Of the 13 cases in Scotland, 3 tested positive for SARS-CoV-2, 5 were negative, and 2 had contracted COVID-19 over the course of the last 3 months.

One positive test for adenovirus was found in 5 of the 13 Scottish cases, out of the 11 that were tested. All the cases reported in the United States tested positive for an adenovirus, five of which were for adenovirus type 41, which is responsible for inflammation of the bowel. Investigations are ongoing to assess any possible involvement of this virus in other cases. It should be noted that adenoviruses can cause hepatitis in children, but generally only in those who are immunosuppressed.

The pandemic could be another possible explanation, Nancy Reau, MD, head of the hepatology department at Rush University, Chicago, told this news organization. “The possibility that these cases are linked to COVID still exists,” she said. Some cases in the United Kingdom tested positive for COVID-19; none of these children had received the COVID-19 vaccine.

“COVID has been regularly seen to raise liver markers. It has also been shown to affect organs other than the lungs,” she stated. “It could be the case that, as it evolves, this virus has the potential to cause hepatitis in children.”

A version of this article first appeared on Medscape.com.

After several cases of acute hepatitis of unknown origin in children in the United Kingdom were reported, further cases have now been reported in France (two cases), Denmark, Ireland, the Netherlands, and Spain. More than 80 cases have been reported overall, raising fears of an epidemic, according to a press release from the European Centre for Disease Prevention and Control (ECDC).

Furthermore, nine cases have allegedly been reported since last autumn in Alabama in the United States. These cases have mainly been in children aged 1-6 years.

Investigations are ongoing in all these countries, particularly as the “exact causes of these cases of acute hepatitis remain unknown.” Nevertheless, the team working on these cases in the United Kingdom believes that, based on clinical and epidemiologic data, the cause is probably infectious in origin.

Coordinated by the ECDC, European medical societies such as the European Association for the Study of the Liver and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) are working together to promote information sharing, according to the European agency.
 

Potential infectious agent

For context, on April 5, the United Kingdom reported about 10 cases of acute hepatitis of unknown origin in children younger than 10 in Scotland with no underlying conditions. Seven days later, the UK reported that 61 additional cases were under investigation in England, Wales, and Northern Ireland, the majority of which were in children aged 2-5 years.

The cases in the United Kingdom presented with severe acute hepatitis, with increased liver enzyme levels (aspartate aminotransferase [AST] and alanine aminotransferase [ALT] levels above 500 IU/L), and most presented with jaundice. Some reported gastrointestinal symptoms such as abdominal pain, diarrhea, and vomiting in the previous weeks.

The majority had no fever.

Although no deaths had been reported at press time, some cases needed to be seen by a liver specialist in the hospital, and others had to undergo transplantation (six transplants in Europe and two in the United States).

Initial hypotheses have focused on a potential infectious agent or exposure to a toxin. No link to COVID-19 vaccination has been established.
 

Which type of hepatitis?

The ECDC reports that laboratory tests have ruled out the possibility of attributing the cases to type A, B, C, D, and E viral hepatitis. Of the 13 cases in Scotland, 3 tested positive for SARS-CoV-2, 5 were negative, and 2 had contracted COVID-19 over the course of the last 3 months.

One positive test for adenovirus was found in 5 of the 13 Scottish cases, out of the 11 that were tested. All the cases reported in the United States tested positive for an adenovirus, five of which were for adenovirus type 41, which is responsible for inflammation of the bowel. Investigations are ongoing to assess any possible involvement of this virus in other cases. It should be noted that adenoviruses can cause hepatitis in children, but generally only in those who are immunosuppressed.

The pandemic could be another possible explanation, Nancy Reau, MD, head of the hepatology department at Rush University, Chicago, told this news organization. “The possibility that these cases are linked to COVID still exists,” she said. Some cases in the United Kingdom tested positive for COVID-19; none of these children had received the COVID-19 vaccine.

“COVID has been regularly seen to raise liver markers. It has also been shown to affect organs other than the lungs,” she stated. “It could be the case that, as it evolves, this virus has the potential to cause hepatitis in children.”

A version of this article first appeared on Medscape.com.

LISBON – Screening for Staphylococcus aureus, decolonization, and use of teicoplanin for surgical antimicrobial prophylaxis among patients with methicillin-resistant S. aureus (MRSA) lowered the number of prosthetic joint infections in elderly patients undergoing surgery for fracture of the femur.

The findings were presented in a poster at the 32nd European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) 2022, which was one of the few awarded the accolade of “top-rated poster.”

“We actually found that with our intervention, all prosthetic joint infections decreased, not just the Staphylococcus aureus but those due to MRSA, too,” Natividad Benito, MD, an infectious diseases specialist at Hospital de la Santa Creu i Sant Pau in Barcelona, said in an interview. “We’re pleased with these results because prosthetic joint infections present such a complicated situation for patients and surgeons. This is also a relatively easy intervention to use, and with time, even the PCR [polymerase chain reaction] technology will become cheaper. Now, in our hospital, prosthetic joint infections are rare.”

At Hospital de la Santa Creu i Sant Pau, around 200 hip hemiarthroplasties are performed per year. Preceding the intervention, the hospital recorded 11 prosthetic joint infections, with up to five infections due to S. aureus and up to four due to MRSA.

The intervention was introduced in 2016. After 2 years, there were no cases of prosthetic joint infections due to S. aureus; in 2018 there, was one case of prosthetic joint infection due to MRSA. In 2019, there was one case of prosthetic joint infection, but it was due neither to S. aureus nor MRSA. In 2020 and 2021, there was one infection each year that was due to MRSA.

Jesús Rodríguez Baño, MD, head of the infectious diseases division, Hospital Universitario Virgen Macarena at the University of Seville, Spain, who was not involved in the study, explained that for patients with hip fracture, “the time frame in which colonization can be studied is too short using traditional methods. Prosthetic joint infections in this population have a devastating effect, with not negligible mortality and very important morbidity and health care costs.”

Referring to the significant reduction in the rate of S. aureus prosthetic joint infections in the postintervention period, Dr. Rodríguez Baño said in an interview, “The results are sound, and the important reduction in infection risk invites for the development of a multicenter, randomized trial to confirm these interesting results.

“The authors are commended for measuring the impact of applying a well-justified preventive protocol,” Dr. Rodríguez Baño added. However, the study has some limitations: “It was performed in one center, it was not randomized, and control for potential confounders is needed.”
 

Decolonization in an emergency femur fracture

This study addressed a particular need in residents of Spain’s long-term care facilities. In 2016, the prevalence of MRSA was high.

Roughly one-third of the general population carry S. aureus in their noses. In care homes, the rate of MRSA is higher than in the general population, at around 30% of those with S. aureus. In Spain, recommendations for patients undergoing elective total joint arthroplasty advise S. aureus decolonization – which can take 5 days – to prevent surgical site infections.

“The problem with the elderly population is not only have they a higher incidence of MRSA but that the surgical prophylaxis is inadequate for MRSA,” Dr. Benito pointed out.

Many patients in long-term care facilities are elderly and frail and are at greater risk of fracture. Unlike elective hip surgery, in which patients are asked to undergo decolonization over the 5 days prior to their operation, with emergent femur fractures, there is insufficient time for such preparation. “These patients with femur fractures need surgery as soon as possible,” said Dr. Benito.

No studies have been conducted to determine the best way to minimize infection risk from S. aureus and MRSA for patients undergoing emergency hip hemiarthroplasty surgery to treat femoral fractures.

In the current study, Dr. Benito and coauthors assessed whether a bundle of measures – including rapid detection of S. aureus nasal carriage by PCR upon arrival in the emergency setting, followed by decolonization of carriers using a topical treatment in the nose and a prescription of surgical antimicrobial prophylaxis (adapted antibiotic prophylaxis for MRSA) – reduces the incidence of prosthetic joint infections after surgery.

The quasi-experimental single-center study included patients admitted to the emergency department at Hospital de la Santa Creu i Sant Pau. The PCR was rapid, with a turnaround of just 1.5 hours. Decolonization of S. aureus carriers was carried out using nasal mupirocin and chlorhexidine gluconate bathing, which was started immediately. It was used for a 5 days and was usually continued throughout and after surgery.

Patients carrying MRSA received teicoplanin as optimal surgical antimicrobial prophylaxis instead of cefazolin. The intervention did not interfere with the timing of surgery. The study’s principal outcomes were overall incidence of prosthetic joint infections and the incidence of those specifically caused by S. aureus and MRSA.

The researchers compared findings regarding these outcomes over 5 consecutive years of the intervention to outcomes during 4 consecutive years prior to the intervention, which started in 2016.

During 2016-2020, from 22% to 31% of the overall number of patients requiring hip hemiarthroplasty were referred from long-term care facilities. From 25% to 29% of these patients tested positive for S. aureus on PCR, and of these, 33%-64% had MRSA.

There were 772 surgical procedures from 2012 to 2015 and 786 from 2017 to 2020.

Prior to the intervention, over the years 2012-2014, S. aureus caused 36%-50% of prosthetic joint infections; 25%-100% of the S. aureus infections were MRSA. This decreased significantly after the intervention.

During 2016-2020, there was an average of 14 prosthetic joint infections (1.5%), compared to 36 (4.7%) in 2012-2015 (P < .001). Similarly, the incidence of prosthetic joint infections due to S. aureus dropped to 0.3% from 1.8% (P < .002). The incidence of MRSA prosthetic joint infections was 0.3% for 2016-2020, versus 1.2% for 2012-2015 (P = .012).

The years 2018, 2020, and 2021 each saw one case of infection due to MRSA. They were most likely due to “the intervention not being performed properly in all cases,” said Dr. Benito.

A prosthetic joint infection is very serious for the patient. “It means reoperating, because antibiotics are not enough to clear the infection. The biofilm and pus of the infection need to be cleaned out, a new prosthesis is needed, after which more antibiotics are needed for around 2 months, which can be hard to tolerate, and even then, the infection might not be eradicated,” explained Dr. Benito. “Many of these people are old and frail, and mortality can be significant. Getting a prosthetic joint infection is catastrophic for these patients.”

Dr. Benito and Dr. Rodríguez-Baño have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

LISBON – Screening for Staphylococcus aureus, decolonization, and use of teicoplanin for surgical antimicrobial prophylaxis among patients with methicillin-resistant S. aureus (MRSA) lowered the number of prosthetic joint infections in elderly patients undergoing surgery for fracture of the femur.

The findings were presented in a poster at the 32nd European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) 2022, which was one of the few awarded the accolade of “top-rated poster.”

“We actually found that with our intervention, all prosthetic joint infections decreased, not just the Staphylococcus aureus but those due to MRSA, too,” Natividad Benito, MD, an infectious diseases specialist at Hospital de la Santa Creu i Sant Pau in Barcelona, said in an interview. “We’re pleased with these results because prosthetic joint infections present such a complicated situation for patients and surgeons. This is also a relatively easy intervention to use, and with time, even the PCR [polymerase chain reaction] technology will become cheaper. Now, in our hospital, prosthetic joint infections are rare.”

At Hospital de la Santa Creu i Sant Pau, around 200 hip hemiarthroplasties are performed per year. Preceding the intervention, the hospital recorded 11 prosthetic joint infections, with up to five infections due to S. aureus and up to four due to MRSA.

The intervention was introduced in 2016. After 2 years, there were no cases of prosthetic joint infections due to S. aureus; in 2018 there, was one case of prosthetic joint infection due to MRSA. In 2019, there was one case of prosthetic joint infection, but it was due neither to S. aureus nor MRSA. In 2020 and 2021, there was one infection each year that was due to MRSA.

Jesús Rodríguez Baño, MD, head of the infectious diseases division, Hospital Universitario Virgen Macarena at the University of Seville, Spain, who was not involved in the study, explained that for patients with hip fracture, “the time frame in which colonization can be studied is too short using traditional methods. Prosthetic joint infections in this population have a devastating effect, with not negligible mortality and very important morbidity and health care costs.”

Referring to the significant reduction in the rate of S. aureus prosthetic joint infections in the postintervention period, Dr. Rodríguez Baño said in an interview, “The results are sound, and the important reduction in infection risk invites for the development of a multicenter, randomized trial to confirm these interesting results.

“The authors are commended for measuring the impact of applying a well-justified preventive protocol,” Dr. Rodríguez Baño added. However, the study has some limitations: “It was performed in one center, it was not randomized, and control for potential confounders is needed.”
 

Decolonization in an emergency femur fracture

This study addressed a particular need in residents of Spain’s long-term care facilities. In 2016, the prevalence of MRSA was high.

Roughly one-third of the general population carry S. aureus in their noses. In care homes, the rate of MRSA is higher than in the general population, at around 30% of those with S. aureus. In Spain, recommendations for patients undergoing elective total joint arthroplasty advise S. aureus decolonization – which can take 5 days – to prevent surgical site infections.

“The problem with the elderly population is not only have they a higher incidence of MRSA but that the surgical prophylaxis is inadequate for MRSA,” Dr. Benito pointed out.

Many patients in long-term care facilities are elderly and frail and are at greater risk of fracture. Unlike elective hip surgery, in which patients are asked to undergo decolonization over the 5 days prior to their operation, with emergent femur fractures, there is insufficient time for such preparation. “These patients with femur fractures need surgery as soon as possible,” said Dr. Benito.

No studies have been conducted to determine the best way to minimize infection risk from S. aureus and MRSA for patients undergoing emergency hip hemiarthroplasty surgery to treat femoral fractures.

In the current study, Dr. Benito and coauthors assessed whether a bundle of measures – including rapid detection of S. aureus nasal carriage by PCR upon arrival in the emergency setting, followed by decolonization of carriers using a topical treatment in the nose and a prescription of surgical antimicrobial prophylaxis (adapted antibiotic prophylaxis for MRSA) – reduces the incidence of prosthetic joint infections after surgery.

The quasi-experimental single-center study included patients admitted to the emergency department at Hospital de la Santa Creu i Sant Pau. The PCR was rapid, with a turnaround of just 1.5 hours. Decolonization of S. aureus carriers was carried out using nasal mupirocin and chlorhexidine gluconate bathing, which was started immediately. It was used for a 5 days and was usually continued throughout and after surgery.

Patients carrying MRSA received teicoplanin as optimal surgical antimicrobial prophylaxis instead of cefazolin. The intervention did not interfere with the timing of surgery. The study’s principal outcomes were overall incidence of prosthetic joint infections and the incidence of those specifically caused by S. aureus and MRSA.

The researchers compared findings regarding these outcomes over 5 consecutive years of the intervention to outcomes during 4 consecutive years prior to the intervention, which started in 2016.

During 2016-2020, from 22% to 31% of the overall number of patients requiring hip hemiarthroplasty were referred from long-term care facilities. From 25% to 29% of these patients tested positive for S. aureus on PCR, and of these, 33%-64% had MRSA.

There were 772 surgical procedures from 2012 to 2015 and 786 from 2017 to 2020.

Prior to the intervention, over the years 2012-2014, S. aureus caused 36%-50% of prosthetic joint infections; 25%-100% of the S. aureus infections were MRSA. This decreased significantly after the intervention.

During 2016-2020, there was an average of 14 prosthetic joint infections (1.5%), compared to 36 (4.7%) in 2012-2015 (P < .001). Similarly, the incidence of prosthetic joint infections due to S. aureus dropped to 0.3% from 1.8% (P < .002). The incidence of MRSA prosthetic joint infections was 0.3% for 2016-2020, versus 1.2% for 2012-2015 (P = .012).

The years 2018, 2020, and 2021 each saw one case of infection due to MRSA. They were most likely due to “the intervention not being performed properly in all cases,” said Dr. Benito.

A prosthetic joint infection is very serious for the patient. “It means reoperating, because antibiotics are not enough to clear the infection. The biofilm and pus of the infection need to be cleaned out, a new prosthesis is needed, after which more antibiotics are needed for around 2 months, which can be hard to tolerate, and even then, the infection might not be eradicated,” explained Dr. Benito. “Many of these people are old and frail, and mortality can be significant. Getting a prosthetic joint infection is catastrophic for these patients.”

Dr. Benito and Dr. Rodríguez-Baño have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

LISBON – Screening for Staphylococcus aureus, decolonization, and use of teicoplanin for surgical antimicrobial prophylaxis among patients with methicillin-resistant S. aureus (MRSA) lowered the number of prosthetic joint infections in elderly patients undergoing surgery for fracture of the femur.

The findings were presented in a poster at the 32nd European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) 2022, which was one of the few awarded the accolade of “top-rated poster.”

“We actually found that with our intervention, all prosthetic joint infections decreased, not just the Staphylococcus aureus but those due to MRSA, too,” Natividad Benito, MD, an infectious diseases specialist at Hospital de la Santa Creu i Sant Pau in Barcelona, said in an interview. “We’re pleased with these results because prosthetic joint infections present such a complicated situation for patients and surgeons. This is also a relatively easy intervention to use, and with time, even the PCR [polymerase chain reaction] technology will become cheaper. Now, in our hospital, prosthetic joint infections are rare.”

At Hospital de la Santa Creu i Sant Pau, around 200 hip hemiarthroplasties are performed per year. Preceding the intervention, the hospital recorded 11 prosthetic joint infections, with up to five infections due to S. aureus and up to four due to MRSA.

The intervention was introduced in 2016. After 2 years, there were no cases of prosthetic joint infections due to S. aureus; in 2018 there, was one case of prosthetic joint infection due to MRSA. In 2019, there was one case of prosthetic joint infection, but it was due neither to S. aureus nor MRSA. In 2020 and 2021, there was one infection each year that was due to MRSA.

Jesús Rodríguez Baño, MD, head of the infectious diseases division, Hospital Universitario Virgen Macarena at the University of Seville, Spain, who was not involved in the study, explained that for patients with hip fracture, “the time frame in which colonization can be studied is too short using traditional methods. Prosthetic joint infections in this population have a devastating effect, with not negligible mortality and very important morbidity and health care costs.”

Referring to the significant reduction in the rate of S. aureus prosthetic joint infections in the postintervention period, Dr. Rodríguez Baño said in an interview, “The results are sound, and the important reduction in infection risk invites for the development of a multicenter, randomized trial to confirm these interesting results.

“The authors are commended for measuring the impact of applying a well-justified preventive protocol,” Dr. Rodríguez Baño added. However, the study has some limitations: “It was performed in one center, it was not randomized, and control for potential confounders is needed.”
 

Decolonization in an emergency femur fracture

This study addressed a particular need in residents of Spain’s long-term care facilities. In 2016, the prevalence of MRSA was high.

Roughly one-third of the general population carry S. aureus in their noses. In care homes, the rate of MRSA is higher than in the general population, at around 30% of those with S. aureus. In Spain, recommendations for patients undergoing elective total joint arthroplasty advise S. aureus decolonization – which can take 5 days – to prevent surgical site infections.

“The problem with the elderly population is not only have they a higher incidence of MRSA but that the surgical prophylaxis is inadequate for MRSA,” Dr. Benito pointed out.

Many patients in long-term care facilities are elderly and frail and are at greater risk of fracture. Unlike elective hip surgery, in which patients are asked to undergo decolonization over the 5 days prior to their operation, with emergent femur fractures, there is insufficient time for such preparation. “These patients with femur fractures need surgery as soon as possible,” said Dr. Benito.

No studies have been conducted to determine the best way to minimize infection risk from S. aureus and MRSA for patients undergoing emergency hip hemiarthroplasty surgery to treat femoral fractures.

In the current study, Dr. Benito and coauthors assessed whether a bundle of measures – including rapid detection of S. aureus nasal carriage by PCR upon arrival in the emergency setting, followed by decolonization of carriers using a topical treatment in the nose and a prescription of surgical antimicrobial prophylaxis (adapted antibiotic prophylaxis for MRSA) – reduces the incidence of prosthetic joint infections after surgery.

The quasi-experimental single-center study included patients admitted to the emergency department at Hospital de la Santa Creu i Sant Pau. The PCR was rapid, with a turnaround of just 1.5 hours. Decolonization of S. aureus carriers was carried out using nasal mupirocin and chlorhexidine gluconate bathing, which was started immediately. It was used for a 5 days and was usually continued throughout and after surgery.

Patients carrying MRSA received teicoplanin as optimal surgical antimicrobial prophylaxis instead of cefazolin. The intervention did not interfere with the timing of surgery. The study’s principal outcomes were overall incidence of prosthetic joint infections and the incidence of those specifically caused by S. aureus and MRSA.

The researchers compared findings regarding these outcomes over 5 consecutive years of the intervention to outcomes during 4 consecutive years prior to the intervention, which started in 2016.

During 2016-2020, from 22% to 31% of the overall number of patients requiring hip hemiarthroplasty were referred from long-term care facilities. From 25% to 29% of these patients tested positive for S. aureus on PCR, and of these, 33%-64% had MRSA.

There were 772 surgical procedures from 2012 to 2015 and 786 from 2017 to 2020.

Prior to the intervention, over the years 2012-2014, S. aureus caused 36%-50% of prosthetic joint infections; 25%-100% of the S. aureus infections were MRSA. This decreased significantly after the intervention.

During 2016-2020, there was an average of 14 prosthetic joint infections (1.5%), compared to 36 (4.7%) in 2012-2015 (P < .001). Similarly, the incidence of prosthetic joint infections due to S. aureus dropped to 0.3% from 1.8% (P < .002). The incidence of MRSA prosthetic joint infections was 0.3% for 2016-2020, versus 1.2% for 2012-2015 (P = .012).

The years 2018, 2020, and 2021 each saw one case of infection due to MRSA. They were most likely due to “the intervention not being performed properly in all cases,” said Dr. Benito.

A prosthetic joint infection is very serious for the patient. “It means reoperating, because antibiotics are not enough to clear the infection. The biofilm and pus of the infection need to be cleaned out, a new prosthesis is needed, after which more antibiotics are needed for around 2 months, which can be hard to tolerate, and even then, the infection might not be eradicated,” explained Dr. Benito. “Many of these people are old and frail, and mortality can be significant. Getting a prosthetic joint infection is catastrophic for these patients.”

Dr. Benito and Dr. Rodríguez-Baño have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

LISBON – Two-thirds of antibiotic prescriptions written for Black patients and more than half of antibiotic prescriptions for Hispanic/Latinx patients are inappropriate, according to data from a study of antibiotic prescribing habits in U.S. doctors’ offices, hospital clinics, and emergency departments.

Eric Young, PharmD, PhD, from the University of Texas at Austin, and UT Health, San Antonio, presented his work as a poster at the 32nd European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) 2022.

“We were really surprised mainly by the racial findings, because Black patients have the highest overall and the highest inappropriate prescribing of antibiotics,” he told this news organization. “There was also a difference seen for age [across all ethnicities].”

Pediatric patients were found to have high overall prescribing but, notably, the lowest inappropriate prescribing among all the patient groups, reported Dr. Young. “This is interesting because oftentimes we think the more antibiotics are prescribed, then surely the greater the inappropriate prescribing would be too, but pediatricians actually have one of the lowest rates of inappropriate antibiotic prescribing. They do a great job.”

The study included more than 7 billion patient visits, 11.3% of which involved an antibiotic prescription.

The rate of antibiotic prescribing was 122 per 1,000 visits in Black patients and 139 per 1,000 visits in Hispanic patients, while in White patients, the rate was 109 per 1,000 visits. The rate was 114 per 1,000 visits in patients younger than 18 years and 170 per 1,000 visits in females.

Dr. Young found that almost 64% of antibiotic prescriptions written for Black patients and 58% for Hispanic patients were inappropriate. For White patients, the rate of inappropriate antibiotic prescribing was 56%. Similarly, 74% of prescriptions dispensed to patients aged 65 years and older and 58% to males were deemed inappropriate.

Kajal Bhakta, PharmD, BCACP, ambulatory care clinical pharmacist, University Health System, UT Health Science Center San Antonio, who was not involved in the study, pointed out that antibiotics are frequently prescribed without confirmation of an infection, owing to the fact that the verification process may delay care, especially in the outpatient setting.

Dr. Bhakta said that overprescribing in the elderly population and in certain ethnic groups was “likely due to socioeconomic and cultural factors. These prescribing methods may lead to unnecessary drug side effects and/or antimicrobial resistance.”

Regarding the patient-doctor consultation process, she pointed out that “older patients may have trouble describing their symptoms, and when those symptoms remain unresolved, providers may be more inclined to prescribe antibiotics to help.”

Sometimes overprescribing can occur because of the logistics involved in getting to the doctor’s office in the outpatient setting. “Sometimes patients struggle with transportation, as two separate trips to the doctor and pharmacy may not be feasible. Additionally, these same patients may have limited access to health care and therefore may use an urgent care facility for their acute infection–like symptoms,” Dr. Bhakta explained.

Dr. Young, who is of Asian descent, first became interested in disparities in health care when he noticed that ethnic minority groups showed greater hesitancy toward COVID-19 vaccination. “I noticed that there weren’t many Asians involved in previous trials and realized at this point that disparities were rampant.”

Dr. Young had been involved in investigating the overall use and the inappropriate use of antibiotics across the whole U.S. population when his interest in health disparities prompted him to study these patterns in specific demographic groups.

“Most previous data are derived from inpatient studies where the physician is giving the antibiotics,” said Dr. Young, who looked specifically at outpatient prescribing.

Dr. Young used prescribing data from the Centers for Disease Control and Prevention’s National Ambulatory Medical Care Survey, which covers more than 5.7 billion adult (aged 18 and older) and 1.3 billion child visits to outpatient practices between 2009 and 2016 across all 50 U.S. states and Washington, D.C.

He gathered patient data on ICD-9-CM and ICD-10 diagnostic codes for infections and for diagnoses that “appeared like infections.” All of the patients who were included had received at least one oral antibiotic. Antibiotic prescribing was defined as visits that included an antibiotic per 1,000 total patient visits.

On the basis of previous research, Dr. Young and his colleagues then determined whether each antibiotic prescription was appropriate, possibly appropriate, or inappropriate. Patient demographics included age (younger than 18 years, 18-64 years, and older than 64 years), sex (male or female), race, and ethnicity (White, Black, more than one race, Hispanic/Latinx, and other). These data were used to evaluate overall and inappropriate use.

“The health care community needs to be really careful with the judicious use of antibiotics,” Dr. Young said. “We have good guidelines on antimicrobial stewardship both in the inpatient and outpatient settings, but sometimes we overlook the disparities and cultural implications held by some patients.”

Typical examples of socioeconomic and cultural factors at play included patients not being able to afford the antibiotics, having limited access to care, or not returning for a follow-up visit for whatever reason.

“Patients of Black and Hispanic descent often don’t have the same degree of established care that many White patients have,” Dr. Young noted.

In the future, Dr. Young wants to conduct research into whether patients are actually taking their prescribed antibiotics, as well as their outcomes. For example, he would like to investigate whether rates of antibiotic resistance or Clostridioides difficile infection are higher among Black patients.

Dr. Young and Dr. Bhakta have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

LISBON – Two-thirds of antibiotic prescriptions written for Black patients and more than half of antibiotic prescriptions for Hispanic/Latinx patients are inappropriate, according to data from a study of antibiotic prescribing habits in U.S. doctors’ offices, hospital clinics, and emergency departments.

Eric Young, PharmD, PhD, from the University of Texas at Austin, and UT Health, San Antonio, presented his work as a poster at the 32nd European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) 2022.

“We were really surprised mainly by the racial findings, because Black patients have the highest overall and the highest inappropriate prescribing of antibiotics,” he told this news organization. “There was also a difference seen for age [across all ethnicities].”

Pediatric patients were found to have high overall prescribing but, notably, the lowest inappropriate prescribing among all the patient groups, reported Dr. Young. “This is interesting because oftentimes we think the more antibiotics are prescribed, then surely the greater the inappropriate prescribing would be too, but pediatricians actually have one of the lowest rates of inappropriate antibiotic prescribing. They do a great job.”

The study included more than 7 billion patient visits, 11.3% of which involved an antibiotic prescription.

The rate of antibiotic prescribing was 122 per 1,000 visits in Black patients and 139 per 1,000 visits in Hispanic patients, while in White patients, the rate was 109 per 1,000 visits. The rate was 114 per 1,000 visits in patients younger than 18 years and 170 per 1,000 visits in females.

Dr. Young found that almost 64% of antibiotic prescriptions written for Black patients and 58% for Hispanic patients were inappropriate. For White patients, the rate of inappropriate antibiotic prescribing was 56%. Similarly, 74% of prescriptions dispensed to patients aged 65 years and older and 58% to males were deemed inappropriate.

Kajal Bhakta, PharmD, BCACP, ambulatory care clinical pharmacist, University Health System, UT Health Science Center San Antonio, who was not involved in the study, pointed out that antibiotics are frequently prescribed without confirmation of an infection, owing to the fact that the verification process may delay care, especially in the outpatient setting.

Dr. Bhakta said that overprescribing in the elderly population and in certain ethnic groups was “likely due to socioeconomic and cultural factors. These prescribing methods may lead to unnecessary drug side effects and/or antimicrobial resistance.”

Regarding the patient-doctor consultation process, she pointed out that “older patients may have trouble describing their symptoms, and when those symptoms remain unresolved, providers may be more inclined to prescribe antibiotics to help.”

Sometimes overprescribing can occur because of the logistics involved in getting to the doctor’s office in the outpatient setting. “Sometimes patients struggle with transportation, as two separate trips to the doctor and pharmacy may not be feasible. Additionally, these same patients may have limited access to health care and therefore may use an urgent care facility for their acute infection–like symptoms,” Dr. Bhakta explained.

Dr. Young, who is of Asian descent, first became interested in disparities in health care when he noticed that ethnic minority groups showed greater hesitancy toward COVID-19 vaccination. “I noticed that there weren’t many Asians involved in previous trials and realized at this point that disparities were rampant.”

Dr. Young had been involved in investigating the overall use and the inappropriate use of antibiotics across the whole U.S. population when his interest in health disparities prompted him to study these patterns in specific demographic groups.

“Most previous data are derived from inpatient studies where the physician is giving the antibiotics,” said Dr. Young, who looked specifically at outpatient prescribing.

Dr. Young used prescribing data from the Centers for Disease Control and Prevention’s National Ambulatory Medical Care Survey, which covers more than 5.7 billion adult (aged 18 and older) and 1.3 billion child visits to outpatient practices between 2009 and 2016 across all 50 U.S. states and Washington, D.C.

He gathered patient data on ICD-9-CM and ICD-10 diagnostic codes for infections and for diagnoses that “appeared like infections.” All of the patients who were included had received at least one oral antibiotic. Antibiotic prescribing was defined as visits that included an antibiotic per 1,000 total patient visits.

On the basis of previous research, Dr. Young and his colleagues then determined whether each antibiotic prescription was appropriate, possibly appropriate, or inappropriate. Patient demographics included age (younger than 18 years, 18-64 years, and older than 64 years), sex (male or female), race, and ethnicity (White, Black, more than one race, Hispanic/Latinx, and other). These data were used to evaluate overall and inappropriate use.

“The health care community needs to be really careful with the judicious use of antibiotics,” Dr. Young said. “We have good guidelines on antimicrobial stewardship both in the inpatient and outpatient settings, but sometimes we overlook the disparities and cultural implications held by some patients.”

Typical examples of socioeconomic and cultural factors at play included patients not being able to afford the antibiotics, having limited access to care, or not returning for a follow-up visit for whatever reason.

“Patients of Black and Hispanic descent often don’t have the same degree of established care that many White patients have,” Dr. Young noted.

In the future, Dr. Young wants to conduct research into whether patients are actually taking their prescribed antibiotics, as well as their outcomes. For example, he would like to investigate whether rates of antibiotic resistance or Clostridioides difficile infection are higher among Black patients.

Dr. Young and Dr. Bhakta have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

LISBON – Two-thirds of antibiotic prescriptions written for Black patients and more than half of antibiotic prescriptions for Hispanic/Latinx patients are inappropriate, according to data from a study of antibiotic prescribing habits in U.S. doctors’ offices, hospital clinics, and emergency departments.

Eric Young, PharmD, PhD, from the University of Texas at Austin, and UT Health, San Antonio, presented his work as a poster at the 32nd European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) 2022.

“We were really surprised mainly by the racial findings, because Black patients have the highest overall and the highest inappropriate prescribing of antibiotics,” he told this news organization. “There was also a difference seen for age [across all ethnicities].”

Pediatric patients were found to have high overall prescribing but, notably, the lowest inappropriate prescribing among all the patient groups, reported Dr. Young. “This is interesting because oftentimes we think the more antibiotics are prescribed, then surely the greater the inappropriate prescribing would be too, but pediatricians actually have one of the lowest rates of inappropriate antibiotic prescribing. They do a great job.”

The study included more than 7 billion patient visits, 11.3% of which involved an antibiotic prescription.

The rate of antibiotic prescribing was 122 per 1,000 visits in Black patients and 139 per 1,000 visits in Hispanic patients, while in White patients, the rate was 109 per 1,000 visits. The rate was 114 per 1,000 visits in patients younger than 18 years and 170 per 1,000 visits in females.

Dr. Young found that almost 64% of antibiotic prescriptions written for Black patients and 58% for Hispanic patients were inappropriate. For White patients, the rate of inappropriate antibiotic prescribing was 56%. Similarly, 74% of prescriptions dispensed to patients aged 65 years and older and 58% to males were deemed inappropriate.

Kajal Bhakta, PharmD, BCACP, ambulatory care clinical pharmacist, University Health System, UT Health Science Center San Antonio, who was not involved in the study, pointed out that antibiotics are frequently prescribed without confirmation of an infection, owing to the fact that the verification process may delay care, especially in the outpatient setting.

Dr. Bhakta said that overprescribing in the elderly population and in certain ethnic groups was “likely due to socioeconomic and cultural factors. These prescribing methods may lead to unnecessary drug side effects and/or antimicrobial resistance.”

Regarding the patient-doctor consultation process, she pointed out that “older patients may have trouble describing their symptoms, and when those symptoms remain unresolved, providers may be more inclined to prescribe antibiotics to help.”

Sometimes overprescribing can occur because of the logistics involved in getting to the doctor’s office in the outpatient setting. “Sometimes patients struggle with transportation, as two separate trips to the doctor and pharmacy may not be feasible. Additionally, these same patients may have limited access to health care and therefore may use an urgent care facility for their acute infection–like symptoms,” Dr. Bhakta explained.

Dr. Young, who is of Asian descent, first became interested in disparities in health care when he noticed that ethnic minority groups showed greater hesitancy toward COVID-19 vaccination. “I noticed that there weren’t many Asians involved in previous trials and realized at this point that disparities were rampant.”

Dr. Young had been involved in investigating the overall use and the inappropriate use of antibiotics across the whole U.S. population when his interest in health disparities prompted him to study these patterns in specific demographic groups.

“Most previous data are derived from inpatient studies where the physician is giving the antibiotics,” said Dr. Young, who looked specifically at outpatient prescribing.

Dr. Young used prescribing data from the Centers for Disease Control and Prevention’s National Ambulatory Medical Care Survey, which covers more than 5.7 billion adult (aged 18 and older) and 1.3 billion child visits to outpatient practices between 2009 and 2016 across all 50 U.S. states and Washington, D.C.

He gathered patient data on ICD-9-CM and ICD-10 diagnostic codes for infections and for diagnoses that “appeared like infections.” All of the patients who were included had received at least one oral antibiotic. Antibiotic prescribing was defined as visits that included an antibiotic per 1,000 total patient visits.

On the basis of previous research, Dr. Young and his colleagues then determined whether each antibiotic prescription was appropriate, possibly appropriate, or inappropriate. Patient demographics included age (younger than 18 years, 18-64 years, and older than 64 years), sex (male or female), race, and ethnicity (White, Black, more than one race, Hispanic/Latinx, and other). These data were used to evaluate overall and inappropriate use.

“The health care community needs to be really careful with the judicious use of antibiotics,” Dr. Young said. “We have good guidelines on antimicrobial stewardship both in the inpatient and outpatient settings, but sometimes we overlook the disparities and cultural implications held by some patients.”

Typical examples of socioeconomic and cultural factors at play included patients not being able to afford the antibiotics, having limited access to care, or not returning for a follow-up visit for whatever reason.

“Patients of Black and Hispanic descent often don’t have the same degree of established care that many White patients have,” Dr. Young noted.

In the future, Dr. Young wants to conduct research into whether patients are actually taking their prescribed antibiotics, as well as their outcomes. For example, he would like to investigate whether rates of antibiotic resistance or Clostridioides difficile infection are higher among Black patients.

Dr. Young and Dr. Bhakta have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In this column I have previously discussed the microbiome and its importance to health, especially as it relates to infections in children. Given the appreciated connection between microbiome and immunity, my group in Rochester, N.Y., recently undertook a study of the effect of antibiotic usage on the immune response to routine early childhood vaccines. In mouse models, it was previously shown that antibiotic exposure induced a reduction in the abundance and diversity of gut microbiota that in turn negatively affected the generation and maintenance of vaccine-induced immunity.^1,2 A study from Stanford University was the first experimental human trial of antibiotic effects on vaccine responses. Adult volunteers were given an antibiotic or not before seasonal influenza vaccination and the researchers identified specific bacteria in the gut that were reduced by the antibiotics given. Those normal bacteria in the gut microbiome were shown to provide positive immunity signals to the systemic immune system that potentiated vaccine responses.³

My group conducted the first-ever study in children to explore whether an association existed between antibiotic use and vaccine-induced antibody levels. In the May issue of Pediatrics we report results from 560 children studied.⁴ From these children, 11,888 serum antibody levels to vaccine antigens were measured. Vaccine-induced antibody levels were determined at various time points after primary vaccination at child age 2, 4, and 6 months and boosters at age 12-18 months for 10 antigens included in four vaccines: DTaP, Hib, IPV, and PCV. The antibody levels to vaccine components were measured to DTaP (diphtheria toxoid, pertussis toxoid, tetanus toxoid, pertactin, and filamentous hemagglutinin), Hib conjugate (polyribosylribitol phosphate), IPV (polio 2), and PCV (serotypes 6B, 14, and 23F). A total of 342 children with 1,678 antibiotic courses prescribed were compared with 218 children with no antibiotic exposures. The predominant antibiotics prescribed were amoxicillin, cefdinir, amoxicillin/clavulanate, and ceftriaxone, since most treatments were for acute otitis media.

Of possible high clinical relevance, we found that from 9 to 24 months of age, children with antibiotic exposure had a higher frequency of vaccine-induced antibody levels below protection compared with children with no antibiotic use, placing them at risk of contracting a vaccine-preventable infection for DTaP antigens DT, TT, and PT and for PCV serotype 14.

For time points where antibody levels were determined within 30 days of completion of a course of antibiotics (recent antibiotic use), individual antibiotics were analyzed for effect on antibody levels below protective levels. Across all vaccine antigens measured, we found that all antibiotics had a negative effect on antibody levels and percentage of children achieving the protective antibody level threshold. Amoxicillin use had a lower association with lower antibody levels than the broader spectrum antibiotics, amoxicillin clavulanate (Augmentin), cefdinir, and ceftriaxone. For children receiving amoxicillin/clavulanate prescriptions, it was possible to compare the effect of shorter versus longer courses and we found that a 5-day course was associated with subprotective antibody levels similar to 10 days of amoxicillin, whereas 10-day amoxicillin/clavulanate was associated with higher frequency of children having subprotective antibody levels (Figure).

We examined whether accumulation of antibiotic courses in the first year of life had an association with subsequent vaccine-induced antibody levels and found that each antibiotic prescription was associated with a reduction in the median antibody level. For DTaP, each prescription was associated with 5.8% drop in antibody level to the vaccine components. For Hib the drop was 6.8%, IPV was 11.3%, and PCV was 10.4% – all statistically significant. To determine if booster vaccination influenced this association, a second analysis was performed using antibiotic prescriptions up to 15 months of age. We found each antibiotic prescription was associated with a reduction in median vaccine-induced antibody levels for DTaP by 18%, Hib by 21%, IPV by 19%, and PCV by 12% – all statistically significant.

Our study is the first in young children during the early age window where vaccine-induced immunity is established. Antibiotic use was associated with increased frequency of subprotective antibody levels for several vaccines used in children up to 2 years of age. The lower antibody levels could leave children vulnerable to vaccine preventable diseases. Perhaps outbreaks of vaccine-preventable diseases, such as pertussis, may be a consequence of multiple courses of antibiotics suppressing vaccine-induced immunity.

A goal of this study was to explore potential acute and long-term effects of antibiotic exposure on vaccine-induced antibody levels. Accumulated antibiotic courses up to booster immunization was associated with decreased vaccine antibody levels both before and after booster, suggesting that booster immunization was not sufficient to change the negative association with antibiotic exposure. The results were similar for all vaccines tested, suggesting that the specific vaccine formulation was not a factor.

The study has several limitations. The antibiotic prescription data and measurements of vaccine-induced antibody levels were recorded and measured prospectively; however, our analysis was done retrospectively. The group of study children was derived from my private practice in Rochester, N.Y., and may not be broadly representative of all children. The number of vaccine antibody measurements was limited by serum availability at some sampling time points in some children; and sometimes, the serum samples were collected far apart, which weakened our ability to perform longitudinal analyses. We did not collect stool samples from the children so we could not directly study the effect of antibiotic courses on the gut microbiome.

Our study adds new reasons to be cautious about overprescribing antibiotics on an individual child basis because an adverse effect extends to reduction in vaccine responses. This should be explained to parents requesting unnecessary antibiotics for colds and coughs. When antibiotics are necessary, the judicious choice of a narrow-spectrum antibiotic or a shorter duration of a broader spectrum antibiotic may reduce adverse effects on vaccine-induced immunity.

References

1. Valdez Y et al. Influence of the microbiota on vaccine effectiveness. Trends Immunol. 2014;35(11):526-37.

2. Lynn MA et al. Early-life antibiotic-driven dysbiosis leads to dysregulated vaccine immune responses in mice. Cell Host Microbe. 2018;23(5):653-60.e5.

3. Hagan T et al. Antibiotics-driven gut microbiome perturbation alters immunity to vaccines in humans. Cell. 2019;178(6):1313-28.e13.

4. Chapman T et al. Antibiotic use and vaccine antibody levels. Pediatrics. 2022;149(5);1-17. doi: 10.1542/peds.2021-052061.

In this column I have previously discussed the microbiome and its importance to health, especially as it relates to infections in children. Given the appreciated connection between microbiome and immunity, my group in Rochester, N.Y., recently undertook a study of the effect of antibiotic usage on the immune response to routine early childhood vaccines. In mouse models, it was previously shown that antibiotic exposure induced a reduction in the abundance and diversity of gut microbiota that in turn negatively affected the generation and maintenance of vaccine-induced immunity.^1,2 A study from Stanford University was the first experimental human trial of antibiotic effects on vaccine responses. Adult volunteers were given an antibiotic or not before seasonal influenza vaccination and the researchers identified specific bacteria in the gut that were reduced by the antibiotics given. Those normal bacteria in the gut microbiome were shown to provide positive immunity signals to the systemic immune system that potentiated vaccine responses.³

My group conducted the first-ever study in children to explore whether an association existed between antibiotic use and vaccine-induced antibody levels. In the May issue of Pediatrics we report results from 560 children studied.⁴ From these children, 11,888 serum antibody levels to vaccine antigens were measured. Vaccine-induced antibody levels were determined at various time points after primary vaccination at child age 2, 4, and 6 months and boosters at age 12-18 months for 10 antigens included in four vaccines: DTaP, Hib, IPV, and PCV. The antibody levels to vaccine components were measured to DTaP (diphtheria toxoid, pertussis toxoid, tetanus toxoid, pertactin, and filamentous hemagglutinin), Hib conjugate (polyribosylribitol phosphate), IPV (polio 2), and PCV (serotypes 6B, 14, and 23F). A total of 342 children with 1,678 antibiotic courses prescribed were compared with 218 children with no antibiotic exposures. The predominant antibiotics prescribed were amoxicillin, cefdinir, amoxicillin/clavulanate, and ceftriaxone, since most treatments were for acute otitis media.

Of possible high clinical relevance, we found that from 9 to 24 months of age, children with antibiotic exposure had a higher frequency of vaccine-induced antibody levels below protection compared with children with no antibiotic use, placing them at risk of contracting a vaccine-preventable infection for DTaP antigens DT, TT, and PT and for PCV serotype 14.

For time points where antibody levels were determined within 30 days of completion of a course of antibiotics (recent antibiotic use), individual antibiotics were analyzed for effect on antibody levels below protective levels. Across all vaccine antigens measured, we found that all antibiotics had a negative effect on antibody levels and percentage of children achieving the protective antibody level threshold. Amoxicillin use had a lower association with lower antibody levels than the broader spectrum antibiotics, amoxicillin clavulanate (Augmentin), cefdinir, and ceftriaxone. For children receiving amoxicillin/clavulanate prescriptions, it was possible to compare the effect of shorter versus longer courses and we found that a 5-day course was associated with subprotective antibody levels similar to 10 days of amoxicillin, whereas 10-day amoxicillin/clavulanate was associated with higher frequency of children having subprotective antibody levels (Figure).

We examined whether accumulation of antibiotic courses in the first year of life had an association with subsequent vaccine-induced antibody levels and found that each antibiotic prescription was associated with a reduction in the median antibody level. For DTaP, each prescription was associated with 5.8% drop in antibody level to the vaccine components. For Hib the drop was 6.8%, IPV was 11.3%, and PCV was 10.4% – all statistically significant. To determine if booster vaccination influenced this association, a second analysis was performed using antibiotic prescriptions up to 15 months of age. We found each antibiotic prescription was associated with a reduction in median vaccine-induced antibody levels for DTaP by 18%, Hib by 21%, IPV by 19%, and PCV by 12% – all statistically significant.

Our study is the first in young children during the early age window where vaccine-induced immunity is established. Antibiotic use was associated with increased frequency of subprotective antibody levels for several vaccines used in children up to 2 years of age. The lower antibody levels could leave children vulnerable to vaccine preventable diseases. Perhaps outbreaks of vaccine-preventable diseases, such as pertussis, may be a consequence of multiple courses of antibiotics suppressing vaccine-induced immunity.

A goal of this study was to explore potential acute and long-term effects of antibiotic exposure on vaccine-induced antibody levels. Accumulated antibiotic courses up to booster immunization was associated with decreased vaccine antibody levels both before and after booster, suggesting that booster immunization was not sufficient to change the negative association with antibiotic exposure. The results were similar for all vaccines tested, suggesting that the specific vaccine formulation was not a factor.

The study has several limitations. The antibiotic prescription data and measurements of vaccine-induced antibody levels were recorded and measured prospectively; however, our analysis was done retrospectively. The group of study children was derived from my private practice in Rochester, N.Y., and may not be broadly representative of all children. The number of vaccine antibody measurements was limited by serum availability at some sampling time points in some children; and sometimes, the serum samples were collected far apart, which weakened our ability to perform longitudinal analyses. We did not collect stool samples from the children so we could not directly study the effect of antibiotic courses on the gut microbiome.

Our study adds new reasons to be cautious about overprescribing antibiotics on an individual child basis because an adverse effect extends to reduction in vaccine responses. This should be explained to parents requesting unnecessary antibiotics for colds and coughs. When antibiotics are necessary, the judicious choice of a narrow-spectrum antibiotic or a shorter duration of a broader spectrum antibiotic may reduce adverse effects on vaccine-induced immunity.

References

1. Valdez Y et al. Influence of the microbiota on vaccine effectiveness. Trends Immunol. 2014;35(11):526-37.

2. Lynn MA et al. Early-life antibiotic-driven dysbiosis leads to dysregulated vaccine immune responses in mice. Cell Host Microbe. 2018;23(5):653-60.e5.

3. Hagan T et al. Antibiotics-driven gut microbiome perturbation alters immunity to vaccines in humans. Cell. 2019;178(6):1313-28.e13.

4. Chapman T et al. Antibiotic use and vaccine antibody levels. Pediatrics. 2022;149(5);1-17. doi: 10.1542/peds.2021-052061.

In this column I have previously discussed the microbiome and its importance to health, especially as it relates to infections in children. Given the appreciated connection between microbiome and immunity, my group in Rochester, N.Y., recently undertook a study of the effect of antibiotic usage on the immune response to routine early childhood vaccines. In mouse models, it was previously shown that antibiotic exposure induced a reduction in the abundance and diversity of gut microbiota that in turn negatively affected the generation and maintenance of vaccine-induced immunity.^1,2 A study from Stanford University was the first experimental human trial of antibiotic effects on vaccine responses. Adult volunteers were given an antibiotic or not before seasonal influenza vaccination and the researchers identified specific bacteria in the gut that were reduced by the antibiotics given. Those normal bacteria in the gut microbiome were shown to provide positive immunity signals to the systemic immune system that potentiated vaccine responses.³

My group conducted the first-ever study in children to explore whether an association existed between antibiotic use and vaccine-induced antibody levels. In the May issue of Pediatrics we report results from 560 children studied.⁴ From these children, 11,888 serum antibody levels to vaccine antigens were measured. Vaccine-induced antibody levels were determined at various time points after primary vaccination at child age 2, 4, and 6 months and boosters at age 12-18 months for 10 antigens included in four vaccines: DTaP, Hib, IPV, and PCV. The antibody levels to vaccine components were measured to DTaP (diphtheria toxoid, pertussis toxoid, tetanus toxoid, pertactin, and filamentous hemagglutinin), Hib conjugate (polyribosylribitol phosphate), IPV (polio 2), and PCV (serotypes 6B, 14, and 23F). A total of 342 children with 1,678 antibiotic courses prescribed were compared with 218 children with no antibiotic exposures. The predominant antibiotics prescribed were amoxicillin, cefdinir, amoxicillin/clavulanate, and ceftriaxone, since most treatments were for acute otitis media.

Of possible high clinical relevance, we found that from 9 to 24 months of age, children with antibiotic exposure had a higher frequency of vaccine-induced antibody levels below protection compared with children with no antibiotic use, placing them at risk of contracting a vaccine-preventable infection for DTaP antigens DT, TT, and PT and for PCV serotype 14.

For time points where antibody levels were determined within 30 days of completion of a course of antibiotics (recent antibiotic use), individual antibiotics were analyzed for effect on antibody levels below protective levels. Across all vaccine antigens measured, we found that all antibiotics had a negative effect on antibody levels and percentage of children achieving the protective antibody level threshold. Amoxicillin use had a lower association with lower antibody levels than the broader spectrum antibiotics, amoxicillin clavulanate (Augmentin), cefdinir, and ceftriaxone. For children receiving amoxicillin/clavulanate prescriptions, it was possible to compare the effect of shorter versus longer courses and we found that a 5-day course was associated with subprotective antibody levels similar to 10 days of amoxicillin, whereas 10-day amoxicillin/clavulanate was associated with higher frequency of children having subprotective antibody levels (Figure).

We examined whether accumulation of antibiotic courses in the first year of life had an association with subsequent vaccine-induced antibody levels and found that each antibiotic prescription was associated with a reduction in the median antibody level. For DTaP, each prescription was associated with 5.8% drop in antibody level to the vaccine components. For Hib the drop was 6.8%, IPV was 11.3%, and PCV was 10.4% – all statistically significant. To determine if booster vaccination influenced this association, a second analysis was performed using antibiotic prescriptions up to 15 months of age. We found each antibiotic prescription was associated with a reduction in median vaccine-induced antibody levels for DTaP by 18%, Hib by 21%, IPV by 19%, and PCV by 12% – all statistically significant.

Our study is the first in young children during the early age window where vaccine-induced immunity is established. Antibiotic use was associated with increased frequency of subprotective antibody levels for several vaccines used in children up to 2 years of age. The lower antibody levels could leave children vulnerable to vaccine preventable diseases. Perhaps outbreaks of vaccine-preventable diseases, such as pertussis, may be a consequence of multiple courses of antibiotics suppressing vaccine-induced immunity.

A goal of this study was to explore potential acute and long-term effects of antibiotic exposure on vaccine-induced antibody levels. Accumulated antibiotic courses up to booster immunization was associated with decreased vaccine antibody levels both before and after booster, suggesting that booster immunization was not sufficient to change the negative association with antibiotic exposure. The results were similar for all vaccines tested, suggesting that the specific vaccine formulation was not a factor.

The study has several limitations. The antibiotic prescription data and measurements of vaccine-induced antibody levels were recorded and measured prospectively; however, our analysis was done retrospectively. The group of study children was derived from my private practice in Rochester, N.Y., and may not be broadly representative of all children. The number of vaccine antibody measurements was limited by serum availability at some sampling time points in some children; and sometimes, the serum samples were collected far apart, which weakened our ability to perform longitudinal analyses. We did not collect stool samples from the children so we could not directly study the effect of antibiotic courses on the gut microbiome.

Our study adds new reasons to be cautious about overprescribing antibiotics on an individual child basis because an adverse effect extends to reduction in vaccine responses. This should be explained to parents requesting unnecessary antibiotics for colds and coughs. When antibiotics are necessary, the judicious choice of a narrow-spectrum antibiotic or a shorter duration of a broader spectrum antibiotic may reduce adverse effects on vaccine-induced immunity.

References

1. Valdez Y et al. Influence of the microbiota on vaccine effectiveness. Trends Immunol. 2014;35(11):526-37.

2. Lynn MA et al. Early-life antibiotic-driven dysbiosis leads to dysregulated vaccine immune responses in mice. Cell Host Microbe. 2018;23(5):653-60.e5.

3. Hagan T et al. Antibiotics-driven gut microbiome perturbation alters immunity to vaccines in humans. Cell. 2019;178(6):1313-28.e13.

4. Chapman T et al. Antibiotic use and vaccine antibody levels. Pediatrics. 2022;149(5);1-17. doi: 10.1542/peds.2021-052061.

Fat shaming doesn’t work. If it did, obesity as we know it wouldn’t exist because if the one thing society ensures isn’t lacking for people with obesity, it’s shame. We know that fat shaming doesn’t lead to weight loss and that it’s actually correlated with weight gain: More shame leads to more gain (Puhl and Suh; Sutin and Terracciano; Tomiyama et al).

Shaming and weight stigma have far more concerning associations than weight gain. People who report experiencing more weight stigma have an increased risk for depression, anxiety, low self-esteem, poor body image, substance abuse, suicidality, unhealthy eating behaviors, disordered eating, increased caloric intake, exercise avoidance, decreased exercise motivation potentially due to heightened cortisol reactivity, elevated C-reactive protein, and elevated blood pressure.

Meanwhile, people with obesity – likely in part owing to negative weight-biased experiences in health care – are reluctant to discuss weight with their health care providers and are less likely to seek care at all for any conditions. When care is sought, people with obesity are more likely to receive substandard treatment, including receiving fewer preventive health screenings, decreased health education, and decreased time spent in appointments.
 

Remember that obesity is not a conscious choice

A fact that is conveniently forgotten by those who are most prone to fat shaming is that obesity, like every chronic noncommunicable disease, isn’t a choice that is consciously made by patients.

And yes, though there are lifestyle means that might affect weight, there are lifestyle means that might affect all chronic diseases – yet obesity is the only one we seem to moralize about. It’s also worth noting that other chronic diseases’ lifestyle levers tend not to be governed by thousands of genes and dozens of hormones; those trying to “lifestyle” their way out of obesity are swimming against strong physiologic currents that influence our most seminally important survival drive: eating.

But forgetting about physiologic currents, there is also staggering privilege associated with intentional perpetual behavior change around food and fitness in the name of health.

Whereas medicine and the world are right and quick to embrace the fights against racism, sexism, and homophobia, the push to confront weight bias is far rarer, despite the fact that it’s been shown to be rampant among health care professionals.
 

Protecting the rights of people with obesity

Perhaps though, times are changing. Movements are popping up to protect the rights of people with obesity while combating hate.

Of note, Brazil seems to have embraced a campaign to fight gordofobia — the Portuguese term used to describe weight-based discrimination. For instance, laws are being passed to ensure appropriate seating is supplied in schools for children with obesity, an annual day was formalized to promote the rights of people with obesity, preferential seating is provided on subways for people with obesity, and fines have been levied against at least one comedian for making fat jokes on the grounds of the state’s duty to protect minorities.

We need to take this fight to medicine. Given the incredibly depressing prevalence of weight bias among trainees, medical schools and residency programs should ensure countering weight bias is not only part of the curriculum but that it’s explicitly examined. National medical licensing examinations should include weight bias as well.

Though we’re closer than ever before to widely effective treatment options for obesity, it’s likely to still be decades before pharmaceutical options to treat obesity are as effective, accepted, and encouraged as medications to treat hypertension, dyslipidemia, diabetes, and more are today.

If you’re curious about your own implicit weight biases, consider taking Harvard’s Implicit Association Test for Weight. You might also want to take a few moments and review the Strategies to Overcome and Prevent Obesity Alliances’ Weight Can’t Wait guide for advice on the management of obesity in primary care.

Treat patients with obesity the same as you would those with any chronic condition.

Also, consider your physical office space. Do you have chairs suitable for patients with obesity (wide base and with arms to help patients rise)? A scale that measures up to high weights that’s in a private location? Appropriately sized blood pressure cuffs?

If not, do you know who is deserving of shame?

Doctors who fat shame or who treat patients with obesity differently than they would any other patient with a chronic medical condition.

Examples include the family doctor who hadn’t checked my patient’s blood pressure in over a decade because he couldn’t be bothered buying an appropriately sized blood pressure cuff. Or the fertility doctor who told one of my patients that perhaps her weight reflected God’s will that she does not have children.

Finally, if reading this article about treating people with obesity the same as you would patients with other chronic, noncommunicable, lifestyle responsive diseases made you angry, there’s a great chance that you’re part of the problem.
 

Dr. Freedhoff, is associate professor of family medicine at the University of Ottawa and medical director of the Bariatric Medical Institute, a nonsurgical weight management center. He is one of Canada’s most outspoken obesity experts and the author of The Diet Fix: Why Diets Fail and How to Make Yours Work. He has disclosed the following: He served as a director, officer, partner, employee, adviser, consultant, or trustee for Bariatric Medical Institute and Constant Health; has received research grant from Novo Nordisk, and has publicly shared opinions via Weighty Matters and social media. A version of this article first appeared on Medscape.com.

Fat shaming doesn’t work. If it did, obesity as we know it wouldn’t exist because if the one thing society ensures isn’t lacking for people with obesity, it’s shame. We know that fat shaming doesn’t lead to weight loss and that it’s actually correlated with weight gain: More shame leads to more gain (Puhl and Suh; Sutin and Terracciano; Tomiyama et al).

Shaming and weight stigma have far more concerning associations than weight gain. People who report experiencing more weight stigma have an increased risk for depression, anxiety, low self-esteem, poor body image, substance abuse, suicidality, unhealthy eating behaviors, disordered eating, increased caloric intake, exercise avoidance, decreased exercise motivation potentially due to heightened cortisol reactivity, elevated C-reactive protein, and elevated blood pressure.

Meanwhile, people with obesity – likely in part owing to negative weight-biased experiences in health care – are reluctant to discuss weight with their health care providers and are less likely to seek care at all for any conditions. When care is sought, people with obesity are more likely to receive substandard treatment, including receiving fewer preventive health screenings, decreased health education, and decreased time spent in appointments.
 

Remember that obesity is not a conscious choice

A fact that is conveniently forgotten by those who are most prone to fat shaming is that obesity, like every chronic noncommunicable disease, isn’t a choice that is consciously made by patients.

And yes, though there are lifestyle means that might affect weight, there are lifestyle means that might affect all chronic diseases – yet obesity is the only one we seem to moralize about. It’s also worth noting that other chronic diseases’ lifestyle levers tend not to be governed by thousands of genes and dozens of hormones; those trying to “lifestyle” their way out of obesity are swimming against strong physiologic currents that influence our most seminally important survival drive: eating.

But forgetting about physiologic currents, there is also staggering privilege associated with intentional perpetual behavior change around food and fitness in the name of health.

Whereas medicine and the world are right and quick to embrace the fights against racism, sexism, and homophobia, the push to confront weight bias is far rarer, despite the fact that it’s been shown to be rampant among health care professionals.
 

Protecting the rights of people with obesity

Perhaps though, times are changing. Movements are popping up to protect the rights of people with obesity while combating hate.

Of note, Brazil seems to have embraced a campaign to fight gordofobia — the Portuguese term used to describe weight-based discrimination. For instance, laws are being passed to ensure appropriate seating is supplied in schools for children with obesity, an annual day was formalized to promote the rights of people with obesity, preferential seating is provided on subways for people with obesity, and fines have been levied against at least one comedian for making fat jokes on the grounds of the state’s duty to protect minorities.

We need to take this fight to medicine. Given the incredibly depressing prevalence of weight bias among trainees, medical schools and residency programs should ensure countering weight bias is not only part of the curriculum but that it’s explicitly examined. National medical licensing examinations should include weight bias as well.

Though we’re closer than ever before to widely effective treatment options for obesity, it’s likely to still be decades before pharmaceutical options to treat obesity are as effective, accepted, and encouraged as medications to treat hypertension, dyslipidemia, diabetes, and more are today.

If you’re curious about your own implicit weight biases, consider taking Harvard’s Implicit Association Test for Weight. You might also want to take a few moments and review the Strategies to Overcome and Prevent Obesity Alliances’ Weight Can’t Wait guide for advice on the management of obesity in primary care.

Treat patients with obesity the same as you would those with any chronic condition.

Also, consider your physical office space. Do you have chairs suitable for patients with obesity (wide base and with arms to help patients rise)? A scale that measures up to high weights that’s in a private location? Appropriately sized blood pressure cuffs?

If not, do you know who is deserving of shame?

Doctors who fat shame or who treat patients with obesity differently than they would any other patient with a chronic medical condition.

Examples include the family doctor who hadn’t checked my patient’s blood pressure in over a decade because he couldn’t be bothered buying an appropriately sized blood pressure cuff. Or the fertility doctor who told one of my patients that perhaps her weight reflected God’s will that she does not have children.

Finally, if reading this article about treating people with obesity the same as you would patients with other chronic, noncommunicable, lifestyle responsive diseases made you angry, there’s a great chance that you’re part of the problem.
 

Dr. Freedhoff, is associate professor of family medicine at the University of Ottawa and medical director of the Bariatric Medical Institute, a nonsurgical weight management center. He is one of Canada’s most outspoken obesity experts and the author of The Diet Fix: Why Diets Fail and How to Make Yours Work. He has disclosed the following: He served as a director, officer, partner, employee, adviser, consultant, or trustee for Bariatric Medical Institute and Constant Health; has received research grant from Novo Nordisk, and has publicly shared opinions via Weighty Matters and social media. A version of this article first appeared on Medscape.com.

Fat shaming doesn’t work. If it did, obesity as we know it wouldn’t exist because if the one thing society ensures isn’t lacking for people with obesity, it’s shame. We know that fat shaming doesn’t lead to weight loss and that it’s actually correlated with weight gain: More shame leads to more gain (Puhl and Suh; Sutin and Terracciano; Tomiyama et al).

Shaming and weight stigma have far more concerning associations than weight gain. People who report experiencing more weight stigma have an increased risk for depression, anxiety, low self-esteem, poor body image, substance abuse, suicidality, unhealthy eating behaviors, disordered eating, increased caloric intake, exercise avoidance, decreased exercise motivation potentially due to heightened cortisol reactivity, elevated C-reactive protein, and elevated blood pressure.

Meanwhile, people with obesity – likely in part owing to negative weight-biased experiences in health care – are reluctant to discuss weight with their health care providers and are less likely to seek care at all for any conditions. When care is sought, people with obesity are more likely to receive substandard treatment, including receiving fewer preventive health screenings, decreased health education, and decreased time spent in appointments.
 

Remember that obesity is not a conscious choice

A fact that is conveniently forgotten by those who are most prone to fat shaming is that obesity, like every chronic noncommunicable disease, isn’t a choice that is consciously made by patients.

And yes, though there are lifestyle means that might affect weight, there are lifestyle means that might affect all chronic diseases – yet obesity is the only one we seem to moralize about. It’s also worth noting that other chronic diseases’ lifestyle levers tend not to be governed by thousands of genes and dozens of hormones; those trying to “lifestyle” their way out of obesity are swimming against strong physiologic currents that influence our most seminally important survival drive: eating.

But forgetting about physiologic currents, there is also staggering privilege associated with intentional perpetual behavior change around food and fitness in the name of health.

Whereas medicine and the world are right and quick to embrace the fights against racism, sexism, and homophobia, the push to confront weight bias is far rarer, despite the fact that it’s been shown to be rampant among health care professionals.
 

Protecting the rights of people with obesity

Perhaps though, times are changing. Movements are popping up to protect the rights of people with obesity while combating hate.

Of note, Brazil seems to have embraced a campaign to fight gordofobia — the Portuguese term used to describe weight-based discrimination. For instance, laws are being passed to ensure appropriate seating is supplied in schools for children with obesity, an annual day was formalized to promote the rights of people with obesity, preferential seating is provided on subways for people with obesity, and fines have been levied against at least one comedian for making fat jokes on the grounds of the state’s duty to protect minorities.

We need to take this fight to medicine. Given the incredibly depressing prevalence of weight bias among trainees, medical schools and residency programs should ensure countering weight bias is not only part of the curriculum but that it’s explicitly examined. National medical licensing examinations should include weight bias as well.

Though we’re closer than ever before to widely effective treatment options for obesity, it’s likely to still be decades before pharmaceutical options to treat obesity are as effective, accepted, and encouraged as medications to treat hypertension, dyslipidemia, diabetes, and more are today.

If you’re curious about your own implicit weight biases, consider taking Harvard’s Implicit Association Test for Weight. You might also want to take a few moments and review the Strategies to Overcome and Prevent Obesity Alliances’ Weight Can’t Wait guide for advice on the management of obesity in primary care.

Treat patients with obesity the same as you would those with any chronic condition.

Also, consider your physical office space. Do you have chairs suitable for patients with obesity (wide base and with arms to help patients rise)? A scale that measures up to high weights that’s in a private location? Appropriately sized blood pressure cuffs?

If not, do you know who is deserving of shame?

Doctors who fat shame or who treat patients with obesity differently than they would any other patient with a chronic medical condition.

Examples include the family doctor who hadn’t checked my patient’s blood pressure in over a decade because he couldn’t be bothered buying an appropriately sized blood pressure cuff. Or the fertility doctor who told one of my patients that perhaps her weight reflected God’s will that she does not have children.

Finally, if reading this article about treating people with obesity the same as you would patients with other chronic, noncommunicable, lifestyle responsive diseases made you angry, there’s a great chance that you’re part of the problem.
 

Dr. Freedhoff, is associate professor of family medicine at the University of Ottawa and medical director of the Bariatric Medical Institute, a nonsurgical weight management center. He is one of Canada’s most outspoken obesity experts and the author of The Diet Fix: Why Diets Fail and How to Make Yours Work. He has disclosed the following: He served as a director, officer, partner, employee, adviser, consultant, or trustee for Bariatric Medical Institute and Constant Health; has received research grant from Novo Nordisk, and has publicly shared opinions via Weighty Matters and social media. A version of this article first appeared on Medscape.com.