Pulmonary Health Hub

A day after the World Health Organization declared on Jan. 14 that no known cases of Ebola-virus transmission or active infection had been identified in West Africa for more than 42 days, the agency revealed the existence of a new, single case of Ebola-virus infection in Sierra Leone.

The appearance of the new case highlighted the challenges that remain in fully stamping out the West African Ebola–virus outbreak. The crisis began in December 2013, raged throughout 2014, and only wound down toward a sputtering halt near the end of 2015.

Christopher Black, World Health Organization

When Dr. Rick Brennan, the World Health Organization (WHO) director for Emergency Risk Management and Humanitarian Response, announced during a press conference on Jan. 14, “the end of Ebola-virus transmission in West Africa” and “the first time since 2014 that all know chains of transmission have stopped in Guinea, Liberia, and Sierra Leone,” he and his colleague, Dr. Peter Graaff, also underscored the ongoing risk for sporadic, isolated cases. The main threat for new cases comes from men who survived Ebola-virus infection but harbored significant quantities of infectious virus in various body fluids and tissues, including their semen, for a period of about 1 year following their infection.

During the press conference, both Dr. Brennan and Dr. Graaff spoke of a new, strengthened infrastructure that WHO had placed in West Africa to better monitor and react quickly to these flare-up cases – the mechanism that led to quick identification of the new Sierra Leone case.

“I think you’ll see a more responsive and effective WHO,” said Dr. Graaff, WHO’s director of Ebola response. “We will use the Ebola experience to be more agile, more operational, and better able to react more quickly to whatever future problems come our way,” including infectious-disease outbreaks by pathogens other than Ebola virus.

The 42-day period without new infections that had led to the announcement of an end to Ebola-virus transmission in West Africa represents two 21-day incubation cycles for the virus. Until the Sierra Leone case reported on Jan. 15, the last confirmed West African case had been identified in Liberia in mid-November. Liberia had previously been declared Ebola free in last May, but four new, isolated infections appeared subsequent to that transmitted by Ebola-infection survivors who still harbored infectious virus. Before the Jan. 15 case, an additional three such flare-ups occurred in Sierra Leone and another three in Guinea since last March, Dr. Brennan said.

CDC/Daniel J. DeNoon

The current tally on the West African Ebola outbreak stands at roughly 28,500 confirmed cases identified, and about 11,300 deaths. Nearly three-quarters of infections occurred during 2014. The case fatality rate at the start of the outbreak ran about 80%, noted Dr. Graaff, but gradually fell as infected patients began receiving better care. Near the outbreak’s end, the case fatality rate stood at roughly 35%, when most patients were receiving optimal clinical care.

WHO staffers are maintaining close surveillance of people who recently survived Ebola-virus infection so that they can identify and isolate any new infections. WHO personnel have also counseled these survivors on the risk they pose for potential transmission, primarily by unprotected sex by men for up to 12 months following the end of active infection. The WHO also plans to launch an investigational protocol to vaccinate sexual partners and other close contacts of adult male survivors with an as-yet unapproved Ebola vaccine to further reduce risk of new infections.

“The WHO and world community reacted slowly at the start of the Ebola outbreak” in early 2014, admitted Dr. Brennan. “Without question, the disease got away from us. In retrospect, there were a number of things that we should have done better and sooner,” he said. “We have done a lot of soul-searching and we [at WHO] have identified a number of weaknesses in our structures and systems. We have already taken several important steps, and we are undergoing major reforms of our emergency operations. I think you’ll see a much more effective WHO in the future.”

Reform of WHO systems for infection prevention and control “will be much better able to detect new cases, not only of Ebola, but of other important diseases,” said Dr. Graaff.

The United States is also strengthening its health screening and monitoring system for travelers coming from affected countries and improving its hospital preparedness to manage cases, said Alice C. Hill, senior adviser for preparedness and resilience at the National Security Council and special assistant to President Obama. Hill, who spoke Jan. 6 at the Public Health Emergency Medical Countermeasures Enterprise stakeholders workshop, acknowledged that challenges still exist that must be addressed, including the development of safe and effective diagnostics, treatments, and vaccines for existing infectious diseases such as influenza and more emerging threats such as Ebola or MERS (Middle East Respiratory Syndrome), developing accurate disease forecasting capabilities to predict what will be the next threat, building rapid clinical trial networks and manufacturing capabilities, and the abilities for mass dispensing of medical countermeasures.

Gregory Twachtman also contributed to this story.

[email protected]

On Twitter @mitchelzoler

A day after the World Health Organization declared on Jan. 14 that no known cases of Ebola-virus transmission or active infection had been identified in West Africa for more than 42 days, the agency revealed the existence of a new, single case of Ebola-virus infection in Sierra Leone.

The appearance of the new case highlighted the challenges that remain in fully stamping out the West African Ebola–virus outbreak. The crisis began in December 2013, raged throughout 2014, and only wound down toward a sputtering halt near the end of 2015.

Christopher Black, World Health Organization

When Dr. Rick Brennan, the World Health Organization (WHO) director for Emergency Risk Management and Humanitarian Response, announced during a press conference on Jan. 14, “the end of Ebola-virus transmission in West Africa” and “the first time since 2014 that all know chains of transmission have stopped in Guinea, Liberia, and Sierra Leone,” he and his colleague, Dr. Peter Graaff, also underscored the ongoing risk for sporadic, isolated cases. The main threat for new cases comes from men who survived Ebola-virus infection but harbored significant quantities of infectious virus in various body fluids and tissues, including their semen, for a period of about 1 year following their infection.

During the press conference, both Dr. Brennan and Dr. Graaff spoke of a new, strengthened infrastructure that WHO had placed in West Africa to better monitor and react quickly to these flare-up cases – the mechanism that led to quick identification of the new Sierra Leone case.

“I think you’ll see a more responsive and effective WHO,” said Dr. Graaff, WHO’s director of Ebola response. “We will use the Ebola experience to be more agile, more operational, and better able to react more quickly to whatever future problems come our way,” including infectious-disease outbreaks by pathogens other than Ebola virus.

The 42-day period without new infections that had led to the announcement of an end to Ebola-virus transmission in West Africa represents two 21-day incubation cycles for the virus. Until the Sierra Leone case reported on Jan. 15, the last confirmed West African case had been identified in Liberia in mid-November. Liberia had previously been declared Ebola free in last May, but four new, isolated infections appeared subsequent to that transmitted by Ebola-infection survivors who still harbored infectious virus. Before the Jan. 15 case, an additional three such flare-ups occurred in Sierra Leone and another three in Guinea since last March, Dr. Brennan said.

CDC/Daniel J. DeNoon

The current tally on the West African Ebola outbreak stands at roughly 28,500 confirmed cases identified, and about 11,300 deaths. Nearly three-quarters of infections occurred during 2014. The case fatality rate at the start of the outbreak ran about 80%, noted Dr. Graaff, but gradually fell as infected patients began receiving better care. Near the outbreak’s end, the case fatality rate stood at roughly 35%, when most patients were receiving optimal clinical care.

WHO staffers are maintaining close surveillance of people who recently survived Ebola-virus infection so that they can identify and isolate any new infections. WHO personnel have also counseled these survivors on the risk they pose for potential transmission, primarily by unprotected sex by men for up to 12 months following the end of active infection. The WHO also plans to launch an investigational protocol to vaccinate sexual partners and other close contacts of adult male survivors with an as-yet unapproved Ebola vaccine to further reduce risk of new infections.

“The WHO and world community reacted slowly at the start of the Ebola outbreak” in early 2014, admitted Dr. Brennan. “Without question, the disease got away from us. In retrospect, there were a number of things that we should have done better and sooner,” he said. “We have done a lot of soul-searching and we [at WHO] have identified a number of weaknesses in our structures and systems. We have already taken several important steps, and we are undergoing major reforms of our emergency operations. I think you’ll see a much more effective WHO in the future.”

Reform of WHO systems for infection prevention and control “will be much better able to detect new cases, not only of Ebola, but of other important diseases,” said Dr. Graaff.

The United States is also strengthening its health screening and monitoring system for travelers coming from affected countries and improving its hospital preparedness to manage cases, said Alice C. Hill, senior adviser for preparedness and resilience at the National Security Council and special assistant to President Obama. Hill, who spoke Jan. 6 at the Public Health Emergency Medical Countermeasures Enterprise stakeholders workshop, acknowledged that challenges still exist that must be addressed, including the development of safe and effective diagnostics, treatments, and vaccines for existing infectious diseases such as influenza and more emerging threats such as Ebola or MERS (Middle East Respiratory Syndrome), developing accurate disease forecasting capabilities to predict what will be the next threat, building rapid clinical trial networks and manufacturing capabilities, and the abilities for mass dispensing of medical countermeasures.

Gregory Twachtman also contributed to this story.

[email protected]

On Twitter @mitchelzoler

A day after the World Health Organization declared on Jan. 14 that no known cases of Ebola-virus transmission or active infection had been identified in West Africa for more than 42 days, the agency revealed the existence of a new, single case of Ebola-virus infection in Sierra Leone.

The appearance of the new case highlighted the challenges that remain in fully stamping out the West African Ebola–virus outbreak. The crisis began in December 2013, raged throughout 2014, and only wound down toward a sputtering halt near the end of 2015.

Christopher Black, World Health Organization

When Dr. Rick Brennan, the World Health Organization (WHO) director for Emergency Risk Management and Humanitarian Response, announced during a press conference on Jan. 14, “the end of Ebola-virus transmission in West Africa” and “the first time since 2014 that all know chains of transmission have stopped in Guinea, Liberia, and Sierra Leone,” he and his colleague, Dr. Peter Graaff, also underscored the ongoing risk for sporadic, isolated cases. The main threat for new cases comes from men who survived Ebola-virus infection but harbored significant quantities of infectious virus in various body fluids and tissues, including their semen, for a period of about 1 year following their infection.

During the press conference, both Dr. Brennan and Dr. Graaff spoke of a new, strengthened infrastructure that WHO had placed in West Africa to better monitor and react quickly to these flare-up cases – the mechanism that led to quick identification of the new Sierra Leone case.

“I think you’ll see a more responsive and effective WHO,” said Dr. Graaff, WHO’s director of Ebola response. “We will use the Ebola experience to be more agile, more operational, and better able to react more quickly to whatever future problems come our way,” including infectious-disease outbreaks by pathogens other than Ebola virus.

The 42-day period without new infections that had led to the announcement of an end to Ebola-virus transmission in West Africa represents two 21-day incubation cycles for the virus. Until the Sierra Leone case reported on Jan. 15, the last confirmed West African case had been identified in Liberia in mid-November. Liberia had previously been declared Ebola free in last May, but four new, isolated infections appeared subsequent to that transmitted by Ebola-infection survivors who still harbored infectious virus. Before the Jan. 15 case, an additional three such flare-ups occurred in Sierra Leone and another three in Guinea since last March, Dr. Brennan said.

CDC/Daniel J. DeNoon

The current tally on the West African Ebola outbreak stands at roughly 28,500 confirmed cases identified, and about 11,300 deaths. Nearly three-quarters of infections occurred during 2014. The case fatality rate at the start of the outbreak ran about 80%, noted Dr. Graaff, but gradually fell as infected patients began receiving better care. Near the outbreak’s end, the case fatality rate stood at roughly 35%, when most patients were receiving optimal clinical care.

WHO staffers are maintaining close surveillance of people who recently survived Ebola-virus infection so that they can identify and isolate any new infections. WHO personnel have also counseled these survivors on the risk they pose for potential transmission, primarily by unprotected sex by men for up to 12 months following the end of active infection. The WHO also plans to launch an investigational protocol to vaccinate sexual partners and other close contacts of adult male survivors with an as-yet unapproved Ebola vaccine to further reduce risk of new infections.

“The WHO and world community reacted slowly at the start of the Ebola outbreak” in early 2014, admitted Dr. Brennan. “Without question, the disease got away from us. In retrospect, there were a number of things that we should have done better and sooner,” he said. “We have done a lot of soul-searching and we [at WHO] have identified a number of weaknesses in our structures and systems. We have already taken several important steps, and we are undergoing major reforms of our emergency operations. I think you’ll see a much more effective WHO in the future.”

Reform of WHO systems for infection prevention and control “will be much better able to detect new cases, not only of Ebola, but of other important diseases,” said Dr. Graaff.

The United States is also strengthening its health screening and monitoring system for travelers coming from affected countries and improving its hospital preparedness to manage cases, said Alice C. Hill, senior adviser for preparedness and resilience at the National Security Council and special assistant to President Obama. Hill, who spoke Jan. 6 at the Public Health Emergency Medical Countermeasures Enterprise stakeholders workshop, acknowledged that challenges still exist that must be addressed, including the development of safe and effective diagnostics, treatments, and vaccines for existing infectious diseases such as influenza and more emerging threats such as Ebola or MERS (Middle East Respiratory Syndrome), developing accurate disease forecasting capabilities to predict what will be the next threat, building rapid clinical trial networks and manufacturing capabilities, and the abilities for mass dispensing of medical countermeasures.

Gregory Twachtman also contributed to this story.

[email protected]

On Twitter @mitchelzoler

Many pediatricians and allergists failed to provide instructions for when and how to use epinephrine and a written emergency action plan to the parents of children with food allergies, a study found.

Researchers asked the parents of 859 children with allergies to share their level of satisfaction with the care and delivery of care from the pediatricians and allergists treating their children over the course of the previous 6 months. While more than 75% of the doctors treated the parents courteously and respectfully and provided clear explanations of children’s allergies, a high percentage of the doctors neglected to provide other information essential for caring for children with food allergies, the parents reported.

©gpointstudio/Thinkstock

The parents most often said they were missing explanations on when and how their children should be receiving epinephrine to treat allergic reactions and instructions on exactly what to do if their children had a medical emergency related to their specific allergies and circumstances. More pediatricians than allergists failed to share such information.

Among allergists, 68% explained when to use epinephrine, while 37% of pediatricians provided such information, the parents reported. Instructions on how to use epinephrine were provided to parents by 47% of allergists and 20% of pediatricians. Written emergency health care plans customized to each child were provided by 56% of the allergists and 24% of the pediatricians

“Although pediatricians might be relying on allergists to deliver [an emergency action plan and training in epinephrine autoinjectors use], with the rise in food allergies, guidelines recommend that pediatricians conduct these steps and not rely solely on the allergist,” said Jesse A. Blumenstock of Northwestern University, Chicago, and colleagues. “With our understanding of food allergy and anaphylaxis constantly evolving, guidelines and recommendations for how and when to give epinephrine and the need for an action plan need to be reinforced by physicians.”

Read the study in the Journal of Allergy and Clinical Immunology: In Practice (doi: 10.1016/j.jaip.2015.10.011).

[email protected]

Many pediatricians and allergists failed to provide instructions for when and how to use epinephrine and a written emergency action plan to the parents of children with food allergies, a study found.

Researchers asked the parents of 859 children with allergies to share their level of satisfaction with the care and delivery of care from the pediatricians and allergists treating their children over the course of the previous 6 months. While more than 75% of the doctors treated the parents courteously and respectfully and provided clear explanations of children’s allergies, a high percentage of the doctors neglected to provide other information essential for caring for children with food allergies, the parents reported.

©gpointstudio/Thinkstock

The parents most often said they were missing explanations on when and how their children should be receiving epinephrine to treat allergic reactions and instructions on exactly what to do if their children had a medical emergency related to their specific allergies and circumstances. More pediatricians than allergists failed to share such information.

Among allergists, 68% explained when to use epinephrine, while 37% of pediatricians provided such information, the parents reported. Instructions on how to use epinephrine were provided to parents by 47% of allergists and 20% of pediatricians. Written emergency health care plans customized to each child were provided by 56% of the allergists and 24% of the pediatricians

“Although pediatricians might be relying on allergists to deliver [an emergency action plan and training in epinephrine autoinjectors use], with the rise in food allergies, guidelines recommend that pediatricians conduct these steps and not rely solely on the allergist,” said Jesse A. Blumenstock of Northwestern University, Chicago, and colleagues. “With our understanding of food allergy and anaphylaxis constantly evolving, guidelines and recommendations for how and when to give epinephrine and the need for an action plan need to be reinforced by physicians.”

Read the study in the Journal of Allergy and Clinical Immunology: In Practice (doi: 10.1016/j.jaip.2015.10.011).

[email protected]

Many pediatricians and allergists failed to provide instructions for when and how to use epinephrine and a written emergency action plan to the parents of children with food allergies, a study found.

Researchers asked the parents of 859 children with allergies to share their level of satisfaction with the care and delivery of care from the pediatricians and allergists treating their children over the course of the previous 6 months. While more than 75% of the doctors treated the parents courteously and respectfully and provided clear explanations of children’s allergies, a high percentage of the doctors neglected to provide other information essential for caring for children with food allergies, the parents reported.

©gpointstudio/Thinkstock

The parents most often said they were missing explanations on when and how their children should be receiving epinephrine to treat allergic reactions and instructions on exactly what to do if their children had a medical emergency related to their specific allergies and circumstances. More pediatricians than allergists failed to share such information.

Among allergists, 68% explained when to use epinephrine, while 37% of pediatricians provided such information, the parents reported. Instructions on how to use epinephrine were provided to parents by 47% of allergists and 20% of pediatricians. Written emergency health care plans customized to each child were provided by 56% of the allergists and 24% of the pediatricians

“Although pediatricians might be relying on allergists to deliver [an emergency action plan and training in epinephrine autoinjectors use], with the rise in food allergies, guidelines recommend that pediatricians conduct these steps and not rely solely on the allergist,” said Jesse A. Blumenstock of Northwestern University, Chicago, and colleagues. “With our understanding of food allergy and anaphylaxis constantly evolving, guidelines and recommendations for how and when to give epinephrine and the need for an action plan need to be reinforced by physicians.”

Read the study in the Journal of Allergy and Clinical Immunology: In Practice (doi: 10.1016/j.jaip.2015.10.011).

[email protected]

Bronchoscopically placed nitinol coils to reduce lung volume markedly improved quality of life and modestly improved walk distance and lung function in a preliminary study of patients with severe emphysema, which was published online Jan. 12 in JAMA.

The magnitude and severity of serious and nonserious adverse effects were far less than has been reported for more invasive lung volume reduction surgery in this patient population. However, the short-term financial costs of coil placement were substantial, said Dr. Gaetan Deslee of University of Reims (France) Hospital and his associates.

Nitinol coils are shape-memory devices delivered into subsegmental airways to reduce regional parenchymal volume, which increases expansion of adjacent nontargeted lung. This increases the nontargeted tissue’s elastic recoil and reestablishes small-airway tethering, which improves expiratory flow and reduces air trapping.

The investigators compared this procedure against usual care in 100 patients with severe emphysema who were treated and followed for 1 year at 10 university hospitals across France. Both groups underwent pretreatment pulmonary rehabilitation and received inhaled bronchodilators with or without inhaled corticosteroids and with or without supplemental oxygen at the discretion of their treating physicians. Then patients were randomly assigned – 50 to receive the coils and 50 to receive usual care.

The coils were inserted under general anesthesia, and approximately 10 coils were placed per targeted lobe. Most patients later underwent the procedure on the opposite side, so that 47 patients received bilateral and 3 received unilateral coils during 97 bronchoscopies. The mean procedure time was 54 minutes, and the treatment significantly decreased lung hyperinflation.

The primary efficacy endpoint, improvement in 6-minute walk test scores after 6 months, was evaluable for 44 patients in each study group. A total of 18 patients (36%) who underwent coil placement and 9 (18%) who received usual care improved their scores by at least 54 m, which was a significant difference, the investigators said (JAMA. 2016 Jan 12. doi: 10.1001/jama.2015.17821).

In addition, all secondary endpoints were significantly better after coil placement than after usual care at both 6 months and 12 months. This included forced expiratory volume in 1 second, forced vital capacity, residual volume, and residual volume/total lung capacity, scores on the Medical Research Council dyspnea scale, and scores on a measure of health-related quality of life.

A cost-benefit analysis at 1 year showed that the mean increase in expenditures was $47,908 per person in the coil group, compared with the usual-care group. The 1-year incremental cost-effectiveness ratio was $782,598 per quality-adjusted life year (QALY). Assuming that the quality of life gains would be maintained over 3 years and that the costs of follow-up care would be identically low in both study groups, this ratio would decrease to $270,000 per QALY at 3 years.

However, neither of these cost-effectiveness ratios would be considered economical enough to warrant adopting this technology in most countries, Dr. Deslee and his associates noted.

At least one serious adverse event developed in 52% of the coil group and in 38% of the usual-care group, and there were four deaths (8%) in the coil group and three deaths (6%) in the usual-care group. The most frequent adverse event was pneumonia, which resolved with medical care in all cases. “The mechanism involved in pneumonia may result from local airway irritation, subsegmental airway closure, tension-induced inflammation, or local ischemia rather than from an infectious mechanism,” the researchers said.

This study was limited in that coil placement was not compared with either a sham or control procedure, patients were not blinded to treatment assignment, the sample size was relatively small, and follow-up was short. Larger studies using more rigorous statistical methods are needed “to draw a definitive conclusion regarding the long-term efficacy of coil treatment,” they added.

Bronchoscopically placed nitinol coils to reduce lung volume markedly improved quality of life and modestly improved walk distance and lung function in a preliminary study of patients with severe emphysema, which was published online Jan. 12 in JAMA.

The magnitude and severity of serious and nonserious adverse effects were far less than has been reported for more invasive lung volume reduction surgery in this patient population. However, the short-term financial costs of coil placement were substantial, said Dr. Gaetan Deslee of University of Reims (France) Hospital and his associates.

Nitinol coils are shape-memory devices delivered into subsegmental airways to reduce regional parenchymal volume, which increases expansion of adjacent nontargeted lung. This increases the nontargeted tissue’s elastic recoil and reestablishes small-airway tethering, which improves expiratory flow and reduces air trapping.

The investigators compared this procedure against usual care in 100 patients with severe emphysema who were treated and followed for 1 year at 10 university hospitals across France. Both groups underwent pretreatment pulmonary rehabilitation and received inhaled bronchodilators with or without inhaled corticosteroids and with or without supplemental oxygen at the discretion of their treating physicians. Then patients were randomly assigned – 50 to receive the coils and 50 to receive usual care.

The coils were inserted under general anesthesia, and approximately 10 coils were placed per targeted lobe. Most patients later underwent the procedure on the opposite side, so that 47 patients received bilateral and 3 received unilateral coils during 97 bronchoscopies. The mean procedure time was 54 minutes, and the treatment significantly decreased lung hyperinflation.

The primary efficacy endpoint, improvement in 6-minute walk test scores after 6 months, was evaluable for 44 patients in each study group. A total of 18 patients (36%) who underwent coil placement and 9 (18%) who received usual care improved their scores by at least 54 m, which was a significant difference, the investigators said (JAMA. 2016 Jan 12. doi: 10.1001/jama.2015.17821).

In addition, all secondary endpoints were significantly better after coil placement than after usual care at both 6 months and 12 months. This included forced expiratory volume in 1 second, forced vital capacity, residual volume, and residual volume/total lung capacity, scores on the Medical Research Council dyspnea scale, and scores on a measure of health-related quality of life.

A cost-benefit analysis at 1 year showed that the mean increase in expenditures was $47,908 per person in the coil group, compared with the usual-care group. The 1-year incremental cost-effectiveness ratio was $782,598 per quality-adjusted life year (QALY). Assuming that the quality of life gains would be maintained over 3 years and that the costs of follow-up care would be identically low in both study groups, this ratio would decrease to $270,000 per QALY at 3 years.

However, neither of these cost-effectiveness ratios would be considered economical enough to warrant adopting this technology in most countries, Dr. Deslee and his associates noted.

At least one serious adverse event developed in 52% of the coil group and in 38% of the usual-care group, and there were four deaths (8%) in the coil group and three deaths (6%) in the usual-care group. The most frequent adverse event was pneumonia, which resolved with medical care in all cases. “The mechanism involved in pneumonia may result from local airway irritation, subsegmental airway closure, tension-induced inflammation, or local ischemia rather than from an infectious mechanism,” the researchers said.

This study was limited in that coil placement was not compared with either a sham or control procedure, patients were not blinded to treatment assignment, the sample size was relatively small, and follow-up was short. Larger studies using more rigorous statistical methods are needed “to draw a definitive conclusion regarding the long-term efficacy of coil treatment,” they added.

Bronchoscopically placed nitinol coils to reduce lung volume markedly improved quality of life and modestly improved walk distance and lung function in a preliminary study of patients with severe emphysema, which was published online Jan. 12 in JAMA.

The magnitude and severity of serious and nonserious adverse effects were far less than has been reported for more invasive lung volume reduction surgery in this patient population. However, the short-term financial costs of coil placement were substantial, said Dr. Gaetan Deslee of University of Reims (France) Hospital and his associates.

Nitinol coils are shape-memory devices delivered into subsegmental airways to reduce regional parenchymal volume, which increases expansion of adjacent nontargeted lung. This increases the nontargeted tissue’s elastic recoil and reestablishes small-airway tethering, which improves expiratory flow and reduces air trapping.

The investigators compared this procedure against usual care in 100 patients with severe emphysema who were treated and followed for 1 year at 10 university hospitals across France. Both groups underwent pretreatment pulmonary rehabilitation and received inhaled bronchodilators with or without inhaled corticosteroids and with or without supplemental oxygen at the discretion of their treating physicians. Then patients were randomly assigned – 50 to receive the coils and 50 to receive usual care.

The coils were inserted under general anesthesia, and approximately 10 coils were placed per targeted lobe. Most patients later underwent the procedure on the opposite side, so that 47 patients received bilateral and 3 received unilateral coils during 97 bronchoscopies. The mean procedure time was 54 minutes, and the treatment significantly decreased lung hyperinflation.

The primary efficacy endpoint, improvement in 6-minute walk test scores after 6 months, was evaluable for 44 patients in each study group. A total of 18 patients (36%) who underwent coil placement and 9 (18%) who received usual care improved their scores by at least 54 m, which was a significant difference, the investigators said (JAMA. 2016 Jan 12. doi: 10.1001/jama.2015.17821).

In addition, all secondary endpoints were significantly better after coil placement than after usual care at both 6 months and 12 months. This included forced expiratory volume in 1 second, forced vital capacity, residual volume, and residual volume/total lung capacity, scores on the Medical Research Council dyspnea scale, and scores on a measure of health-related quality of life.

A cost-benefit analysis at 1 year showed that the mean increase in expenditures was $47,908 per person in the coil group, compared with the usual-care group. The 1-year incremental cost-effectiveness ratio was $782,598 per quality-adjusted life year (QALY). Assuming that the quality of life gains would be maintained over 3 years and that the costs of follow-up care would be identically low in both study groups, this ratio would decrease to $270,000 per QALY at 3 years.

However, neither of these cost-effectiveness ratios would be considered economical enough to warrant adopting this technology in most countries, Dr. Deslee and his associates noted.

At least one serious adverse event developed in 52% of the coil group and in 38% of the usual-care group, and there were four deaths (8%) in the coil group and three deaths (6%) in the usual-care group. The most frequent adverse event was pneumonia, which resolved with medical care in all cases. “The mechanism involved in pneumonia may result from local airway irritation, subsegmental airway closure, tension-induced inflammation, or local ischemia rather than from an infectious mechanism,” the researchers said.

This study was limited in that coil placement was not compared with either a sham or control procedure, patients were not blinded to treatment assignment, the sample size was relatively small, and follow-up was short. Larger studies using more rigorous statistical methods are needed “to draw a definitive conclusion regarding the long-term efficacy of coil treatment,” they added.

Intensified antituberculosis therapy doesn’t appear to improve survival in adults with tuberculous meningitis, compared with standard treatment, according to a report published online Jan. 14 in the New England Journal of Medicine.

This result, from a 3-year randomized double-blind placebo controlled clinical trial involving 817 adults in Vietnam, contradicts findings from previous small studies which suggested that increasing the rifampin dose and adding a fluoroquinolone to the standard regimen might improve outcomes, said Dr. A. Dorothee Heemskerk of the Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam, and her associates.

©Komolafe, M., Sunmonu, T., Esan, O./Wikimedia Commons/CC-BY-2.0

Current guidelines recommend at least 2 months of therapy with four antituberculosis agents, followed by treatment with rifampin (10 mg/kg) and isoniazid for an additional 7-10 months. “However, these recommendations are based on data from pulmonary tuberculosis and do not take into account the differential ability of antituberculosis drugs to penetrate the brain,” the investigators noted.

The concentration of rifampin in cerebrospinal fluid reaches only 30% of that in the plasma, so it has been proposed that higher-dose rifampin (15 mg/kg) might be more effective for tuberculous meningitis. Fluoroquinolones such as levofloxacin were proposed because they are active against tuberculosis and achieve good penetration of the blood-brain barrier.

Dr. Heemskerk and her associates tested this hypothesis at two tertiary referral centers for severe cases of tuberculosis or infectious diseases in Vietnam. All the study participants received standard daily isoniazid (5 mg/kg), rifampin (10 mg/kg), pyrazinamide (25 mg/kg), and ethambutol (20 mg/kg) for 3 months, followed by the same doses of rifampin and isoniazid for an additional 6 months. Approximately half (408 patients in the intensive-therapy group) received additional rifampin (5 mg/kg) and levofloxacin (20 mg/kg), while the other half (409 patients in the control group) received matching placebos.

The median patient age was 35 years. Approximately 43% of patients were coinfected with HIV.

The primary outcome measure – death at 9-month follow-up – occurred in 113 of the intensive-therapy group and 114 of the control group, a nonsignificant difference (HR, 0.94). The intensified treatment was no better than was standard treatment in any subgroup of patients or in any secondary outcomes, including neurologic disability and time to a new neurologic event or death, the investigators said (N Engl J Med. 2016 Jan 14. doi:10.1056/NEJMoa1507062).

However, intensive therapy was associated with a higher frequency of seizures (23 vs. 11 patients), visual impairment (14 vs. 4 patients), allergic reactions (30 patients vs. 17 patients), jaundice (19 vs. 7 patients), grade 3 or 4 hyponatremia (112 patients vs. 81 patients), and adverse events leading to treatment interruptions (95 patients vs. 64 patients).

It is possible that raising the dose of rifampin by only 5 mg/kg may not have increased intracerebral drug concentrations “sufficiently to enhance bacterial killing. Recent data suggest that much higher doses (up to 35 mg/kg per day) may have an acceptable side-effect profile and may be necessary to significantly increase the killing of M. tuberculosis in pulmonary tuberculosis,” Dr. Heemskerk and her associates noted.

“Although the results of our study do not support a change in the currently recommended treatment regimens for tuberculous meningitis, enhanced antituberculosis treatment with higher doses of first-line drugs, including intravenous rifampin, or the newer antituberculosis drugs bedaquiline and delamanid, still require investigation,” they added.

Wellcome Trust and the Li Ka Shing Foundation supported the study. Dr. Heemskerk and her associates reported having no relevant financial disclosures.

Intensified antituberculosis therapy doesn’t appear to improve survival in adults with tuberculous meningitis, compared with standard treatment, according to a report published online Jan. 14 in the New England Journal of Medicine.

This result, from a 3-year randomized double-blind placebo controlled clinical trial involving 817 adults in Vietnam, contradicts findings from previous small studies which suggested that increasing the rifampin dose and adding a fluoroquinolone to the standard regimen might improve outcomes, said Dr. A. Dorothee Heemskerk of the Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam, and her associates.

©Komolafe, M., Sunmonu, T., Esan, O./Wikimedia Commons/CC-BY-2.0

Current guidelines recommend at least 2 months of therapy with four antituberculosis agents, followed by treatment with rifampin (10 mg/kg) and isoniazid for an additional 7-10 months. “However, these recommendations are based on data from pulmonary tuberculosis and do not take into account the differential ability of antituberculosis drugs to penetrate the brain,” the investigators noted.

The concentration of rifampin in cerebrospinal fluid reaches only 30% of that in the plasma, so it has been proposed that higher-dose rifampin (15 mg/kg) might be more effective for tuberculous meningitis. Fluoroquinolones such as levofloxacin were proposed because they are active against tuberculosis and achieve good penetration of the blood-brain barrier.

Dr. Heemskerk and her associates tested this hypothesis at two tertiary referral centers for severe cases of tuberculosis or infectious diseases in Vietnam. All the study participants received standard daily isoniazid (5 mg/kg), rifampin (10 mg/kg), pyrazinamide (25 mg/kg), and ethambutol (20 mg/kg) for 3 months, followed by the same doses of rifampin and isoniazid for an additional 6 months. Approximately half (408 patients in the intensive-therapy group) received additional rifampin (5 mg/kg) and levofloxacin (20 mg/kg), while the other half (409 patients in the control group) received matching placebos.

The median patient age was 35 years. Approximately 43% of patients were coinfected with HIV.

The primary outcome measure – death at 9-month follow-up – occurred in 113 of the intensive-therapy group and 114 of the control group, a nonsignificant difference (HR, 0.94). The intensified treatment was no better than was standard treatment in any subgroup of patients or in any secondary outcomes, including neurologic disability and time to a new neurologic event or death, the investigators said (N Engl J Med. 2016 Jan 14. doi:10.1056/NEJMoa1507062).

However, intensive therapy was associated with a higher frequency of seizures (23 vs. 11 patients), visual impairment (14 vs. 4 patients), allergic reactions (30 patients vs. 17 patients), jaundice (19 vs. 7 patients), grade 3 or 4 hyponatremia (112 patients vs. 81 patients), and adverse events leading to treatment interruptions (95 patients vs. 64 patients).

It is possible that raising the dose of rifampin by only 5 mg/kg may not have increased intracerebral drug concentrations “sufficiently to enhance bacterial killing. Recent data suggest that much higher doses (up to 35 mg/kg per day) may have an acceptable side-effect profile and may be necessary to significantly increase the killing of M. tuberculosis in pulmonary tuberculosis,” Dr. Heemskerk and her associates noted.

“Although the results of our study do not support a change in the currently recommended treatment regimens for tuberculous meningitis, enhanced antituberculosis treatment with higher doses of first-line drugs, including intravenous rifampin, or the newer antituberculosis drugs bedaquiline and delamanid, still require investigation,” they added.

Wellcome Trust and the Li Ka Shing Foundation supported the study. Dr. Heemskerk and her associates reported having no relevant financial disclosures.

Intensified antituberculosis therapy doesn’t appear to improve survival in adults with tuberculous meningitis, compared with standard treatment, according to a report published online Jan. 14 in the New England Journal of Medicine.

This result, from a 3-year randomized double-blind placebo controlled clinical trial involving 817 adults in Vietnam, contradicts findings from previous small studies which suggested that increasing the rifampin dose and adding a fluoroquinolone to the standard regimen might improve outcomes, said Dr. A. Dorothee Heemskerk of the Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam, and her associates.

©Komolafe, M., Sunmonu, T., Esan, O./Wikimedia Commons/CC-BY-2.0

Current guidelines recommend at least 2 months of therapy with four antituberculosis agents, followed by treatment with rifampin (10 mg/kg) and isoniazid for an additional 7-10 months. “However, these recommendations are based on data from pulmonary tuberculosis and do not take into account the differential ability of antituberculosis drugs to penetrate the brain,” the investigators noted.

The concentration of rifampin in cerebrospinal fluid reaches only 30% of that in the plasma, so it has been proposed that higher-dose rifampin (15 mg/kg) might be more effective for tuberculous meningitis. Fluoroquinolones such as levofloxacin were proposed because they are active against tuberculosis and achieve good penetration of the blood-brain barrier.

Dr. Heemskerk and her associates tested this hypothesis at two tertiary referral centers for severe cases of tuberculosis or infectious diseases in Vietnam. All the study participants received standard daily isoniazid (5 mg/kg), rifampin (10 mg/kg), pyrazinamide (25 mg/kg), and ethambutol (20 mg/kg) for 3 months, followed by the same doses of rifampin and isoniazid for an additional 6 months. Approximately half (408 patients in the intensive-therapy group) received additional rifampin (5 mg/kg) and levofloxacin (20 mg/kg), while the other half (409 patients in the control group) received matching placebos.

The median patient age was 35 years. Approximately 43% of patients were coinfected with HIV.

The primary outcome measure – death at 9-month follow-up – occurred in 113 of the intensive-therapy group and 114 of the control group, a nonsignificant difference (HR, 0.94). The intensified treatment was no better than was standard treatment in any subgroup of patients or in any secondary outcomes, including neurologic disability and time to a new neurologic event or death, the investigators said (N Engl J Med. 2016 Jan 14. doi:10.1056/NEJMoa1507062).

However, intensive therapy was associated with a higher frequency of seizures (23 vs. 11 patients), visual impairment (14 vs. 4 patients), allergic reactions (30 patients vs. 17 patients), jaundice (19 vs. 7 patients), grade 3 or 4 hyponatremia (112 patients vs. 81 patients), and adverse events leading to treatment interruptions (95 patients vs. 64 patients).

It is possible that raising the dose of rifampin by only 5 mg/kg may not have increased intracerebral drug concentrations “sufficiently to enhance bacterial killing. Recent data suggest that much higher doses (up to 35 mg/kg per day) may have an acceptable side-effect profile and may be necessary to significantly increase the killing of M. tuberculosis in pulmonary tuberculosis,” Dr. Heemskerk and her associates noted.

“Although the results of our study do not support a change in the currently recommended treatment regimens for tuberculous meningitis, enhanced antituberculosis treatment with higher doses of first-line drugs, including intravenous rifampin, or the newer antituberculosis drugs bedaquiline and delamanid, still require investigation,” they added.

Wellcome Trust and the Li Ka Shing Foundation supported the study. Dr. Heemskerk and her associates reported having no relevant financial disclosures.

A large European study published in the journal AIDS has confirmed that HIV-positive status is a strong risk factor for an adverse tuberculosis treatment outcome.

Researchers at the Robert Koch Institute in Berlin analyzed the treatment outcomes of 61,138 TB cases reported from nine European countries during 2010-2012, and investigated the effect of HIV on TB outcomes using multilevel and multinomial logistic models. They also considered the interaction between HIV and multidrug-resistant TB (MDR-TB).

Courtesy Dr. Tom Folks, NIAID/National Institutes of Health

According to lead author Basel Karo and his colleagues, 5.5% of the TB cases analyzed were HIV positive. HIV coinfected cases had a significantly lower TB treatment success rate, compared with HIV-negative cases (57% vs. 79%). In the multilevel model adjusted for age and an interaction with MDR-TB, HIV was significantly associated with lower treatment success in all MDR strata, while in the multinomial regression model, HIV-positive cases had significantly higher relative risk ratio for death. Mr. Karo and coauthors said an increased risk of still being on treatment (more than 12 months for non-MDR-TB; more than 24 months for MDR-TB) is another indicator of less successful TB regimens in HIV-positive patients. The research team did not find any significant association between HIV and TB treatment failure.

Negative treatment outcomes may be explained by difficulties in diagnosis of TB, sometimes due to “alternation of the clinical manifestation of TB and lack of a rapid and sensitive TB diagnostic test” in HIV coinfected patients, which may lead to a delayed diagnosis and treatment. TB treatment of TB in HIV coinfected patients also “presents with major challenges regarding the drug interactions between the rifamycins and some antiretroviral agents, overlapping toxic effects, and the occurrence of immune reconstitution inflammatory syndrome (IRIS),” the investigators said.

The results of the trial should encourage future studies “including randomized clinical trials to investigate the optimal duration of TB treatment in HIV coinfected individuals,” Mr. Karo said.

Read the study in the journal AIDS (AIDS. 2016 Jan 8. doi:10.1097/QAD.0000000000001016).

[email protected]

On Twitter @richpizzi

A large European study published in the journal AIDS has confirmed that HIV-positive status is a strong risk factor for an adverse tuberculosis treatment outcome.

Researchers at the Robert Koch Institute in Berlin analyzed the treatment outcomes of 61,138 TB cases reported from nine European countries during 2010-2012, and investigated the effect of HIV on TB outcomes using multilevel and multinomial logistic models. They also considered the interaction between HIV and multidrug-resistant TB (MDR-TB).

Courtesy Dr. Tom Folks, NIAID/National Institutes of Health

According to lead author Basel Karo and his colleagues, 5.5% of the TB cases analyzed were HIV positive. HIV coinfected cases had a significantly lower TB treatment success rate, compared with HIV-negative cases (57% vs. 79%). In the multilevel model adjusted for age and an interaction with MDR-TB, HIV was significantly associated with lower treatment success in all MDR strata, while in the multinomial regression model, HIV-positive cases had significantly higher relative risk ratio for death. Mr. Karo and coauthors said an increased risk of still being on treatment (more than 12 months for non-MDR-TB; more than 24 months for MDR-TB) is another indicator of less successful TB regimens in HIV-positive patients. The research team did not find any significant association between HIV and TB treatment failure.

Negative treatment outcomes may be explained by difficulties in diagnosis of TB, sometimes due to “alternation of the clinical manifestation of TB and lack of a rapid and sensitive TB diagnostic test” in HIV coinfected patients, which may lead to a delayed diagnosis and treatment. TB treatment of TB in HIV coinfected patients also “presents with major challenges regarding the drug interactions between the rifamycins and some antiretroviral agents, overlapping toxic effects, and the occurrence of immune reconstitution inflammatory syndrome (IRIS),” the investigators said.

The results of the trial should encourage future studies “including randomized clinical trials to investigate the optimal duration of TB treatment in HIV coinfected individuals,” Mr. Karo said.

Read the study in the journal AIDS (AIDS. 2016 Jan 8. doi:10.1097/QAD.0000000000001016).

[email protected]

On Twitter @richpizzi

A large European study published in the journal AIDS has confirmed that HIV-positive status is a strong risk factor for an adverse tuberculosis treatment outcome.

Researchers at the Robert Koch Institute in Berlin analyzed the treatment outcomes of 61,138 TB cases reported from nine European countries during 2010-2012, and investigated the effect of HIV on TB outcomes using multilevel and multinomial logistic models. They also considered the interaction between HIV and multidrug-resistant TB (MDR-TB).

Courtesy Dr. Tom Folks, NIAID/National Institutes of Health

According to lead author Basel Karo and his colleagues, 5.5% of the TB cases analyzed were HIV positive. HIV coinfected cases had a significantly lower TB treatment success rate, compared with HIV-negative cases (57% vs. 79%). In the multilevel model adjusted for age and an interaction with MDR-TB, HIV was significantly associated with lower treatment success in all MDR strata, while in the multinomial regression model, HIV-positive cases had significantly higher relative risk ratio for death. Mr. Karo and coauthors said an increased risk of still being on treatment (more than 12 months for non-MDR-TB; more than 24 months for MDR-TB) is another indicator of less successful TB regimens in HIV-positive patients. The research team did not find any significant association between HIV and TB treatment failure.

Negative treatment outcomes may be explained by difficulties in diagnosis of TB, sometimes due to “alternation of the clinical manifestation of TB and lack of a rapid and sensitive TB diagnostic test” in HIV coinfected patients, which may lead to a delayed diagnosis and treatment. TB treatment of TB in HIV coinfected patients also “presents with major challenges regarding the drug interactions between the rifamycins and some antiretroviral agents, overlapping toxic effects, and the occurrence of immune reconstitution inflammatory syndrome (IRIS),” the investigators said.

The results of the trial should encourage future studies “including randomized clinical trials to investigate the optimal duration of TB treatment in HIV coinfected individuals,” Mr. Karo said.

Read the study in the journal AIDS (AIDS. 2016 Jan 8. doi:10.1097/QAD.0000000000001016).

[email protected]

On Twitter @richpizzi

Preschool-age children who have been fully vaccinated against pertussis can still develop symptoms of illness consistent with a whooping cough diagnosis, according to a study of toddlers in a Tallahassee, Fla., school that experienced an outbreak of pertussis in late 2013 (Emerg Infect Dis. 2016 Feb;22[2]. doi: 10.3201/eid2202.150325)

The study, published in Emerging Infectious Diseases by the Centers for Disease Control and Prevention, is the result of an outbreak investigation at the preschool that began after a 1-year-old and two 3-year-old children developed illness consistent with pertussis, and were confirmed to have pertussis after undergoing a polymerase chain reaction (PCR) test.

©DavidWhalen/thinkstockphotos.com

The Florida Department of Health administered a questionnaire to be completed by families of the 117 students (ages 10 months to 6 years) and 26 staff members. Questionnaire completion rate was 98%, with three student households and one staff household failing to complete it.

Overall, 28 cases were determined to be “probable” pertussis and 11 were confirmed as pertussis via PCR or other laboratory testing methods. Of these, 26 were students aged 1-5 years (22% of total student population), 2 were attributed to the staff (7%), and 11 were linked to the preschool, of which 9 originated from the households of the individual students and 2 from “camp counselors who had contact with a sibling of a laboratory-confirmed case-patient who attended the preschool.”

However, 28 of the students who had pertussis had received at least three vaccinations, with 23 of them having received at least four vaccinations, meaning they were classified as being fully vaccinated against the disease. Only 5 out of the school’s 117 children had not received the complete series of vaccinations, out of which 2 ended up being case-patients; both of those children, however, had received at least one vaccination prior to falling sick.

“Poor performance of a vaccine in a defined cohort might suggest a provider-level failure to store, use, and administer the vaccine properly,” noted the researchers, led by Dr. James Matthias of the Florida Department of Health. “Although we did not assess vaccine storage and handling practices, children from this investigation were seen by multiple providers in the community [and] no general increase in reported pertussis incidence was observed in the county at the same time as this outbreak.”

The bottom line, the authors concluded, is for pediatricians and primary care doctors to be wary that vaccination against pertussis doesn’t necessarily mean patients can’t ever get it. If pertussis symptoms arise in a vaccinated child, especially one 5 years old or younger, it may still be whooping cough.

The CDC supported the study. Dr. Matthias and his coauthors are all affiliated with the Florida Department of Health and the CDC, but reported no other relevant financial disclosures.

[email protected]

Preschool-age children who have been fully vaccinated against pertussis can still develop symptoms of illness consistent with a whooping cough diagnosis, according to a study of toddlers in a Tallahassee, Fla., school that experienced an outbreak of pertussis in late 2013 (Emerg Infect Dis. 2016 Feb;22[2]. doi: 10.3201/eid2202.150325)

The study, published in Emerging Infectious Diseases by the Centers for Disease Control and Prevention, is the result of an outbreak investigation at the preschool that began after a 1-year-old and two 3-year-old children developed illness consistent with pertussis, and were confirmed to have pertussis after undergoing a polymerase chain reaction (PCR) test.

©DavidWhalen/thinkstockphotos.com

The Florida Department of Health administered a questionnaire to be completed by families of the 117 students (ages 10 months to 6 years) and 26 staff members. Questionnaire completion rate was 98%, with three student households and one staff household failing to complete it.

Overall, 28 cases were determined to be “probable” pertussis and 11 were confirmed as pertussis via PCR or other laboratory testing methods. Of these, 26 were students aged 1-5 years (22% of total student population), 2 were attributed to the staff (7%), and 11 were linked to the preschool, of which 9 originated from the households of the individual students and 2 from “camp counselors who had contact with a sibling of a laboratory-confirmed case-patient who attended the preschool.”

However, 28 of the students who had pertussis had received at least three vaccinations, with 23 of them having received at least four vaccinations, meaning they were classified as being fully vaccinated against the disease. Only 5 out of the school’s 117 children had not received the complete series of vaccinations, out of which 2 ended up being case-patients; both of those children, however, had received at least one vaccination prior to falling sick.

“Poor performance of a vaccine in a defined cohort might suggest a provider-level failure to store, use, and administer the vaccine properly,” noted the researchers, led by Dr. James Matthias of the Florida Department of Health. “Although we did not assess vaccine storage and handling practices, children from this investigation were seen by multiple providers in the community [and] no general increase in reported pertussis incidence was observed in the county at the same time as this outbreak.”

The bottom line, the authors concluded, is for pediatricians and primary care doctors to be wary that vaccination against pertussis doesn’t necessarily mean patients can’t ever get it. If pertussis symptoms arise in a vaccinated child, especially one 5 years old or younger, it may still be whooping cough.

The CDC supported the study. Dr. Matthias and his coauthors are all affiliated with the Florida Department of Health and the CDC, but reported no other relevant financial disclosures.

[email protected]

Preschool-age children who have been fully vaccinated against pertussis can still develop symptoms of illness consistent with a whooping cough diagnosis, according to a study of toddlers in a Tallahassee, Fla., school that experienced an outbreak of pertussis in late 2013 (Emerg Infect Dis. 2016 Feb;22[2]. doi: 10.3201/eid2202.150325)

The study, published in Emerging Infectious Diseases by the Centers for Disease Control and Prevention, is the result of an outbreak investigation at the preschool that began after a 1-year-old and two 3-year-old children developed illness consistent with pertussis, and were confirmed to have pertussis after undergoing a polymerase chain reaction (PCR) test.

©DavidWhalen/thinkstockphotos.com

The Florida Department of Health administered a questionnaire to be completed by families of the 117 students (ages 10 months to 6 years) and 26 staff members. Questionnaire completion rate was 98%, with three student households and one staff household failing to complete it.

Overall, 28 cases were determined to be “probable” pertussis and 11 were confirmed as pertussis via PCR or other laboratory testing methods. Of these, 26 were students aged 1-5 years (22% of total student population), 2 were attributed to the staff (7%), and 11 were linked to the preschool, of which 9 originated from the households of the individual students and 2 from “camp counselors who had contact with a sibling of a laboratory-confirmed case-patient who attended the preschool.”

However, 28 of the students who had pertussis had received at least three vaccinations, with 23 of them having received at least four vaccinations, meaning they were classified as being fully vaccinated against the disease. Only 5 out of the school’s 117 children had not received the complete series of vaccinations, out of which 2 ended up being case-patients; both of those children, however, had received at least one vaccination prior to falling sick.

“Poor performance of a vaccine in a defined cohort might suggest a provider-level failure to store, use, and administer the vaccine properly,” noted the researchers, led by Dr. James Matthias of the Florida Department of Health. “Although we did not assess vaccine storage and handling practices, children from this investigation were seen by multiple providers in the community [and] no general increase in reported pertussis incidence was observed in the county at the same time as this outbreak.”

The bottom line, the authors concluded, is for pediatricians and primary care doctors to be wary that vaccination against pertussis doesn’t necessarily mean patients can’t ever get it. If pertussis symptoms arise in a vaccinated child, especially one 5 years old or younger, it may still be whooping cough.

The CDC supported the study. Dr. Matthias and his coauthors are all affiliated with the Florida Department of Health and the CDC, but reported no other relevant financial disclosures.

[email protected]