CID Journal: Outcomes Of Prompt Influenza Antiviral Treatment Of Older Adults

Photo Credit – Wikipedia

 

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Although it runs contrary to to what some in the `popular press’- and some activists - would like to project, there is a substantial body of evidence showing that antiviral medications – like oseltamivir (aka Tamiflu ®) - can make a real difference in the outcome of severe influenza infection.

 

Unfortunately, what most people know or remember about these drugs comes from hyperbolic media reports like the Guardian’s Tamiflu’s limitations in preventing pandemics exposed by trial results  and the Daily Mail’s  Ministers blew £650MILLION on useless anti-flu drugs.

 

Much of the ire surrounding this drug has been garnered through Roche’s long-standing resistance to releasing all of their testing data, and that has led to critical editorials in the BMJ, and frequent excoriation in the British press.

 

Fueling this fire have been repeated Cochrane group analyses that have found insufficient evidence that the drug reduces seasonal influenza complications in healthy adults, although they limit their analyses to RCTs (Randomized Controlled Trials) of which few exist for this drug.  

 

We’ve seen numerous observational studies that show antivirals are useful in the treatment of severe flu (see Study: Antivirals Saved Lives Of Pregnant Women  and  Study: The Benefits Of Antiviral Therapy During the 2009 Pandemic), particularly in those with heightened risk factors. 

 

Sadly,  many people (and probably even some doctors) have come away with the erroneous impression that these drugs are worthless – or worse.  We saw evidence of this last summer, in  CID Journal: Under Utilization Of Antivirals For At Risk Flu Patients, showing that antiviral drugs are underused for at-risk patients, while antibiotics (which don’t work against viral infections) are overused.

Working to address these beliefs, have been the CDC (see The CDC Responds To The Cochrane Tamiflu Study) and the UK PHE (see Revisiting Influenza Antiviral Recommendations), while  last January we saw a meta-analysis in The Lancet that supported its use as well (see CIDRAP News On The Lancet Oseltamivir (Tamiflu ®) Meta-Analysis).

Today we’ve new CDC research that looked at the extended care needs of elderly post-hospital-discharge flu patients who either received, or did not receive, early antiviral treatments.  As you will see, early administration of antivirals was associated with reductions in length of hospital stays, and reduced odds of needing extended care after discharge.

 

Impact of prompt influenza antiviral treatment on extended care needs after influenza hospitalization among community-dwelling older adults

Sandra S. Chaves1, Alejandro Pérez1, Lisa Miller2, Nancy M. Bennett3, Ananda Bandyopadhyay4, Monica M. Farley5,6,  Brian Fowler7,  Emily B. Hancock8, Pam Daily Kirley9,  Ruth Lynfield10, Patricia Ryan11, Craig Morin10, William Schaffner12, Ruta Sharangpani13, Mary Lou Lindegren12, Leslie Tengelsen14, Ann Thomas15, Mary B. Hill16, Kristy K. Bradley17, Oluwakemi Oni18, James Meek19, Shelley Zansky20, Marc-Alain Widdowson1, and Lyn Finelli1

 

Abstract

Background.  Patients hospitalized with influenza may require extended care upon discharge. We aimed to explore predictors for extended care needs and the potential mitigating effect of antiviral treatment among community-dwelling adults aged ≥65 years hospitalized with influenza.

Methods. We used laboratory-confirmed influenza hospitalizations from 3 influenza seasons. Extended care was defined as new placement in a skilled nursing home/long-term/rehabilitation facility upon hospital discharge. We focused on those treated with antiviral agents to explore the effect of early treatment on extended care and hospital length of stay (LOS) using logistic regression and competing risk survival analysis, accounting for time from illness onset to hospitalization. Treatment was categorized as early (≤4 days) and late (>4 days) in reference to date of illness onset.

Results. Among 6,593 community-dwelling adults aged ≥65 years hospitalized for influenza, 18% required extended care at discharge. Need for care increased with age and neurologic disorders, ICU admission, and pneumonia were predictors of care needs. Early treatment reduced the odds of extended care after hospital discharge for those hospitalized ≤2 or >2 days from illness onset (adjusted odds ratio [aOR] 0.38; 95% confidence interval [CI] 0.17, 0.85, and aOR 0.75; 95% CI 0.56, 0.97 respectively). Early treatment was also independently associated with reduction in LOS for those hospitalized ≤2 days from illness onset (adjusted hazard ratio [aHR] 1.81; 95% CI 1.43, 2.30) or >2 days (aHR 1.30; 95% CI 1.20, 1.40).

Conclusions. Prompt antiviral treatment decreases the impact of influenza on older adults through shorten hospitalization and reduced extended care needs.

 

The CDC has released a statement regarding this study, excerpts of which follow:

 

Early flu treatment reduces hospitalization time, disability risk in older people

Press Release

For Immediate Release: Wednesday, September 2, 2015

Early treatment of flu-hospitalized people 65 and older with flu antiviral medications cuts the duration of their hospital stay and reduces their risk of needing extended care after discharge, a new CDC study finds. The study is the first to look at the benefits of early antiviral treatment on preventing the need for extended care in community-dwelling flu-hospitalized people 65 and older.

Because people 65 and older are at high risk of serious flu complications, CDC recommends that they be treated for flu with influenza antiviral medications as early as possible because these drugs work best when started early. The study, published today in the journal Clinical Infectious Diseases, supports this recommendation.

“Flu can be extremely serious in older people, leading to hospitalization and in some cases long-term disability. This important study shows that people 65 and older should seek medical care early when they develop flu symptoms,” says Dr. Dan Jernigan, director of CDC's Influenza Division.

The study found that community-dwelling patients 65 years and older who sought medical care or who were hospitalized within two days of illness onset and who were treated with antiviral medications early (in the first four days of illness) had hospital stays that were substantially shorter than those who received treatment later (after 4 days of illness onset). This benefit was observed even among those who sought care later (more than two days after they got sick), but the reduction in hospital stay was not as great.

Similarly, early treatment was associated with patients being 25 percent to 60 percent less likely to need extended care after leaving the hospital. The study authors suggest that the shorter hospital stays associated with early treatment could account for the reduced risk of needing extended care after discharge since lengthy bed restriction can lead to disability. Other factors like older age, the presence of neurologic disorders, intensive care unit (ICU) admission, and pneumonia at admission were also independent risk factors for extended care needs.

(Continue . . .)

 

While far from perfect, and certainly not a `cure’ for flu, antivirals remain our best pharmaceutical option for the treatment of severe influenza.

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Saudi MOH: Four New MERS Cases

 

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The latest update from the Saudi MOH indicates 4 new MERS cases (2 HCWs in Riyadh, 1 in Najran, and 1 in Al Kharj), along with two recent deaths.  This makes 135 cases reported out of Saudi Arabia over the past 30 days, an unusually high number of cases for this time of year.

While most of the activity has been centered around the capital Riyadh, the past few days we’ve seen a growing number of cases from Najran, near the Yemen border.  

 

Today, we also see the first case in several weeks from Al Kharj, the source of which isn’t stated.  

 

The source of these  sporadic `primary cases’ – community cases without a known risk exposure –  are the topic of a blog overnight by Dr. Ian Mackay (see Where do these 'primary' MERS cases come from?), which includes a fascinating chart showing their incidence.

 

This is also an issue we’ve looked at previously, in  WHO EMRO: Scientific Meeting Reviews MERS Progress & Knowledge Gaps  and The Community Transmission Mystery).

 

Based on the limited scientific studies that have been released, for now, we still have more questions than answers.

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#NatlPrep : Disaster Preparedness For Kids

Credit Ready.gov

 

Note: This is day 3 of National Preparedness Month.  Follow this year’s campaign on Twitter by searching for the #NatlPrep hash tag.  This month, as part of NPM15, I’ll be rerunning some updated  preparedness essays, along with some new ones.

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Growing up in Hurricane Alley, during the very active 1950s and 1960s, I was primed at an early age to respect the power of nature and to be prepared for the unexpected. If that wasn’t enough, our daily barrage of lightning storms during the summer months only added emphasis to the need to always keep a weather eye out. 

 

During my `formative years’, a lot of named storms crossed my path (I spent most of that time living in the green circle around Tampa Bay), and like most kids in Florida, I kept a hurricane tracking map my  bedroom wall to monitor their progress.  

 

I knew their strength, forward speed, and direction of movement, and dutifully updated the map every 6 hours.

 

Call it therapeutic. But I took comfort in knowing where these storms were, where they were likely headed, and knowing when they posed a potential threat - and more importantly – when they didn’t.   

 

I was involved, and so I felt in control.

Throw in the cold war, the 1962 Cuban Missile Crisis, and constant school duck & cover drills and evacuations, CONELRAD alerts on TV, films like Survival Under Atomic Attack and `Bert the turtle’ PSAs in elementary school, and you’d think you’d have a recipe for night terrors and phobias.

 

But amazingly, most of us just took it in stride.  In large part, I believe, because we were encouraged at a very young age to participate in disaster preparedness. 

 

While the atomic attack scenarios were certainly scary, we were empowered by being `prepared for the worst’, even if some of those preparations were a bit dubious (the protective properties of student desks against high yield atomic blasts likely being less than advertised).

 

Fortunately, disaster preparedness – particularly for kids - has come a long way from the `bad old days’ of the cold war.

 

Today, our concerns are focused on natural disasters, like floods, hurricanes, and earthquakes.  Scenarios that are far more survivable than an all-out nuclear attack, and that can be approached in a more `kid-friendly’ fashion.

 

Still, the core message – that disasters happen, and we should all be prepared – hasn’t changed.

 

Ready.gov’s kid friendly preparedness page contains games and activities for kids along with information for parents and educators on how to teach simple, but effective preparedness lessons.  

Many states have their own preparedness site for kids, such as Florida Division of Emergency Management’s Kids Get A Plan page, which provides an excellent interactive introduction to preparedness for children. 

Florida’s http://www.kidsgetaplan.com/  Disaster Preparedness For Kids

 

Most of these programs are designed for younger kids, so I was pleased earlier this year to find an online disaster preparedness game more suitable for older kids; the ISDR: The `Stop Disasters’ Simulation Game.  The game has five scenarios, with three levels of difficulty in each, to choose from.  Earthquake, tsunami, hurricane, wildfire or flood.

 

For more ideas on teaching kids to be disaster resilient (albeit, earthquake centric) SHAKEOUT.ORG has a long list of educational resources divided up by suitable school grade brackets (K-6, 7-12). 

 

Although most parents want to protect their kids from undo worry - when a disaster threatens, it threatens all of us – regardless of our age. 

 

Helping kids to understand more about emergency preparedness and community resilience will help them cope (and perhaps, even help) in the event they, or their community, are caught up in a disaster.

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ECDC: Epidemiological Update On MERS-CoV - Sept 2nd

MERS by month of Onset – Credit ECDC

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The ECDC has published an updated Epidemiological Update on MERS cases, which includes the 1st four Jordanian cases of 2015, along with Saudi cases reported through September 2nd.  As always, they pack a lot of information, and some excellent graphics, into their updates.

As the chart above illustrates, while our history of tracking  MERS is pretty short, we do seem to be seeing more MERS activity the past few months than we have during previous summers. These numbers, however, are largely being propelled by three major nosocomial outbreaks (Hofuf, South Korea, Riyadh). 

 

I’ve only included the outbreak summaries, so follow the link for the entire update:

 

Epidemiological update: Middle East respiratory syndrome coronavirus (MERS-CoV)

02 Sep 2015

 

Jordan

According to WHO the four cases reported from Jordan between 26 and 28 August 2015 seem to be part of a MERS-CoV outbreak at a hospital in Amman.

The first case reported was a 60-year-old man who lived in Jeddah, Saudi Arabia, but had travelled to Amman on 28 July 2015. The onset of symptoms began on 31 July and he was hospitalised for the first time from 10 to 18 August. However, he was readmitted to another hospital on 20 August. It is not known how this case  became infected.

The second case is a 38-year-old man from Kuwait City who travelled to Amman on 7 August 2015. He developed symptoms on 12 August. He was hospitalised on 17 August in the same hospital where the first case was treated. One possible exposure is that he frequently visited a family member who was being treated at the same hospital as the first case.

The third case is a 76-year-old man from Amman who was hospitalised for treatment of a chronic health condition on three different occasions at the same hospital as the two previous cases. According to WHO he was hospitalised twice for an underlying condition and then admitted on 20 August 2015 after he was diagnosed with MERS-CoV.

The fourth case is a 47-year-old woman from Kuwait City who travelled to Amman on 15 July 2015. She is a contact of the second case and tested positive for MERS-CoV on screening tests. She is asymptomatic and is in home isolation. Her only known exposure is that she visited family members at the hospital where the first patient was being treated.

In addition to the four cases mentioned, Jordan has announced two extra cases, a 56-year-old Jordanian man who was diagnosed with MERS-CoV after undergoing surgery and a 74-year-old woman who has pre-existing medical conditions.

 

Saudi Arabia

Since the beginning of 2015, Saudi Arabia has reported 367 cases, of which 30 were reported after ECDC’s risk assessment of 27 August 2015. Twenty-eight of the cases occurred in Riyadh (Figure 4) and two in Najran.

Figure 3. Number of cases (n=131) reported by Saudi Arabia in Riyadh, 3 August 2015 – 2 September 2015, by date of reporting

For four of the 30 cases it was clearly indicated that they did not have any contact with a previously identified or suspected case. The remaining 26 cases had either had contact, or were under review for having had contact, with suspected or confirmed cases in the community or hospital. This may indicate that there might be a low-level community transmission but the majority of the cases are clearly related to nosocomial transmission of MERS-CoV in Saudi Arabia. Six of the 30 cases are healthcare workers.

(Continue . . .)

 

 

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WHO MERS Update – Saudi Arabia Sept 2nd

Credit WHO

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We’ve another lengthy WHO GAR update on the ongoing MERS outbreak in Saudi Arabia.  Today’s update lists 15 cases reported by the MOH between August 24th and 25th. Due to the length of this update, I’ve elected to briefly chart the cases (see spreadsheet below), rather than print the entire update.

 

Only one is listed as having direct contact with a known case, while 10 appear to be the unlucky recipients of  `collateral infection’  while admitted to - or visiting - a healthcare facility. In four cases, the mode of infection isn’t stated.

 

Two are healthcare workers, but none are described as having provided care to a known MERS case.  As we’ve seen previously, the actual chain of transmission within hospitals is often murky. .  

 

The average patient age for this batch is 63.57 years, 6 are female while 9 are male. Four are listed in critical condition, 2 have died, while the rest are listed in stable condition.  The average delay between testing positive and being reported by the MOH is near to 3 days, with a maximum of 7.

 

 

Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Saudi Arabia

Disease outbreak news
2 September 2015

Between 24 and 25 August 2015, the National IHR Focal Point for the Kingdom of Saudi Arabia notified WHO of 15 additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, including 2 deaths. Eleven (11) of these reported cases are associated with a MERS-CoV outbreak currently occurring in a hospital in Riyadh city.

(SNIP DETAILS OF CASES)

 

Contact tracing of household and healthcare contacts is ongoing for these cases.

The National IHR Focal Point for the Kingdom of Saudi Arabia also notified WHO of the death of 9 MERS-CoV case that were reported in previous DONs on 26 August (case no. 4, 5, 8, 13, 14, 17), on 21 August (case no. 4, 9) and on 18 August (case no. 7).

Globally, since September 2012, WHO has been notified of 1,493 laboratory-confirmed cases of infection with MERS-CoV, including at least 527 related deaths.

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Korea Announces Major Changes In Wake Of MERS Outbreak

Coronavirus – Credit CDC PHIL

 

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The explosive spread of MERS in South Korea’s medical establishment last May and June was credited to both design deficits in hospital wards and emergency rooms that helped to spread the virus and cultural practices that encouraged family members to stay with hospitalized patients to provide routine care. 

 

The following excerpt comes from the WHO summary Middle East Respiratory Syndrome (MERS) in the Republic of Korea issued 15 June 2015.

 

MERS CoV spread in Korea

Conditions and cultural traditions specific to Korea have likely also played a role in the outbreak’s rapid spread. The accessibility and affordability of health care in Korea encourage “doctor shopping”; patients frequently consult specialists in several facilities before deciding on a first-choice facility.

Moreover, it is customary in Korea for many family members and friends to visit loved ones when they are in the emergency room or admitted to hospital. It is also customary for family members to provide almost constant bedside care often staying in the hospital room overnight, increasing the risk of close exposures in the health care setting.

 

Now that their MERS outbreak is over, hospitals are examining ways to prevent future outbreaks of MERS  . . . or any other infectious disease.

 

The hardest hit hospital in the Korean outbreak was Samsung Hospital in Seoul, which accounted for nearly half (90 of 186) patients.  Today they have announced a 50 Billion Won (42 million USD) renovation plan designed to limit the spread of any future outbreak. 

 

Among the planned changes:

• The hospital will allow only one visitor per patient in the emergency room.  Visitors will be required to book their visits in advance.
• Emergency rooms will have separate areas to treat infections vs. non-infectious patients
• The SMC will enlarge their ER room size by 60%
• SMC will add negative pressure isolation rooms to the ER
• SMC will also partner with the International Vaccine Institute (IVI) to try to develop a MERS vaccine.

 

Additional details are available via the following Korea Times article.

Samsung hospital announces post-MERS measures

By Kim Se-jeong

Samsung Medical Center (SMC) will refurbish its emergency room and limit the number of visitors for patients in an effort to prevent another infectious disease from spreading there and to ensure the safety of patients.

SMC's director Song Jae-hoon said Wednesday that the hospital will spend almost 50 billion won to build necessary infrastructure and facilities.

(Continue . . . )

 

This move by Samsung Seoul is just part of a much larger nation-wide initiative to prepare Korea’s hospital system to deal with infectious diseases like MERS, Ebola, and avian flu.  Korea’s government has also announced an ambitious  comprehensive `national defense strategy’ against infectious diseases:

Since this statement doesn’t translated particularly well, we’ll turn to a lengthy English language summary carried today by the Asian News Network.  Follow the link to read it in its entirety:

 

Wednesday, 2 September 2015

Seoul announces post-MERS plan for infectious diseases

Claire Lee The Korea Herald

Publication Date : 02-09-2015

All general hospitals with 300 or more patient beds in South Korea will be required to establish negative air pressure rooms to prevent cross-contamination, Seoul announced on Tuesday as part of its post-Middle East respiratory syndrome plan to better deal with contagious diseases.

The Ministry of Health and Welfare also announced that the head of Korea Center for Disease Control and Prevention will be appointed as the ministry’s joint vice minister to strengthen public health sector, and establish an emergency operations center that runs 24-hours a day to readily detect any possible epidemic.

South Korea's shortage of nursing staff and negative pressure rooms had been blamed for the MERS spread earlier this year, which claimed 36 lives. Many Koreans who contracted the virus did so while caring for their family members at MERS-affected hospital rooms.

(Continue . . . )

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Saudi MERS Cluster Grows By 7 Cases

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Based on the limited and cryptic information we have from the Saudi MOH, it isn’t possible to tell exactly what index case sparked the current (largely) nosocomial MERS outbreak in Riyadh.  Based on FluTracker’s Tracking List there were 5 cases reported from the capital city in June, and 14 cases in July, but it wasn’t until early August that the numbers really took off.

Since then, the Saudi MOH has announced 126 additional cases from Riyadh – the vast majority of whom are believed part of this hospital-acquired cluster.

I say `believed’ because specifics, such as who infected who, when, where and how remain largely unknown. 

 

Despite multiple large nosocomial outbreaks (Jeddah, Taif, Hofuf & Riyadh) over the past couple of years, the Saudis have never shared the level of epidemiological detail such as we saw come out of South Korea this past summer. 

Nor have they released the long-promised case-control study on MERS, which is hoped will shed some light on how the virus is sporadically being acquired in the community.

Today things become even more confusing, as the latest MOH update offers conflicting information.   As they map at the top of this blog indicates, the MOH is reporting 7 new cases in Riyadh.

 

Unfortunately, the accompanying chart of cases doesn’t match.  It shows 5 new cases in Riyadh, and 2 in Najran.  (Your guess is as good as mine).

 

Three of the cases are listed as Health Care Workers, and 6 of the 7 are listed as contacts of known cases, with 1 under review.

 

Despite this confusing report, one thing remains apparent. 

 

Three weeks before the start of the Hajj – and after more than a month of trying - the Saudis still haven’t gotten control of this large, high profile MERS outbreak in the nation’s capital.

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