Lorraine L. Janeczko, MPH

Version 11.0 of the 2021 revised European AIDS Clinical Society (EACS) Guidelines updates all aspects of HIV care and adds recommendations on COVID-19 and antiretroviral treatment (ART) in children and adolescents, the guidelines authors reported in HIV Medicine.

“Conducting a systematic and timely annual revision of all guidelines recommendations is an EACS cornerstone,” EACS Guidelines coordinator Lene Ryom, MD, PhD, DMSc, a researcher at the University of Copenhagen, said in an interview. “These revisions ensure that the EACS Guidelines remain clinically relevant, are updated with the latest scientific evidence, and that they cover all key aspects related to HIV management.”

Key revisions in this update include:
 

Antiretroviral therapy (ART)

• Six recommended treatment options for first-line regimens for ART-naive adults include triple-drug regimens consisting of tenofovir (either tenofovir disoproxil fumarate or tenofovir alafenamide) with either lamivudine or emtricitabine plus dolutegravir, raltegravir, bictegravir, or doravirine; abacavir/lamivudine plus dolutegravir; or dual therapy with emtricitabine plus dolutegravir. These drug combinations are recommended in single-tablet form if available.
• Alternatives consisting of triple-drug tenofovir-based regimens along with efavirenz, rilpivirine, or boosted darunavir, are advised when no recommended regimens are feasible.
• Bimonthly injections with long-acting cabotegravir plus rilpivirine are now advised as a switch option for people who are virologically suppressed.
• Pre-exposure prophylaxis on demand is advised for cisgender men, and PrEP may be continued during pregnancy and breastfeeding for people at risk of acquiring HIV.

Drug-drug interactions (DDIs) and other prescribing issues

• Four new DDI tables cover antituberculosis drugs, anxiolytics, hormone therapy, and COVID-19 therapies.

Comorbidities

• This update acknowledged the impact of the COVID-19 pandemic on routine health care, provides recommendations, and highlights the role of shared care and consultation for anxiety and other mental health disorders.
• Treatments involving diabetes, hypertension, cardiovascular disease, heart failure, chronic kidney disease, hypercholesterolemia, obesity, cancer, and sexual health have been updated, with new information about elderly and frail patients, women’s sexual health, and special considerations for transgender people.

Viral hepatitis coinfection

Immediate treatment of recently acquired hepatitis C is recommended for people living with HIV and ongoing risk behavior. Bulevirtide is added as a treatment option for hepatitis Delta virus.

Opportunistic infections and COVID-19

• The revision adds new guidance on management of HIV and COVID-19, covering epidemiology, risk factors for severe COVID-19, COVID-19 management, HIV care during a pandemic, HIV management during COVID-19 treatment, and management of long-term COVID-19 symptoms and prophylaxis.
• It includes guidance on management of tuberculosis meningitis, cryptococcosis, Pneumocystis jirovecii pneumonia, and drug-resistant tuberculosis.

Pediatric HIV infection treatments

• This new section, developed with the European pediatric research organization Penta, updates guidance for the use of preferred and alternative first-line drugs from birth to adolescence. Combinations include new child-friendly formulations of dolutegravir as early as 4 weeks of age and 3 kg (6.6 lb) of weight as well as an increased emphasis on dolutegravir as first-line preferred agent for all children except newborns. Abacavir is recommended for children younger than 3 months.
• ART regimens for children with infectious hepatitis or tuberculosis are also provided.

Laura Jane Waters, MD, a genitourinary consultant and HIV and hepatitis lead at Central and North West London National Health Service Mortimer Market Centre, and chair of the British HIV Association (BHIVA), shared her perspective on the revision. She was not involved with the EACS Guidelines revision.

“The addition of a section on COVID-19 in people with HIV, including management, drug interactions, and vaccination, is welcomed, as is the inclusion of key references and, for selected references, the key findings,” Dr. Waters said in an interview.

“Finally, for the first time, EACS covers pediatric HIV treatment by integrating with the Penta guidelines,” she added. “This is an important evolution, considering there are still cases of vertical HIV transmission in Europe, not to mention children living with HIV who have immigrated. Ensuring high and equitable standards of HIV treatment for young people is crucial.”

“This update to the always-pragmatic EACS guidelines further diverges from the United States Department of Health & Human Services guidelines,” Dr. Waters explained. “For 6 months, both guidelines preferred the same ... regimens for first-line therapy, but since DHSS removed raltegravir-based ART in June 2021 and EACS added doravirine-based regimens in October 2021, we’re back in the more familiar territory of EACS offering a broader range of preferred choices.”

Dr. Ryom noted that modern HIV care needs to consider managing coinfections, opportunistic diseases, comorbidities, aging, addictions, and mental health.

“Ensuring an integrated and personalized approach to HIV management is becoming increasingly important in an aging population living with HIV with the potential for complex needs,” she said.

The guidelines are available in several formats: as a free smartphone app, an interactive web version, and an online PDF.

Funding information was not provided. Dr. Ryom and several coauthors disclosed no relevant financial relationships. Most of the guideline coauthors declared financial relationships with pharmaceutical companies “outside the submitted work.” Dr. Waters provided no information on conflicts of interest.

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

Version 11.0 of the 2021 revised European AIDS Clinical Society (EACS) Guidelines updates all aspects of HIV care and adds recommendations on COVID-19 and antiretroviral treatment (ART) in children and adolescents, the guidelines authors reported in HIV Medicine.

“Conducting a systematic and timely annual revision of all guidelines recommendations is an EACS cornerstone,” EACS Guidelines coordinator Lene Ryom, MD, PhD, DMSc, a researcher at the University of Copenhagen, said in an interview. “These revisions ensure that the EACS Guidelines remain clinically relevant, are updated with the latest scientific evidence, and that they cover all key aspects related to HIV management.”

Key revisions in this update include:
 

Antiretroviral therapy (ART)

• Six recommended treatment options for first-line regimens for ART-naive adults include triple-drug regimens consisting of tenofovir (either tenofovir disoproxil fumarate or tenofovir alafenamide) with either lamivudine or emtricitabine plus dolutegravir, raltegravir, bictegravir, or doravirine; abacavir/lamivudine plus dolutegravir; or dual therapy with emtricitabine plus dolutegravir. These drug combinations are recommended in single-tablet form if available.
• Alternatives consisting of triple-drug tenofovir-based regimens along with efavirenz, rilpivirine, or boosted darunavir, are advised when no recommended regimens are feasible.
• Bimonthly injections with long-acting cabotegravir plus rilpivirine are now advised as a switch option for people who are virologically suppressed.
• Pre-exposure prophylaxis on demand is advised for cisgender men, and PrEP may be continued during pregnancy and breastfeeding for people at risk of acquiring HIV.

Drug-drug interactions (DDIs) and other prescribing issues

• Four new DDI tables cover antituberculosis drugs, anxiolytics, hormone therapy, and COVID-19 therapies.

Comorbidities

• This update acknowledged the impact of the COVID-19 pandemic on routine health care, provides recommendations, and highlights the role of shared care and consultation for anxiety and other mental health disorders.
• Treatments involving diabetes, hypertension, cardiovascular disease, heart failure, chronic kidney disease, hypercholesterolemia, obesity, cancer, and sexual health have been updated, with new information about elderly and frail patients, women’s sexual health, and special considerations for transgender people.

Viral hepatitis coinfection

Immediate treatment of recently acquired hepatitis C is recommended for people living with HIV and ongoing risk behavior. Bulevirtide is added as a treatment option for hepatitis Delta virus.

Opportunistic infections and COVID-19

• The revision adds new guidance on management of HIV and COVID-19, covering epidemiology, risk factors for severe COVID-19, COVID-19 management, HIV care during a pandemic, HIV management during COVID-19 treatment, and management of long-term COVID-19 symptoms and prophylaxis.
• It includes guidance on management of tuberculosis meningitis, cryptococcosis, Pneumocystis jirovecii pneumonia, and drug-resistant tuberculosis.

Pediatric HIV infection treatments

• This new section, developed with the European pediatric research organization Penta, updates guidance for the use of preferred and alternative first-line drugs from birth to adolescence. Combinations include new child-friendly formulations of dolutegravir as early as 4 weeks of age and 3 kg (6.6 lb) of weight as well as an increased emphasis on dolutegravir as first-line preferred agent for all children except newborns. Abacavir is recommended for children younger than 3 months.
• ART regimens for children with infectious hepatitis or tuberculosis are also provided.

Laura Jane Waters, MD, a genitourinary consultant and HIV and hepatitis lead at Central and North West London National Health Service Mortimer Market Centre, and chair of the British HIV Association (BHIVA), shared her perspective on the revision. She was not involved with the EACS Guidelines revision.

“The addition of a section on COVID-19 in people with HIV, including management, drug interactions, and vaccination, is welcomed, as is the inclusion of key references and, for selected references, the key findings,” Dr. Waters said in an interview.

“Finally, for the first time, EACS covers pediatric HIV treatment by integrating with the Penta guidelines,” she added. “This is an important evolution, considering there are still cases of vertical HIV transmission in Europe, not to mention children living with HIV who have immigrated. Ensuring high and equitable standards of HIV treatment for young people is crucial.”

“This update to the always-pragmatic EACS guidelines further diverges from the United States Department of Health & Human Services guidelines,” Dr. Waters explained. “For 6 months, both guidelines preferred the same ... regimens for first-line therapy, but since DHSS removed raltegravir-based ART in June 2021 and EACS added doravirine-based regimens in October 2021, we’re back in the more familiar territory of EACS offering a broader range of preferred choices.”

Dr. Ryom noted that modern HIV care needs to consider managing coinfections, opportunistic diseases, comorbidities, aging, addictions, and mental health.

“Ensuring an integrated and personalized approach to HIV management is becoming increasingly important in an aging population living with HIV with the potential for complex needs,” she said.

The guidelines are available in several formats: as a free smartphone app, an interactive web version, and an online PDF.

Funding information was not provided. Dr. Ryom and several coauthors disclosed no relevant financial relationships. Most of the guideline coauthors declared financial relationships with pharmaceutical companies “outside the submitted work.” Dr. Waters provided no information on conflicts of interest.

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

Version 11.0 of the 2021 revised European AIDS Clinical Society (EACS) Guidelines updates all aspects of HIV care and adds recommendations on COVID-19 and antiretroviral treatment (ART) in children and adolescents, the guidelines authors reported in HIV Medicine.

“Conducting a systematic and timely annual revision of all guidelines recommendations is an EACS cornerstone,” EACS Guidelines coordinator Lene Ryom, MD, PhD, DMSc, a researcher at the University of Copenhagen, said in an interview. “These revisions ensure that the EACS Guidelines remain clinically relevant, are updated with the latest scientific evidence, and that they cover all key aspects related to HIV management.”

Key revisions in this update include:
 

Antiretroviral therapy (ART)

• Six recommended treatment options for first-line regimens for ART-naive adults include triple-drug regimens consisting of tenofovir (either tenofovir disoproxil fumarate or tenofovir alafenamide) with either lamivudine or emtricitabine plus dolutegravir, raltegravir, bictegravir, or doravirine; abacavir/lamivudine plus dolutegravir; or dual therapy with emtricitabine plus dolutegravir. These drug combinations are recommended in single-tablet form if available.
• Alternatives consisting of triple-drug tenofovir-based regimens along with efavirenz, rilpivirine, or boosted darunavir, are advised when no recommended regimens are feasible.
• Bimonthly injections with long-acting cabotegravir plus rilpivirine are now advised as a switch option for people who are virologically suppressed.
• Pre-exposure prophylaxis on demand is advised for cisgender men, and PrEP may be continued during pregnancy and breastfeeding for people at risk of acquiring HIV.

Drug-drug interactions (DDIs) and other prescribing issues

• Four new DDI tables cover antituberculosis drugs, anxiolytics, hormone therapy, and COVID-19 therapies.

Comorbidities

• This update acknowledged the impact of the COVID-19 pandemic on routine health care, provides recommendations, and highlights the role of shared care and consultation for anxiety and other mental health disorders.
• Treatments involving diabetes, hypertension, cardiovascular disease, heart failure, chronic kidney disease, hypercholesterolemia, obesity, cancer, and sexual health have been updated, with new information about elderly and frail patients, women’s sexual health, and special considerations for transgender people.

Viral hepatitis coinfection

Immediate treatment of recently acquired hepatitis C is recommended for people living with HIV and ongoing risk behavior. Bulevirtide is added as a treatment option for hepatitis Delta virus.

Opportunistic infections and COVID-19

• The revision adds new guidance on management of HIV and COVID-19, covering epidemiology, risk factors for severe COVID-19, COVID-19 management, HIV care during a pandemic, HIV management during COVID-19 treatment, and management of long-term COVID-19 symptoms and prophylaxis.
• It includes guidance on management of tuberculosis meningitis, cryptococcosis, Pneumocystis jirovecii pneumonia, and drug-resistant tuberculosis.

Pediatric HIV infection treatments

• This new section, developed with the European pediatric research organization Penta, updates guidance for the use of preferred and alternative first-line drugs from birth to adolescence. Combinations include new child-friendly formulations of dolutegravir as early as 4 weeks of age and 3 kg (6.6 lb) of weight as well as an increased emphasis on dolutegravir as first-line preferred agent for all children except newborns. Abacavir is recommended for children younger than 3 months.
• ART regimens for children with infectious hepatitis or tuberculosis are also provided.

Laura Jane Waters, MD, a genitourinary consultant and HIV and hepatitis lead at Central and North West London National Health Service Mortimer Market Centre, and chair of the British HIV Association (BHIVA), shared her perspective on the revision. She was not involved with the EACS Guidelines revision.

“The addition of a section on COVID-19 in people with HIV, including management, drug interactions, and vaccination, is welcomed, as is the inclusion of key references and, for selected references, the key findings,” Dr. Waters said in an interview.

“Finally, for the first time, EACS covers pediatric HIV treatment by integrating with the Penta guidelines,” she added. “This is an important evolution, considering there are still cases of vertical HIV transmission in Europe, not to mention children living with HIV who have immigrated. Ensuring high and equitable standards of HIV treatment for young people is crucial.”

“This update to the always-pragmatic EACS guidelines further diverges from the United States Department of Health & Human Services guidelines,” Dr. Waters explained. “For 6 months, both guidelines preferred the same ... regimens for first-line therapy, but since DHSS removed raltegravir-based ART in June 2021 and EACS added doravirine-based regimens in October 2021, we’re back in the more familiar territory of EACS offering a broader range of preferred choices.”

Dr. Ryom noted that modern HIV care needs to consider managing coinfections, opportunistic diseases, comorbidities, aging, addictions, and mental health.

“Ensuring an integrated and personalized approach to HIV management is becoming increasingly important in an aging population living with HIV with the potential for complex needs,” she said.

The guidelines are available in several formats: as a free smartphone app, an interactive web version, and an online PDF.

Funding information was not provided. Dr. Ryom and several coauthors disclosed no relevant financial relationships. Most of the guideline coauthors declared financial relationships with pharmaceutical companies “outside the submitted work.” Dr. Waters provided no information on conflicts of interest.

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.

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.

Testing the DNA of antimicrobial-resistant Plasmodium falciparum in the blood of travelers from malaria-endemic regions may help researchers monitor how drug resistance changes over time, a study from Canada reports.

“Malaria remains the deadliest vector-borne infectious disease worldwide. Plasmodium spp., most commonly P. falciparum, are responsible for [approximately] 229 million cases and 500,000 deaths from malaria annually,” the authors write in Emerging Infectious Diseases.

“Our findings demonstrate an absence of genetic markers of resistance to the most powerful antimalarials on the planet – the artemisinins – in potentially deadly malaria imported primarily from sub-Saharan Africa over time. This is good news,” senior study author Andrea K. Boggild, MD, MSc, DTMH, told this news organization.

“We also showed that over 90% of falciparum malaria imports were resistant to the proguanil component of the fixed drug combination atovaquone-proguanil, a popular oral antimalarial that is first-line treatment for uncomplicated malaria in Canada,” Dr. Boggild, an associate professor in the department of medicine at the University of Toronto, Canada, added in an email. “We documented no genetic markers of atovaquone resistance.”
 

Search for global patterns of emerging drug resistance

Dr. Boggild, the medical director of the tropical disease unit at Toronto General Hospital, and colleagues analyzed 243 whole-blood specimens that contained P. falciparum and no other Plasmodium species from the malaria biobank at the Public Health Ontario Laboratory in Toronto. They analyzed specimens from the years 2008-2009, 2013-2014, and 2017-2018 from patients ranging in age from 3 to 88 years. Of the 186 patients with a documented travel history, 81 had traveled in West Africa, the most common region, and 40 in Nigeria, the most common country. Five specimens came from travelers to Southeast Asia, and one came from a traveler to the Caribbean.

The researchers extracted DNA from whole blood and detected the parasite’s DNA by real-time quantitative polymerase chain reaction (qPCR). They analyzed 23 different single-nucleotide polymorphisms (SNPs) in six genes, and quantified the prevalence of resistance markers, including genes that provoke resistance to the most common antimalarial drugs: chloroquine, mefloquine, atovaquone/proguanil, and the artemisinins.

They analyzed SNPs at atpase6 (pfATPase6), pfcrt (chloroquine resistance transporter, cytb (cytochrome b), dhfr (dihydrofolate reductase), dhps (dihydropteroate synthetase), mdr1 (multidrug resistance protein) and mdr1 copy number, and kelch13 (kelch protein gene on chromosome 13).

Over time, they detected increasing mutant genotypes for dhfr S108N (P = .001) and dhps A613T (P = .029) but decreasing mutant genotypes for mdr1 N86Y (P < .001), D1246Y (P = .003), pfcrt K76T (P = .011), and pfcrt 74-75 (P = .014). They found no kelch13 mutations. They detected fewer mutations indicating chloroquine resistance over time, suggesting less chloroquine pressure in specimens from travelers to Africa, but mutations that provided proguanil resistance increased.

“Antimalarial resistance – particularly resistance to the powerful artemisinins – continues to expand globally, and it is important to conduct routine surveillance for resistant parasites in order to inform appropriate prevention and treatment guidelines,” Dr. Boggild explained. “It cannot be presumed that a drug’s efficacy will be durable over time given the global landscape of antimalarial resistance.”

Dr. Boggild acknowledged limitations to the study, including incomplete travel history in about half of the patients, relatively few patients from Southeast Asia, and the small sample set.

“Clinicians caring for travelers before or after travel should familiarize themselves with the options for malaria prevention and treatment and understand the risk–benefit profile of each drug,” Dr. Boggild advised. 

“Resistance to proguanil means that we are reliant on the partner drug atovaquone for the antimalarial action of this formulation, which is effective only when taken with food,” she added.

Anne N. Cowell, MD, MPH, of the division of infectious diseases at the University of California, San Diego, was not surprised by the findings.

“The study demonstrates how quickly malaria parasites adapt and evolve to survive changes in malaria treatment,” Dr. Cowell, who was not involved in the study, told this news organization.

“These changes reflect changing malaria treatment and thus drug pressure during the time period,” she said in an email. “Because the majority of the clinical samples with a known travel history came from West Africa, and there was no clear evidence of artemisinin resistance in the area during the final time period studied, it is not surprising that they did not find kelch13 resistance mutations.

“The increase in mutations associated with proguanil resistance is concerning because atovaquone-proguanil is frequently used for prophylaxis during travel,” Dr. Cowell added. “There is no widespread evidence of resistance in travelers at this time, but it warrants monitoring.”

Sean C. Murphy, MD, PhD, an associate professor of laboratory medicine and the director of the malaria molecular diagnostic laboratory at the University of Washington in Seattle, also was not surprised by the study’s results.

“It may be just a matter of time before evidence of artemisinin resistance crops up among returning travelers,” he said in an email. “When that happens, we may lose the opportunity to easily use common go-to drugs like atovaquone/proguanil to treat these patients.

“The biggest takeaway of this study is the reminder that drug-resistant malaria (including the future potential for artemisinin-resistant malaria) is just an airplane flight or two away from nonendemic places like Canada and the United States,” Dr. Murphy noted. He was not involved with this Canadian study.

“Continued investment is needed to support malaria control, drug resistance monitoring, and vaccine efforts in order to fight this relentless, terrible parasite,” he urged.

The Project Initiation Fund of Public Health Ontario funded the study. The study authors, Dr. Cowell, and Dr. Murphy have disclosed no relevant financial relationships.  

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

Testing the DNA of antimicrobial-resistant Plasmodium falciparum in the blood of travelers from malaria-endemic regions may help researchers monitor how drug resistance changes over time, a study from Canada reports.

“Malaria remains the deadliest vector-borne infectious disease worldwide. Plasmodium spp., most commonly P. falciparum, are responsible for [approximately] 229 million cases and 500,000 deaths from malaria annually,” the authors write in Emerging Infectious Diseases.

“Our findings demonstrate an absence of genetic markers of resistance to the most powerful antimalarials on the planet – the artemisinins – in potentially deadly malaria imported primarily from sub-Saharan Africa over time. This is good news,” senior study author Andrea K. Boggild, MD, MSc, DTMH, told this news organization.

“We also showed that over 90% of falciparum malaria imports were resistant to the proguanil component of the fixed drug combination atovaquone-proguanil, a popular oral antimalarial that is first-line treatment for uncomplicated malaria in Canada,” Dr. Boggild, an associate professor in the department of medicine at the University of Toronto, Canada, added in an email. “We documented no genetic markers of atovaquone resistance.”
 

Search for global patterns of emerging drug resistance

Dr. Boggild, the medical director of the tropical disease unit at Toronto General Hospital, and colleagues analyzed 243 whole-blood specimens that contained P. falciparum and no other Plasmodium species from the malaria biobank at the Public Health Ontario Laboratory in Toronto. They analyzed specimens from the years 2008-2009, 2013-2014, and 2017-2018 from patients ranging in age from 3 to 88 years. Of the 186 patients with a documented travel history, 81 had traveled in West Africa, the most common region, and 40 in Nigeria, the most common country. Five specimens came from travelers to Southeast Asia, and one came from a traveler to the Caribbean.

The researchers extracted DNA from whole blood and detected the parasite’s DNA by real-time quantitative polymerase chain reaction (qPCR). They analyzed 23 different single-nucleotide polymorphisms (SNPs) in six genes, and quantified the prevalence of resistance markers, including genes that provoke resistance to the most common antimalarial drugs: chloroquine, mefloquine, atovaquone/proguanil, and the artemisinins.

They analyzed SNPs at atpase6 (pfATPase6), pfcrt (chloroquine resistance transporter, cytb (cytochrome b), dhfr (dihydrofolate reductase), dhps (dihydropteroate synthetase), mdr1 (multidrug resistance protein) and mdr1 copy number, and kelch13 (kelch protein gene on chromosome 13).

Over time, they detected increasing mutant genotypes for dhfr S108N (P = .001) and dhps A613T (P = .029) but decreasing mutant genotypes for mdr1 N86Y (P < .001), D1246Y (P = .003), pfcrt K76T (P = .011), and pfcrt 74-75 (P = .014). They found no kelch13 mutations. They detected fewer mutations indicating chloroquine resistance over time, suggesting less chloroquine pressure in specimens from travelers to Africa, but mutations that provided proguanil resistance increased.

“Antimalarial resistance – particularly resistance to the powerful artemisinins – continues to expand globally, and it is important to conduct routine surveillance for resistant parasites in order to inform appropriate prevention and treatment guidelines,” Dr. Boggild explained. “It cannot be presumed that a drug’s efficacy will be durable over time given the global landscape of antimalarial resistance.”

Dr. Boggild acknowledged limitations to the study, including incomplete travel history in about half of the patients, relatively few patients from Southeast Asia, and the small sample set.

“Clinicians caring for travelers before or after travel should familiarize themselves with the options for malaria prevention and treatment and understand the risk–benefit profile of each drug,” Dr. Boggild advised. 

“Resistance to proguanil means that we are reliant on the partner drug atovaquone for the antimalarial action of this formulation, which is effective only when taken with food,” she added.

Anne N. Cowell, MD, MPH, of the division of infectious diseases at the University of California, San Diego, was not surprised by the findings.

“The study demonstrates how quickly malaria parasites adapt and evolve to survive changes in malaria treatment,” Dr. Cowell, who was not involved in the study, told this news organization.

“These changes reflect changing malaria treatment and thus drug pressure during the time period,” she said in an email. “Because the majority of the clinical samples with a known travel history came from West Africa, and there was no clear evidence of artemisinin resistance in the area during the final time period studied, it is not surprising that they did not find kelch13 resistance mutations.

“The increase in mutations associated with proguanil resistance is concerning because atovaquone-proguanil is frequently used for prophylaxis during travel,” Dr. Cowell added. “There is no widespread evidence of resistance in travelers at this time, but it warrants monitoring.”

Sean C. Murphy, MD, PhD, an associate professor of laboratory medicine and the director of the malaria molecular diagnostic laboratory at the University of Washington in Seattle, also was not surprised by the study’s results.

“It may be just a matter of time before evidence of artemisinin resistance crops up among returning travelers,” he said in an email. “When that happens, we may lose the opportunity to easily use common go-to drugs like atovaquone/proguanil to treat these patients.

“The biggest takeaway of this study is the reminder that drug-resistant malaria (including the future potential for artemisinin-resistant malaria) is just an airplane flight or two away from nonendemic places like Canada and the United States,” Dr. Murphy noted. He was not involved with this Canadian study.

“Continued investment is needed to support malaria control, drug resistance monitoring, and vaccine efforts in order to fight this relentless, terrible parasite,” he urged.

The Project Initiation Fund of Public Health Ontario funded the study. The study authors, Dr. Cowell, and Dr. Murphy have disclosed no relevant financial relationships.  

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

Testing the DNA of antimicrobial-resistant Plasmodium falciparum in the blood of travelers from malaria-endemic regions may help researchers monitor how drug resistance changes over time, a study from Canada reports.

“Malaria remains the deadliest vector-borne infectious disease worldwide. Plasmodium spp., most commonly P. falciparum, are responsible for [approximately] 229 million cases and 500,000 deaths from malaria annually,” the authors write in Emerging Infectious Diseases.

“Our findings demonstrate an absence of genetic markers of resistance to the most powerful antimalarials on the planet – the artemisinins – in potentially deadly malaria imported primarily from sub-Saharan Africa over time. This is good news,” senior study author Andrea K. Boggild, MD, MSc, DTMH, told this news organization.

“We also showed that over 90% of falciparum malaria imports were resistant to the proguanil component of the fixed drug combination atovaquone-proguanil, a popular oral antimalarial that is first-line treatment for uncomplicated malaria in Canada,” Dr. Boggild, an associate professor in the department of medicine at the University of Toronto, Canada, added in an email. “We documented no genetic markers of atovaquone resistance.”
 

Search for global patterns of emerging drug resistance

Dr. Boggild, the medical director of the tropical disease unit at Toronto General Hospital, and colleagues analyzed 243 whole-blood specimens that contained P. falciparum and no other Plasmodium species from the malaria biobank at the Public Health Ontario Laboratory in Toronto. They analyzed specimens from the years 2008-2009, 2013-2014, and 2017-2018 from patients ranging in age from 3 to 88 years. Of the 186 patients with a documented travel history, 81 had traveled in West Africa, the most common region, and 40 in Nigeria, the most common country. Five specimens came from travelers to Southeast Asia, and one came from a traveler to the Caribbean.

The researchers extracted DNA from whole blood and detected the parasite’s DNA by real-time quantitative polymerase chain reaction (qPCR). They analyzed 23 different single-nucleotide polymorphisms (SNPs) in six genes, and quantified the prevalence of resistance markers, including genes that provoke resistance to the most common antimalarial drugs: chloroquine, mefloquine, atovaquone/proguanil, and the artemisinins.

They analyzed SNPs at atpase6 (pfATPase6), pfcrt (chloroquine resistance transporter, cytb (cytochrome b), dhfr (dihydrofolate reductase), dhps (dihydropteroate synthetase), mdr1 (multidrug resistance protein) and mdr1 copy number, and kelch13 (kelch protein gene on chromosome 13).

Over time, they detected increasing mutant genotypes for dhfr S108N (P = .001) and dhps A613T (P = .029) but decreasing mutant genotypes for mdr1 N86Y (P < .001), D1246Y (P = .003), pfcrt K76T (P = .011), and pfcrt 74-75 (P = .014). They found no kelch13 mutations. They detected fewer mutations indicating chloroquine resistance over time, suggesting less chloroquine pressure in specimens from travelers to Africa, but mutations that provided proguanil resistance increased.

“Antimalarial resistance – particularly resistance to the powerful artemisinins – continues to expand globally, and it is important to conduct routine surveillance for resistant parasites in order to inform appropriate prevention and treatment guidelines,” Dr. Boggild explained. “It cannot be presumed that a drug’s efficacy will be durable over time given the global landscape of antimalarial resistance.”

Dr. Boggild acknowledged limitations to the study, including incomplete travel history in about half of the patients, relatively few patients from Southeast Asia, and the small sample set.

“Clinicians caring for travelers before or after travel should familiarize themselves with the options for malaria prevention and treatment and understand the risk–benefit profile of each drug,” Dr. Boggild advised. 

“Resistance to proguanil means that we are reliant on the partner drug atovaquone for the antimalarial action of this formulation, which is effective only when taken with food,” she added.

Anne N. Cowell, MD, MPH, of the division of infectious diseases at the University of California, San Diego, was not surprised by the findings.

“The study demonstrates how quickly malaria parasites adapt and evolve to survive changes in malaria treatment,” Dr. Cowell, who was not involved in the study, told this news organization.

“These changes reflect changing malaria treatment and thus drug pressure during the time period,” she said in an email. “Because the majority of the clinical samples with a known travel history came from West Africa, and there was no clear evidence of artemisinin resistance in the area during the final time period studied, it is not surprising that they did not find kelch13 resistance mutations.

“The increase in mutations associated with proguanil resistance is concerning because atovaquone-proguanil is frequently used for prophylaxis during travel,” Dr. Cowell added. “There is no widespread evidence of resistance in travelers at this time, but it warrants monitoring.”

Sean C. Murphy, MD, PhD, an associate professor of laboratory medicine and the director of the malaria molecular diagnostic laboratory at the University of Washington in Seattle, also was not surprised by the study’s results.

“It may be just a matter of time before evidence of artemisinin resistance crops up among returning travelers,” he said in an email. “When that happens, we may lose the opportunity to easily use common go-to drugs like atovaquone/proguanil to treat these patients.

“The biggest takeaway of this study is the reminder that drug-resistant malaria (including the future potential for artemisinin-resistant malaria) is just an airplane flight or two away from nonendemic places like Canada and the United States,” Dr. Murphy noted. He was not involved with this Canadian study.

“Continued investment is needed to support malaria control, drug resistance monitoring, and vaccine efforts in order to fight this relentless, terrible parasite,” he urged.

The Project Initiation Fund of Public Health Ontario funded the study. The study authors, Dr. Cowell, and Dr. Murphy have disclosed no relevant financial relationships.  

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

Hospitalized patients who are asymptomatic Clostridioides difficile carriers may infect people they live with after they return home, a study based on U.S. insurance claim data suggests.

Although C. difficile infection (CDI) is considered to be a common hospital-acquired infection, reports of community-associated CDI in patients who have not been hospitalized are increasing, the authors wrote in Emerging Infectious Diseases.

“Individuals in households where another family member was recently hospitalized but not diagnosed with a CDI appear to be at increased risk for CDI,” said lead author Aaron C. Miller, PhD, a research assistant professor in the department of internal medicine at the University of Iowa, Iowa City. “When individuals are hospitalized, they may become colonized with C. difficile without developing symptoms and subsequently transmit the pathogen to other family members after they return home,” he said by email.

Dr. Miller and colleagues analyzed insurance claims data from 2001 through 2017 using the U.S. Commercial Claims and Medicare Supplemental datasets of IBM MarketScan Research Databases. Over that period, they searched employer-sponsored commercial insurance claims and Medicare supplemental claims of 194,424 enrollees, and they linked claims from multiple family members in the same enrollment plan.

They identified 224,818 CDI cases, and 3,871 of them were considered potential asymptomatic C. difficile transmissions from a recently hospitalized family member.

The researchers gathered monthly C. difficile incidence data from households with a family member who had been hospitalized within the past 60 days and compared them with data from households without a hospitalized family member.

Enrollees exposed to a recently hospitalized family member had a 73% greater incidence of CDI compared with enrollees who were not exposed. The longer the family member’s hospital stay, the greater the risk that someone in the household became infected.

Compared with people whose family members were hospitalized less than 1 day, people whose family members were hospitalized from 1 to 3 days had an incidence rate ratio (IRR) of 1.30 (95% confidence interval [CI], 1.19-1.41), and those whose family members were hospitalized for more than 30 days had an IRR of 2.45 (95% CI, 1.66-3.60).

CDI incidence increased with age. Compared with people 17 years of age or younger, the IRR increased to 9.32 (95% CI, 8.92-9.73) for those over 65.

Females had higher CDI incidence than males (IRR 1.30; 95% CI, 1.28-1.33).

Households with an infant also had higher CDI incidence than those without (IRR 1.5; 95% CI, 1.44-1.58).

People taking antimicrobials had higher CDI IRRs: 2.69 (95% CI, 2.59-2.79) for low-CDI-risk antibiotics and 8.83 (95% CI, 8.63-9.03) for high-CDI-risk antibiotics.

People taking proton-pump inhibitors had an IRR of 2.23 (95% CI, 2.15-2.30).
 

Reactions from four experts

Douglas S. Paauw MD, MACP, professor of medicine and the chair for patient-centered clinical education at the University of Washington, Seattle, was not surprised by the findings. “We have wondered for a while how community-acquired CDI occurs,” he said in an email. “This important study offers a plausible explanation for some cases.”

Dr. Paauw advises doctors to consider CDI in their patients who have been exposed to hospitalized people.

David M. Aronoff, MD, FIDSA, FAAM, professor of medicine and the chair of the department of medicine at Indiana University, Indianapolis, advises providers to educate hospital patients being discharged about how CDI is spread and how they can practice good hand hygiene at home.

“An open question of this strong study is whether we should be testing certain hospital patients for asymptomatic C. difficile carriage before they are discharged,” he added in an email.

In a phone interview, Paul G. Auwaerter, MD, MBA, professor of medicine and clinical director of the division of infectious diseases at Johns Hopkins University, Baltimore, noted that community-acquired CDI is frequent enough that his institution performs routine C. difficile testing on all patients with unexplained severe diarrhea.

“This intriguing study bears additional research and follow-up because clearly these spores are hardy,” he said. “But a key point in this billings- and claims-based study is that no one knows where household members acquired CDI, whether it was actually through household transmission.”

Ramin Asgary, MD, MPH, FASTMH, associate professor of global health in the Milken Institute School of Public Health at George Washington University, Washington, cautioned about “an increasing issue with drug-resistant CDI.

“This important, timely study provides another step in the right direction to better understanding and addressing CDI and other hospital-based infections that have become increasing threats to the safety of our patients, their families, and health care in general,” he said in an email.

Dr. Miller said that the scale and scope of the data are strengths of the study, and he acknowledged that its basis in claims and billing data is a limitation. He and his group plan to explore genetic relationships involved in CDI transmission.

The study was funded by the Centers for Disease Control and Prevention. All authors and independent experts have disclosed no relevant financial relationships.

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

Hospitalized patients who are asymptomatic Clostridioides difficile carriers may infect people they live with after they return home, a study based on U.S. insurance claim data suggests.

Although C. difficile infection (CDI) is considered to be a common hospital-acquired infection, reports of community-associated CDI in patients who have not been hospitalized are increasing, the authors wrote in Emerging Infectious Diseases.

“Individuals in households where another family member was recently hospitalized but not diagnosed with a CDI appear to be at increased risk for CDI,” said lead author Aaron C. Miller, PhD, a research assistant professor in the department of internal medicine at the University of Iowa, Iowa City. “When individuals are hospitalized, they may become colonized with C. difficile without developing symptoms and subsequently transmit the pathogen to other family members after they return home,” he said by email.

Dr. Miller and colleagues analyzed insurance claims data from 2001 through 2017 using the U.S. Commercial Claims and Medicare Supplemental datasets of IBM MarketScan Research Databases. Over that period, they searched employer-sponsored commercial insurance claims and Medicare supplemental claims of 194,424 enrollees, and they linked claims from multiple family members in the same enrollment plan.

They identified 224,818 CDI cases, and 3,871 of them were considered potential asymptomatic C. difficile transmissions from a recently hospitalized family member.

The researchers gathered monthly C. difficile incidence data from households with a family member who had been hospitalized within the past 60 days and compared them with data from households without a hospitalized family member.

Enrollees exposed to a recently hospitalized family member had a 73% greater incidence of CDI compared with enrollees who were not exposed. The longer the family member’s hospital stay, the greater the risk that someone in the household became infected.

Compared with people whose family members were hospitalized less than 1 day, people whose family members were hospitalized from 1 to 3 days had an incidence rate ratio (IRR) of 1.30 (95% confidence interval [CI], 1.19-1.41), and those whose family members were hospitalized for more than 30 days had an IRR of 2.45 (95% CI, 1.66-3.60).

CDI incidence increased with age. Compared with people 17 years of age or younger, the IRR increased to 9.32 (95% CI, 8.92-9.73) for those over 65.

Females had higher CDI incidence than males (IRR 1.30; 95% CI, 1.28-1.33).

Households with an infant also had higher CDI incidence than those without (IRR 1.5; 95% CI, 1.44-1.58).

People taking antimicrobials had higher CDI IRRs: 2.69 (95% CI, 2.59-2.79) for low-CDI-risk antibiotics and 8.83 (95% CI, 8.63-9.03) for high-CDI-risk antibiotics.

People taking proton-pump inhibitors had an IRR of 2.23 (95% CI, 2.15-2.30).
 

Reactions from four experts

Douglas S. Paauw MD, MACP, professor of medicine and the chair for patient-centered clinical education at the University of Washington, Seattle, was not surprised by the findings. “We have wondered for a while how community-acquired CDI occurs,” he said in an email. “This important study offers a plausible explanation for some cases.”

Dr. Paauw advises doctors to consider CDI in their patients who have been exposed to hospitalized people.

David M. Aronoff, MD, FIDSA, FAAM, professor of medicine and the chair of the department of medicine at Indiana University, Indianapolis, advises providers to educate hospital patients being discharged about how CDI is spread and how they can practice good hand hygiene at home.

“An open question of this strong study is whether we should be testing certain hospital patients for asymptomatic C. difficile carriage before they are discharged,” he added in an email.

In a phone interview, Paul G. Auwaerter, MD, MBA, professor of medicine and clinical director of the division of infectious diseases at Johns Hopkins University, Baltimore, noted that community-acquired CDI is frequent enough that his institution performs routine C. difficile testing on all patients with unexplained severe diarrhea.

“This intriguing study bears additional research and follow-up because clearly these spores are hardy,” he said. “But a key point in this billings- and claims-based study is that no one knows where household members acquired CDI, whether it was actually through household transmission.”

Ramin Asgary, MD, MPH, FASTMH, associate professor of global health in the Milken Institute School of Public Health at George Washington University, Washington, cautioned about “an increasing issue with drug-resistant CDI.

“This important, timely study provides another step in the right direction to better understanding and addressing CDI and other hospital-based infections that have become increasing threats to the safety of our patients, their families, and health care in general,” he said in an email.

Dr. Miller said that the scale and scope of the data are strengths of the study, and he acknowledged that its basis in claims and billing data is a limitation. He and his group plan to explore genetic relationships involved in CDI transmission.

The study was funded by the Centers for Disease Control and Prevention. All authors and independent experts have disclosed no relevant financial relationships.

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

Hospitalized patients who are asymptomatic Clostridioides difficile carriers may infect people they live with after they return home, a study based on U.S. insurance claim data suggests.

Although C. difficile infection (CDI) is considered to be a common hospital-acquired infection, reports of community-associated CDI in patients who have not been hospitalized are increasing, the authors wrote in Emerging Infectious Diseases.

“Individuals in households where another family member was recently hospitalized but not diagnosed with a CDI appear to be at increased risk for CDI,” said lead author Aaron C. Miller, PhD, a research assistant professor in the department of internal medicine at the University of Iowa, Iowa City. “When individuals are hospitalized, they may become colonized with C. difficile without developing symptoms and subsequently transmit the pathogen to other family members after they return home,” he said by email.

Dr. Miller and colleagues analyzed insurance claims data from 2001 through 2017 using the U.S. Commercial Claims and Medicare Supplemental datasets of IBM MarketScan Research Databases. Over that period, they searched employer-sponsored commercial insurance claims and Medicare supplemental claims of 194,424 enrollees, and they linked claims from multiple family members in the same enrollment plan.

They identified 224,818 CDI cases, and 3,871 of them were considered potential asymptomatic C. difficile transmissions from a recently hospitalized family member.

The researchers gathered monthly C. difficile incidence data from households with a family member who had been hospitalized within the past 60 days and compared them with data from households without a hospitalized family member.

Enrollees exposed to a recently hospitalized family member had a 73% greater incidence of CDI compared with enrollees who were not exposed. The longer the family member’s hospital stay, the greater the risk that someone in the household became infected.

Compared with people whose family members were hospitalized less than 1 day, people whose family members were hospitalized from 1 to 3 days had an incidence rate ratio (IRR) of 1.30 (95% confidence interval [CI], 1.19-1.41), and those whose family members were hospitalized for more than 30 days had an IRR of 2.45 (95% CI, 1.66-3.60).

CDI incidence increased with age. Compared with people 17 years of age or younger, the IRR increased to 9.32 (95% CI, 8.92-9.73) for those over 65.

Females had higher CDI incidence than males (IRR 1.30; 95% CI, 1.28-1.33).

Households with an infant also had higher CDI incidence than those without (IRR 1.5; 95% CI, 1.44-1.58).

People taking antimicrobials had higher CDI IRRs: 2.69 (95% CI, 2.59-2.79) for low-CDI-risk antibiotics and 8.83 (95% CI, 8.63-9.03) for high-CDI-risk antibiotics.

People taking proton-pump inhibitors had an IRR of 2.23 (95% CI, 2.15-2.30).
 

Reactions from four experts

Douglas S. Paauw MD, MACP, professor of medicine and the chair for patient-centered clinical education at the University of Washington, Seattle, was not surprised by the findings. “We have wondered for a while how community-acquired CDI occurs,” he said in an email. “This important study offers a plausible explanation for some cases.”

Dr. Paauw advises doctors to consider CDI in their patients who have been exposed to hospitalized people.

David M. Aronoff, MD, FIDSA, FAAM, professor of medicine and the chair of the department of medicine at Indiana University, Indianapolis, advises providers to educate hospital patients being discharged about how CDI is spread and how they can practice good hand hygiene at home.

“An open question of this strong study is whether we should be testing certain hospital patients for asymptomatic C. difficile carriage before they are discharged,” he added in an email.

In a phone interview, Paul G. Auwaerter, MD, MBA, professor of medicine and clinical director of the division of infectious diseases at Johns Hopkins University, Baltimore, noted that community-acquired CDI is frequent enough that his institution performs routine C. difficile testing on all patients with unexplained severe diarrhea.

“This intriguing study bears additional research and follow-up because clearly these spores are hardy,” he said. “But a key point in this billings- and claims-based study is that no one knows where household members acquired CDI, whether it was actually through household transmission.”

Ramin Asgary, MD, MPH, FASTMH, associate professor of global health in the Milken Institute School of Public Health at George Washington University, Washington, cautioned about “an increasing issue with drug-resistant CDI.

“This important, timely study provides another step in the right direction to better understanding and addressing CDI and other hospital-based infections that have become increasing threats to the safety of our patients, their families, and health care in general,” he said in an email.

Dr. Miller said that the scale and scope of the data are strengths of the study, and he acknowledged that its basis in claims and billing data is a limitation. He and his group plan to explore genetic relationships involved in CDI transmission.

The study was funded by the Centers for Disease Control and Prevention. All authors and independent experts have disclosed no relevant financial relationships.

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

When polio paralyzed a 3-year-old girl in Lilongwe, Malawi, in November 2021, public health experts in Malawi’s Ministry of Health responded quickly. The ministry partnered with the Global Polio Eradication Initiative, the World Health Organization, and the United Nations International Children’s Emergency Fund to mobilize a surge team of personnel and resources to vaccinate all 2.9 million Malawian children aged under 5 years, WHO reported in a news release.

The first of four sequential campaigns began on March 20 and expanded on March 24 to neighboring Mozambique, Tanzania, and Zambia. The multinational, multiagency effort aims to include Zimbabwean children as well and deliver over 80 million supplemental doses of bivalent oral polio vaccines to over 23 million children in these five countries by July.

Because it takes multiple polio vaccine doses to become fully immunized, the children are expected to receive four rounds of vaccine regardless of their vaccination history.

“It is important to conduct the campaigns now to boost the immunity of our children,” Annie Chauma-Mwale, MBBS, MPH, the chief medical officer of epidemiology and surveillance in Malawi’s Ministry of Health in Lilongwe, said in an interview. “Polio is not only a medical issue. Polio is also a socioeconomic issue with long-term impacts on the child, the country, and the globe.

“In Malawi, we are using our community health and health care facility structures to ensure we do not miss any eligible child,” explained Dr. Chauma-Mwale, who is also the deputy incident manager of the poliovirus outbreak response. “We aim to play our role in the global eradication of polio by protecting the vulnerable and curtailing any potential transmission as early as possible.”

Of the three variants of wild, naturally occurring poliovirus, types 2 and 3 have been eradicated, but wild poliovirus type 1 (WPV1) remains endemic in Afghanistan and Pakistan.

As reported recently by this news organization, the girl in Malawi was infected with a WPV1 strain that had been circulating for years in Pakistan’s Sindh Province.

Malawi’s most recent clinically confirmed WPV1 case was reported in 1992, and this is the first WPV1 case detected in Africa since 2016. The continent was declared free of indigenous wild polio in 2020 and is still considered free of wild poliovirus because the child’s illness was imported from elsewhere.

The 3-year-old girl developed acute flaccid paralysis in November 2021. In February 2022, virus from her stool was sequenced by the National Institute of Communicable Disease in South Africa and the U.S. Centers for Disease Control and Prevention. On Feb. 16, Malawi was notified of the case, which was genetically linked to a sequence detected in Sindh Province around 2 years earlier.
 

‘Do not ignore polio’

Within 24 hours, the Government of Malawi declared a public health emergency and activated the national Emergency Operations Centre. Within 72 hours, the GPEI rapid response team arrived in the country. The Ministry of Health partnered with GPEI, WHO, and UNICEF to mobilize the campaign and begin vaccinating children on March 20.

‘’We rely on clinicians to support the surveillance of polio through case searches, both active and passive,” Mike Nenani Chisema, MBBS, MPH, the program manager of the expanded program on immunization and the polio response operations manager in Malawi’s Ministry of Health, said in an interview.

He noted that the young girl was diagnosed correctly and millions of children are now being protected against the disease, thanks to the acumen of one hospital clinician.

“Remember, we still have polio in some countries, and every country is at risk,” he cautioned. “Don’t forget to look for the obvious and do not ignore polio, regardless of economic status.’’

According to GPEI, all countries – especially those with weak immunization and other public health programs whose residents trade or travel to and from endemic countries – are at risk for imported polio.

Anita Gupta, DO, MPP, PharmD, an adjunct assistant professor of anesthesiology and critical care medicine and pain medicine at the Johns Hopkins University, Baltimore, said that she welcomes this effort.

“Given the decades of published evidence and understanding on the vaccine’s safety and efficacy, this program in Malawi is the right step to take,” Gupta, who is not involved in the campaigns, said in an interview. “Polio is preventable, and acting now will prevent spread later.”

Dr. Chauma-Mwale and Dr. Chisema are employees of Malawi’s Ministry of Health. Dr. Gupta disclosed no relevant financial relationships.

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

When polio paralyzed a 3-year-old girl in Lilongwe, Malawi, in November 2021, public health experts in Malawi’s Ministry of Health responded quickly. The ministry partnered with the Global Polio Eradication Initiative, the World Health Organization, and the United Nations International Children’s Emergency Fund to mobilize a surge team of personnel and resources to vaccinate all 2.9 million Malawian children aged under 5 years, WHO reported in a news release.

The first of four sequential campaigns began on March 20 and expanded on March 24 to neighboring Mozambique, Tanzania, and Zambia. The multinational, multiagency effort aims to include Zimbabwean children as well and deliver over 80 million supplemental doses of bivalent oral polio vaccines to over 23 million children in these five countries by July.

Because it takes multiple polio vaccine doses to become fully immunized, the children are expected to receive four rounds of vaccine regardless of their vaccination history.

“It is important to conduct the campaigns now to boost the immunity of our children,” Annie Chauma-Mwale, MBBS, MPH, the chief medical officer of epidemiology and surveillance in Malawi’s Ministry of Health in Lilongwe, said in an interview. “Polio is not only a medical issue. Polio is also a socioeconomic issue with long-term impacts on the child, the country, and the globe.

“In Malawi, we are using our community health and health care facility structures to ensure we do not miss any eligible child,” explained Dr. Chauma-Mwale, who is also the deputy incident manager of the poliovirus outbreak response. “We aim to play our role in the global eradication of polio by protecting the vulnerable and curtailing any potential transmission as early as possible.”

Of the three variants of wild, naturally occurring poliovirus, types 2 and 3 have been eradicated, but wild poliovirus type 1 (WPV1) remains endemic in Afghanistan and Pakistan.

As reported recently by this news organization, the girl in Malawi was infected with a WPV1 strain that had been circulating for years in Pakistan’s Sindh Province.

Malawi’s most recent clinically confirmed WPV1 case was reported in 1992, and this is the first WPV1 case detected in Africa since 2016. The continent was declared free of indigenous wild polio in 2020 and is still considered free of wild poliovirus because the child’s illness was imported from elsewhere.

The 3-year-old girl developed acute flaccid paralysis in November 2021. In February 2022, virus from her stool was sequenced by the National Institute of Communicable Disease in South Africa and the U.S. Centers for Disease Control and Prevention. On Feb. 16, Malawi was notified of the case, which was genetically linked to a sequence detected in Sindh Province around 2 years earlier.
 

‘Do not ignore polio’

Within 24 hours, the Government of Malawi declared a public health emergency and activated the national Emergency Operations Centre. Within 72 hours, the GPEI rapid response team arrived in the country. The Ministry of Health partnered with GPEI, WHO, and UNICEF to mobilize the campaign and begin vaccinating children on March 20.

‘’We rely on clinicians to support the surveillance of polio through case searches, both active and passive,” Mike Nenani Chisema, MBBS, MPH, the program manager of the expanded program on immunization and the polio response operations manager in Malawi’s Ministry of Health, said in an interview.

He noted that the young girl was diagnosed correctly and millions of children are now being protected against the disease, thanks to the acumen of one hospital clinician.

“Remember, we still have polio in some countries, and every country is at risk,” he cautioned. “Don’t forget to look for the obvious and do not ignore polio, regardless of economic status.’’

According to GPEI, all countries – especially those with weak immunization and other public health programs whose residents trade or travel to and from endemic countries – are at risk for imported polio.

Anita Gupta, DO, MPP, PharmD, an adjunct assistant professor of anesthesiology and critical care medicine and pain medicine at the Johns Hopkins University, Baltimore, said that she welcomes this effort.

“Given the decades of published evidence and understanding on the vaccine’s safety and efficacy, this program in Malawi is the right step to take,” Gupta, who is not involved in the campaigns, said in an interview. “Polio is preventable, and acting now will prevent spread later.”

Dr. Chauma-Mwale and Dr. Chisema are employees of Malawi’s Ministry of Health. Dr. Gupta disclosed no relevant financial relationships.

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

When polio paralyzed a 3-year-old girl in Lilongwe, Malawi, in November 2021, public health experts in Malawi’s Ministry of Health responded quickly. The ministry partnered with the Global Polio Eradication Initiative, the World Health Organization, and the United Nations International Children’s Emergency Fund to mobilize a surge team of personnel and resources to vaccinate all 2.9 million Malawian children aged under 5 years, WHO reported in a news release.

The first of four sequential campaigns began on March 20 and expanded on March 24 to neighboring Mozambique, Tanzania, and Zambia. The multinational, multiagency effort aims to include Zimbabwean children as well and deliver over 80 million supplemental doses of bivalent oral polio vaccines to over 23 million children in these five countries by July.

Because it takes multiple polio vaccine doses to become fully immunized, the children are expected to receive four rounds of vaccine regardless of their vaccination history.

“It is important to conduct the campaigns now to boost the immunity of our children,” Annie Chauma-Mwale, MBBS, MPH, the chief medical officer of epidemiology and surveillance in Malawi’s Ministry of Health in Lilongwe, said in an interview. “Polio is not only a medical issue. Polio is also a socioeconomic issue with long-term impacts on the child, the country, and the globe.

“In Malawi, we are using our community health and health care facility structures to ensure we do not miss any eligible child,” explained Dr. Chauma-Mwale, who is also the deputy incident manager of the poliovirus outbreak response. “We aim to play our role in the global eradication of polio by protecting the vulnerable and curtailing any potential transmission as early as possible.”

Of the three variants of wild, naturally occurring poliovirus, types 2 and 3 have been eradicated, but wild poliovirus type 1 (WPV1) remains endemic in Afghanistan and Pakistan.

As reported recently by this news organization, the girl in Malawi was infected with a WPV1 strain that had been circulating for years in Pakistan’s Sindh Province.

Malawi’s most recent clinically confirmed WPV1 case was reported in 1992, and this is the first WPV1 case detected in Africa since 2016. The continent was declared free of indigenous wild polio in 2020 and is still considered free of wild poliovirus because the child’s illness was imported from elsewhere.

The 3-year-old girl developed acute flaccid paralysis in November 2021. In February 2022, virus from her stool was sequenced by the National Institute of Communicable Disease in South Africa and the U.S. Centers for Disease Control and Prevention. On Feb. 16, Malawi was notified of the case, which was genetically linked to a sequence detected in Sindh Province around 2 years earlier.
 

‘Do not ignore polio’

Within 24 hours, the Government of Malawi declared a public health emergency and activated the national Emergency Operations Centre. Within 72 hours, the GPEI rapid response team arrived in the country. The Ministry of Health partnered with GPEI, WHO, and UNICEF to mobilize the campaign and begin vaccinating children on March 20.

‘’We rely on clinicians to support the surveillance of polio through case searches, both active and passive,” Mike Nenani Chisema, MBBS, MPH, the program manager of the expanded program on immunization and the polio response operations manager in Malawi’s Ministry of Health, said in an interview.

He noted that the young girl was diagnosed correctly and millions of children are now being protected against the disease, thanks to the acumen of one hospital clinician.

“Remember, we still have polio in some countries, and every country is at risk,” he cautioned. “Don’t forget to look for the obvious and do not ignore polio, regardless of economic status.’’

According to GPEI, all countries – especially those with weak immunization and other public health programs whose residents trade or travel to and from endemic countries – are at risk for imported polio.

Anita Gupta, DO, MPP, PharmD, an adjunct assistant professor of anesthesiology and critical care medicine and pain medicine at the Johns Hopkins University, Baltimore, said that she welcomes this effort.

“Given the decades of published evidence and understanding on the vaccine’s safety and efficacy, this program in Malawi is the right step to take,” Gupta, who is not involved in the campaigns, said in an interview. “Polio is preventable, and acting now will prevent spread later.”

Dr. Chauma-Mwale and Dr. Chisema are employees of Malawi’s Ministry of Health. Dr. Gupta disclosed no relevant financial relationships.

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

Third-party vendor physicians appear to be more much more likely than their system-employed counterparts to prescribe antibiotics during acute care telehealth visits for acute respiratory infection (ARI), according to a study in the Journal of Telemedicine and Telecare.

As health systems expand their direct-to-consumer (DTC) virtual care, the quality of that care seems to vary, write the authors. Patients with ARI symptoms make up about one-third of virtual visits. Prescribing practice is a commonly cited measure of care quality for ARI, which is usually viral and rarely benefits from antibiotics.

“When providing care through telehealth, hospital-affiliated emergency physicians practiced better antibiotic stewardship than vendor-supplied, non–hospital-affiliated physicians,” lead study author Kathleen Li, MD, MS, a clinical lecturer in the department of emergency medicine at the University of Michigan, Ann Arbor, told this news organization.

“We had a sense that a difference existed, but the magnitude of the difference was larger than expected,” she said.

Dr. Li and her colleagues retrospectively analyzed on-demand telehealth visits available to health system employees and dependents of a large urban academic health system from March 2018, when the service began, through July 2019.

All 16 affiliated physicians providing ARI care were board-certified in emergency medicine, compared with 2 (8%) of the 25 unaffiliated (vendor-employed) physicians. Most unaffiliated physicians were known to be board-certified in family medicine, internal medicine, or pediatrics.

Unaffiliated physicians were not given access to the health system’s electronic medical record. Instead, all their patient histories, exams, assessments, plans, impressions, and discharge instructions were scanned into the electronic medical record system by other staff the next day.
 

Unaffiliated doctors were more than twice as likely to prescribe antibiotics

The researchers extracted data on all 257 virtual ARI visits from the electronic health record system, including prescriptions and medication therapeutic class. They performed multivariable logistic regression, adjusting for patient age and time of visit (weekday vs. weekend; day vs. overnight).

Antibiotic prescription rates were similar between weekday and weekend visits, and between day and night visits. Regardless of provider status, older patients were more likely to be prescribed antibiotics (P = .01). 

Overall, affiliated physicians prescribed antibiotics during 18% of visits, whereas vendor physicians prescribed antibiotics during 37% of visits. After adjustments, the odds were 2.3 times higher that a patient in a telehealth visit with a vendor provider would be prescribed antibiotics (95% confidence interval, 1.1-4.5).

The predicted antibiotic prescribing rate for ARI was 19% (95% confidence interval, 13%-25%) for affiliated providers vs. 35% (95% CI, 22%-47%) for unaffiliated providers, an average marginal effect of 15% (95% CI, 2%-29%). The difference was even greater (average marginal effect 20%, 95% CI, 4%-35%) when children and patients over 65 were excluded.
 

Consistent, high-quality care and antibiotic stewardship are needed in all settings

Three experts who were not involved in the study commented on the study.

Joshua W. Elder, MD, MPH, MHS, medical director of Telehealth Express Care (direct-to-consumer telemedicine) at UC Davis Health in Sacramento, Calif., said, “An important unanswered question is how factors such as communication (policy and procedures, practice guidelines), connection (electronic health records), and reimbursement and incentives that health system and vendor-based providers received impacted this outcome.

“As the volume of virtual practices grows, most health systems will need to create a hybrid between health-system-employed and vendor-and/or-payer-supplied physicians,” he added. “Finding ways to create similar quality and outcomes will be essential in the evolving digital health infrastructure being developed.”

Charles Teixeira, DO, an infectious disease specialist at the Medical University of South Carolina in Charleston, said that this study highlighted the need to consistently provide high-quality, evidence-based care regardless of the encounter setting.

“It was important to compare the prescribing practices for commonly used medications, especially those as important as antibiotics,” he added. “Overprescribing antibiotics can have a progressive, long-term effect on a community and increase the risk for patients to develop multidrug-resistant bacteria.”

Jeffrey A. Linder, MD, MPH, the chief of general internal medicine and geriatrics in the department of medicine at Northwestern University in Chicago, commended the authors for investigating the quality of telehealth.

“The major limitation,” he found, “is that the investigators lumped all ARI visits – including those that are potentially antibiotic appropriate (e.g., otitis media, pharyngitis, sinusitis), those that are non–antibiotic appropriate (e.g., bronchitis, influenza, laryngitis, URI, viral syndrome), and those that are nonspecific symptoms (e.g., cough, congestion, fever, sore throat) – into the same category.”

No clinical information was collected or presented that would enable the reader to tell if these two groups of physicians were evaluating different patient populations or even if they just diagnosed patients differently,” he added.

“Our study did not delve into why we saw the difference,” Dr. Li explained. “Exploring potential reasons further will have important implications for how to optimally deliver care via telehealth.”

All authors and independent experts have disclosed no relevant financial relationships. The study received no financial support.

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

Third-party vendor physicians appear to be more much more likely than their system-employed counterparts to prescribe antibiotics during acute care telehealth visits for acute respiratory infection (ARI), according to a study in the Journal of Telemedicine and Telecare.

As health systems expand their direct-to-consumer (DTC) virtual care, the quality of that care seems to vary, write the authors. Patients with ARI symptoms make up about one-third of virtual visits. Prescribing practice is a commonly cited measure of care quality for ARI, which is usually viral and rarely benefits from antibiotics.

“When providing care through telehealth, hospital-affiliated emergency physicians practiced better antibiotic stewardship than vendor-supplied, non–hospital-affiliated physicians,” lead study author Kathleen Li, MD, MS, a clinical lecturer in the department of emergency medicine at the University of Michigan, Ann Arbor, told this news organization.

“We had a sense that a difference existed, but the magnitude of the difference was larger than expected,” she said.

Dr. Li and her colleagues retrospectively analyzed on-demand telehealth visits available to health system employees and dependents of a large urban academic health system from March 2018, when the service began, through July 2019.

All 16 affiliated physicians providing ARI care were board-certified in emergency medicine, compared with 2 (8%) of the 25 unaffiliated (vendor-employed) physicians. Most unaffiliated physicians were known to be board-certified in family medicine, internal medicine, or pediatrics.

Unaffiliated physicians were not given access to the health system’s electronic medical record. Instead, all their patient histories, exams, assessments, plans, impressions, and discharge instructions were scanned into the electronic medical record system by other staff the next day.
 

Unaffiliated doctors were more than twice as likely to prescribe antibiotics

The researchers extracted data on all 257 virtual ARI visits from the electronic health record system, including prescriptions and medication therapeutic class. They performed multivariable logistic regression, adjusting for patient age and time of visit (weekday vs. weekend; day vs. overnight).

Antibiotic prescription rates were similar between weekday and weekend visits, and between day and night visits. Regardless of provider status, older patients were more likely to be prescribed antibiotics (P = .01). 

Overall, affiliated physicians prescribed antibiotics during 18% of visits, whereas vendor physicians prescribed antibiotics during 37% of visits. After adjustments, the odds were 2.3 times higher that a patient in a telehealth visit with a vendor provider would be prescribed antibiotics (95% confidence interval, 1.1-4.5).

The predicted antibiotic prescribing rate for ARI was 19% (95% confidence interval, 13%-25%) for affiliated providers vs. 35% (95% CI, 22%-47%) for unaffiliated providers, an average marginal effect of 15% (95% CI, 2%-29%). The difference was even greater (average marginal effect 20%, 95% CI, 4%-35%) when children and patients over 65 were excluded.
 

Consistent, high-quality care and antibiotic stewardship are needed in all settings

Three experts who were not involved in the study commented on the study.

Joshua W. Elder, MD, MPH, MHS, medical director of Telehealth Express Care (direct-to-consumer telemedicine) at UC Davis Health in Sacramento, Calif., said, “An important unanswered question is how factors such as communication (policy and procedures, practice guidelines), connection (electronic health records), and reimbursement and incentives that health system and vendor-based providers received impacted this outcome.

“As the volume of virtual practices grows, most health systems will need to create a hybrid between health-system-employed and vendor-and/or-payer-supplied physicians,” he added. “Finding ways to create similar quality and outcomes will be essential in the evolving digital health infrastructure being developed.”

Charles Teixeira, DO, an infectious disease specialist at the Medical University of South Carolina in Charleston, said that this study highlighted the need to consistently provide high-quality, evidence-based care regardless of the encounter setting.

“It was important to compare the prescribing practices for commonly used medications, especially those as important as antibiotics,” he added. “Overprescribing antibiotics can have a progressive, long-term effect on a community and increase the risk for patients to develop multidrug-resistant bacteria.”

Jeffrey A. Linder, MD, MPH, the chief of general internal medicine and geriatrics in the department of medicine at Northwestern University in Chicago, commended the authors for investigating the quality of telehealth.

“The major limitation,” he found, “is that the investigators lumped all ARI visits – including those that are potentially antibiotic appropriate (e.g., otitis media, pharyngitis, sinusitis), those that are non–antibiotic appropriate (e.g., bronchitis, influenza, laryngitis, URI, viral syndrome), and those that are nonspecific symptoms (e.g., cough, congestion, fever, sore throat) – into the same category.”

No clinical information was collected or presented that would enable the reader to tell if these two groups of physicians were evaluating different patient populations or even if they just diagnosed patients differently,” he added.

“Our study did not delve into why we saw the difference,” Dr. Li explained. “Exploring potential reasons further will have important implications for how to optimally deliver care via telehealth.”

All authors and independent experts have disclosed no relevant financial relationships. The study received no financial support.

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

Third-party vendor physicians appear to be more much more likely than their system-employed counterparts to prescribe antibiotics during acute care telehealth visits for acute respiratory infection (ARI), according to a study in the Journal of Telemedicine and Telecare.

As health systems expand their direct-to-consumer (DTC) virtual care, the quality of that care seems to vary, write the authors. Patients with ARI symptoms make up about one-third of virtual visits. Prescribing practice is a commonly cited measure of care quality for ARI, which is usually viral and rarely benefits from antibiotics.

“When providing care through telehealth, hospital-affiliated emergency physicians practiced better antibiotic stewardship than vendor-supplied, non–hospital-affiliated physicians,” lead study author Kathleen Li, MD, MS, a clinical lecturer in the department of emergency medicine at the University of Michigan, Ann Arbor, told this news organization.

“We had a sense that a difference existed, but the magnitude of the difference was larger than expected,” she said.

Dr. Li and her colleagues retrospectively analyzed on-demand telehealth visits available to health system employees and dependents of a large urban academic health system from March 2018, when the service began, through July 2019.

All 16 affiliated physicians providing ARI care were board-certified in emergency medicine, compared with 2 (8%) of the 25 unaffiliated (vendor-employed) physicians. Most unaffiliated physicians were known to be board-certified in family medicine, internal medicine, or pediatrics.

Unaffiliated physicians were not given access to the health system’s electronic medical record. Instead, all their patient histories, exams, assessments, plans, impressions, and discharge instructions were scanned into the electronic medical record system by other staff the next day.
 

Unaffiliated doctors were more than twice as likely to prescribe antibiotics

The researchers extracted data on all 257 virtual ARI visits from the electronic health record system, including prescriptions and medication therapeutic class. They performed multivariable logistic regression, adjusting for patient age and time of visit (weekday vs. weekend; day vs. overnight).

Antibiotic prescription rates were similar between weekday and weekend visits, and between day and night visits. Regardless of provider status, older patients were more likely to be prescribed antibiotics (P = .01). 

Overall, affiliated physicians prescribed antibiotics during 18% of visits, whereas vendor physicians prescribed antibiotics during 37% of visits. After adjustments, the odds were 2.3 times higher that a patient in a telehealth visit with a vendor provider would be prescribed antibiotics (95% confidence interval, 1.1-4.5).

The predicted antibiotic prescribing rate for ARI was 19% (95% confidence interval, 13%-25%) for affiliated providers vs. 35% (95% CI, 22%-47%) for unaffiliated providers, an average marginal effect of 15% (95% CI, 2%-29%). The difference was even greater (average marginal effect 20%, 95% CI, 4%-35%) when children and patients over 65 were excluded.
 

Consistent, high-quality care and antibiotic stewardship are needed in all settings

Three experts who were not involved in the study commented on the study.

Joshua W. Elder, MD, MPH, MHS, medical director of Telehealth Express Care (direct-to-consumer telemedicine) at UC Davis Health in Sacramento, Calif., said, “An important unanswered question is how factors such as communication (policy and procedures, practice guidelines), connection (electronic health records), and reimbursement and incentives that health system and vendor-based providers received impacted this outcome.

“As the volume of virtual practices grows, most health systems will need to create a hybrid between health-system-employed and vendor-and/or-payer-supplied physicians,” he added. “Finding ways to create similar quality and outcomes will be essential in the evolving digital health infrastructure being developed.”

Charles Teixeira, DO, an infectious disease specialist at the Medical University of South Carolina in Charleston, said that this study highlighted the need to consistently provide high-quality, evidence-based care regardless of the encounter setting.

“It was important to compare the prescribing practices for commonly used medications, especially those as important as antibiotics,” he added. “Overprescribing antibiotics can have a progressive, long-term effect on a community and increase the risk for patients to develop multidrug-resistant bacteria.”

Jeffrey A. Linder, MD, MPH, the chief of general internal medicine and geriatrics in the department of medicine at Northwestern University in Chicago, commended the authors for investigating the quality of telehealth.

“The major limitation,” he found, “is that the investigators lumped all ARI visits – including those that are potentially antibiotic appropriate (e.g., otitis media, pharyngitis, sinusitis), those that are non–antibiotic appropriate (e.g., bronchitis, influenza, laryngitis, URI, viral syndrome), and those that are nonspecific symptoms (e.g., cough, congestion, fever, sore throat) – into the same category.”

No clinical information was collected or presented that would enable the reader to tell if these two groups of physicians were evaluating different patient populations or even if they just diagnosed patients differently,” he added.

“Our study did not delve into why we saw the difference,” Dr. Li explained. “Exploring potential reasons further will have important implications for how to optimally deliver care via telehealth.”

All authors and independent experts have disclosed no relevant financial relationships. The study received no financial support.

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

Babies born to moms who were vaccinated against respiratory syncytial virus (RSV) while pregnant appear to need fewer antimicrobial prescriptions than babies of unvaccinated moms, according to authors of a recent study.

To fight antimicrobial resistance, we need to use fewer antimicrobial drugs, the authors write in Proceedings of the National Academy of Sciences.

“In this study, an RSV vaccine was administered to pregnant women to prevent infection in their infants by the transfer of protective antibody to the infant,” Kathryn M. Edwards, MD, a professor of pediatrics and the scientific director of the Vanderbilt vaccine research program at Vanderbilt University in Nashville, Tenn., told this news organization. Dr. Edwards was not involved in the study.

“The authors investigated the impact of the vaccine on the use of antibiotics in infants during the first 90 days of life,” Dr. Edwards added in an email. “They found that the use of antibiotics was less in infants born to mothers who received the RSV vaccine than in infants born to mothers who received placebo. … They suggest that reducing RSV infection in infants will reduce respiratory infections that trigger antibiotic use.”

Senior author Ramanan Laxminarayan, PhD, MPH, director and senior fellow at the Center for Disease Dynamics, Economics & Policy in Washington and his colleagues conducted a secondary analysis of a double-blind, randomized controlled trial at 87 sites in 11 countries on several continents.

In the original study, which was conducted between December 2015 and May 2018, 3,005 maternal participants and 2,978 infant participants received the experimental RSV F vaccine, and 1,573 maternal participants and 1,546 infants received a placebo shot. Baseline characteristics of mothers and infants were well balanced, according to the authors.

In the current study, infants born to mothers who received the RSV vaccine were found to be 12.9% (95% confidence interval, 1.3%-23.1%) less likely to be prescribed antimicrobials during their first 3 months of life, compared with infants whose mothers received placebo. Vaccine efficacy against antimicrobial prescriptions for acute lower respiratory tract infections was 16.9% (95% CI, 1.4%-29.4%).

During the first 3 months of life, for every 100 infants born, maternal vaccination prevented 3.6 courses of antimicrobials in high-income countries (20.2% of all antimicrobial prescribing), and 5.1 courses in low- and middle-income countries (10.9% of all antimicrobial prescribing).

In addition to finding that lower respiratory tract infections accounted for 69%-73% of all antimicrobial prescribing prevented by maternal vaccination, the researchers found marked vaccine efficacy (71.3% [95% CI, 28.1%-88.6%]) against acute otitis media–associated antimicrobial prescription in infants in high-income countries.
 

RSV vaccine is ‘one of our best investments’

RSV, the authors explain, is a major cause of upper and lower respiratory tract infections that develop as a single agent or along with bacterial pathogens.

“With decreases in bacterial pneumonia following the introduction of the pneumococcal conjugate vaccine, a vaccine against RSV represents one of our best investments to lower the burden of respiratory infections in children,” Dr. Laxminarayan said in a press release.

“These findings are not unexpected because viral infections can trigger bacterial infections such as otitis, and reducing viral infections will reduce bacterial infections,” Dr. Edwards said. “Also, viral infections are often treated with antibiotics because the provider cannot rule out a bacterial infection.”

She acknowledged the value of investigating multiple outcomes but added that “the study was underpowered to assess the full impact of the antibiotics.”

“If a more effective RSV vaccine can be designed, the impact on reducing antibiotic use will likely be even greater,” Dr. Edwards advised. “Also, the vaccine was not highly effective in preventing RSV pneumonia. If it had been more effective, the antibiotic impact would likely have been greater.”

The authors acknowledged the study’s limitations. “Results of this post hoc secondary analysis should be viewed as hypothesis generating, as the trial was not powered for determination of effects against antimicrobial prescribing, and our analyses were not adjusted for multiplicity,” they write, and they joined Dr. Edwards in recommending further related research.

First author Joseph A. Lewnard, PhD, declares financial support from Pfizer unrelated to this research, three authors are employees of Novavax, and Dr. Laxminarayan has disclosed no relevant financial relationships. Dr. Edwards reports funding from the National Institutes of Health and the Centers for Disease Control and Prevention; consultancy to BioNEt and IBM; membership on data safety and monitoring boards for Pfizer, Sanofi, GSK, Merck, X-4 Pharma, Roche, and Seqirus. The Bill & Melinda Gates Foundation supported the study.

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

Babies born to moms who were vaccinated against respiratory syncytial virus (RSV) while pregnant appear to need fewer antimicrobial prescriptions than babies of unvaccinated moms, according to authors of a recent study.

To fight antimicrobial resistance, we need to use fewer antimicrobial drugs, the authors write in Proceedings of the National Academy of Sciences.

“In this study, an RSV vaccine was administered to pregnant women to prevent infection in their infants by the transfer of protective antibody to the infant,” Kathryn M. Edwards, MD, a professor of pediatrics and the scientific director of the Vanderbilt vaccine research program at Vanderbilt University in Nashville, Tenn., told this news organization. Dr. Edwards was not involved in the study.

“The authors investigated the impact of the vaccine on the use of antibiotics in infants during the first 90 days of life,” Dr. Edwards added in an email. “They found that the use of antibiotics was less in infants born to mothers who received the RSV vaccine than in infants born to mothers who received placebo. … They suggest that reducing RSV infection in infants will reduce respiratory infections that trigger antibiotic use.”

Senior author Ramanan Laxminarayan, PhD, MPH, director and senior fellow at the Center for Disease Dynamics, Economics & Policy in Washington and his colleagues conducted a secondary analysis of a double-blind, randomized controlled trial at 87 sites in 11 countries on several continents.

In the original study, which was conducted between December 2015 and May 2018, 3,005 maternal participants and 2,978 infant participants received the experimental RSV F vaccine, and 1,573 maternal participants and 1,546 infants received a placebo shot. Baseline characteristics of mothers and infants were well balanced, according to the authors.

In the current study, infants born to mothers who received the RSV vaccine were found to be 12.9% (95% confidence interval, 1.3%-23.1%) less likely to be prescribed antimicrobials during their first 3 months of life, compared with infants whose mothers received placebo. Vaccine efficacy against antimicrobial prescriptions for acute lower respiratory tract infections was 16.9% (95% CI, 1.4%-29.4%).

During the first 3 months of life, for every 100 infants born, maternal vaccination prevented 3.6 courses of antimicrobials in high-income countries (20.2% of all antimicrobial prescribing), and 5.1 courses in low- and middle-income countries (10.9% of all antimicrobial prescribing).

In addition to finding that lower respiratory tract infections accounted for 69%-73% of all antimicrobial prescribing prevented by maternal vaccination, the researchers found marked vaccine efficacy (71.3% [95% CI, 28.1%-88.6%]) against acute otitis media–associated antimicrobial prescription in infants in high-income countries.
 

RSV vaccine is ‘one of our best investments’

RSV, the authors explain, is a major cause of upper and lower respiratory tract infections that develop as a single agent or along with bacterial pathogens.

“With decreases in bacterial pneumonia following the introduction of the pneumococcal conjugate vaccine, a vaccine against RSV represents one of our best investments to lower the burden of respiratory infections in children,” Dr. Laxminarayan said in a press release.

“These findings are not unexpected because viral infections can trigger bacterial infections such as otitis, and reducing viral infections will reduce bacterial infections,” Dr. Edwards said. “Also, viral infections are often treated with antibiotics because the provider cannot rule out a bacterial infection.”

She acknowledged the value of investigating multiple outcomes but added that “the study was underpowered to assess the full impact of the antibiotics.”

“If a more effective RSV vaccine can be designed, the impact on reducing antibiotic use will likely be even greater,” Dr. Edwards advised. “Also, the vaccine was not highly effective in preventing RSV pneumonia. If it had been more effective, the antibiotic impact would likely have been greater.”

The authors acknowledged the study’s limitations. “Results of this post hoc secondary analysis should be viewed as hypothesis generating, as the trial was not powered for determination of effects against antimicrobial prescribing, and our analyses were not adjusted for multiplicity,” they write, and they joined Dr. Edwards in recommending further related research.

First author Joseph A. Lewnard, PhD, declares financial support from Pfizer unrelated to this research, three authors are employees of Novavax, and Dr. Laxminarayan has disclosed no relevant financial relationships. Dr. Edwards reports funding from the National Institutes of Health and the Centers for Disease Control and Prevention; consultancy to BioNEt and IBM; membership on data safety and monitoring boards for Pfizer, Sanofi, GSK, Merck, X-4 Pharma, Roche, and Seqirus. The Bill & Melinda Gates Foundation supported the study.

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

Babies born to moms who were vaccinated against respiratory syncytial virus (RSV) while pregnant appear to need fewer antimicrobial prescriptions than babies of unvaccinated moms, according to authors of a recent study.

To fight antimicrobial resistance, we need to use fewer antimicrobial drugs, the authors write in Proceedings of the National Academy of Sciences.

“In this study, an RSV vaccine was administered to pregnant women to prevent infection in their infants by the transfer of protective antibody to the infant,” Kathryn M. Edwards, MD, a professor of pediatrics and the scientific director of the Vanderbilt vaccine research program at Vanderbilt University in Nashville, Tenn., told this news organization. Dr. Edwards was not involved in the study.

“The authors investigated the impact of the vaccine on the use of antibiotics in infants during the first 90 days of life,” Dr. Edwards added in an email. “They found that the use of antibiotics was less in infants born to mothers who received the RSV vaccine than in infants born to mothers who received placebo. … They suggest that reducing RSV infection in infants will reduce respiratory infections that trigger antibiotic use.”

Senior author Ramanan Laxminarayan, PhD, MPH, director and senior fellow at the Center for Disease Dynamics, Economics & Policy in Washington and his colleagues conducted a secondary analysis of a double-blind, randomized controlled trial at 87 sites in 11 countries on several continents.

In the original study, which was conducted between December 2015 and May 2018, 3,005 maternal participants and 2,978 infant participants received the experimental RSV F vaccine, and 1,573 maternal participants and 1,546 infants received a placebo shot. Baseline characteristics of mothers and infants were well balanced, according to the authors.

In the current study, infants born to mothers who received the RSV vaccine were found to be 12.9% (95% confidence interval, 1.3%-23.1%) less likely to be prescribed antimicrobials during their first 3 months of life, compared with infants whose mothers received placebo. Vaccine efficacy against antimicrobial prescriptions for acute lower respiratory tract infections was 16.9% (95% CI, 1.4%-29.4%).

During the first 3 months of life, for every 100 infants born, maternal vaccination prevented 3.6 courses of antimicrobials in high-income countries (20.2% of all antimicrobial prescribing), and 5.1 courses in low- and middle-income countries (10.9% of all antimicrobial prescribing).

In addition to finding that lower respiratory tract infections accounted for 69%-73% of all antimicrobial prescribing prevented by maternal vaccination, the researchers found marked vaccine efficacy (71.3% [95% CI, 28.1%-88.6%]) against acute otitis media–associated antimicrobial prescription in infants in high-income countries.
 

RSV vaccine is ‘one of our best investments’

RSV, the authors explain, is a major cause of upper and lower respiratory tract infections that develop as a single agent or along with bacterial pathogens.

“With decreases in bacterial pneumonia following the introduction of the pneumococcal conjugate vaccine, a vaccine against RSV represents one of our best investments to lower the burden of respiratory infections in children,” Dr. Laxminarayan said in a press release.

“These findings are not unexpected because viral infections can trigger bacterial infections such as otitis, and reducing viral infections will reduce bacterial infections,” Dr. Edwards said. “Also, viral infections are often treated with antibiotics because the provider cannot rule out a bacterial infection.”

She acknowledged the value of investigating multiple outcomes but added that “the study was underpowered to assess the full impact of the antibiotics.”

“If a more effective RSV vaccine can be designed, the impact on reducing antibiotic use will likely be even greater,” Dr. Edwards advised. “Also, the vaccine was not highly effective in preventing RSV pneumonia. If it had been more effective, the antibiotic impact would likely have been greater.”

The authors acknowledged the study’s limitations. “Results of this post hoc secondary analysis should be viewed as hypothesis generating, as the trial was not powered for determination of effects against antimicrobial prescribing, and our analyses were not adjusted for multiplicity,” they write, and they joined Dr. Edwards in recommending further related research.

First author Joseph A. Lewnard, PhD, declares financial support from Pfizer unrelated to this research, three authors are employees of Novavax, and Dr. Laxminarayan has disclosed no relevant financial relationships. Dr. Edwards reports funding from the National Institutes of Health and the Centers for Disease Control and Prevention; consultancy to BioNEt and IBM; membership on data safety and monitoring boards for Pfizer, Sanofi, GSK, Merck, X-4 Pharma, Roche, and Seqirus. The Bill & Melinda Gates Foundation supported the study.

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

Legionnaires’ disease (LD) in the United States appears to be on an upswing that started in 2003, according to a study from the Centers for Disease Control and Prevention.

The reasons for this increased incidence are unclear, the researchers write in Emerging Infectious Diseases.

“The findings revealed a rising national trend in cases, widening racial disparities between Black or African American persons and White persons, and an increasing geographic focus in the Middle Atlantic, the East North Central, and New England,” lead author Albert E. Barskey, MPH, an epidemiologist in CDC’s Division of Bacterial Diseases, Atlanta, said in an email.

“Legionnaires’ disease cannot be diagnosed based on clinical features alone, and studies estimate that it is underdiagnosed, perhaps by 50%,” he added. “Our findings may serve to heighten clinicians’ awareness of this severe pneumonia’s etiology, so with an earlier correct diagnosis, appropriate treatment can be rendered sooner.”

Mr. Barskey and his coauthors at CDC – mathematical statistician Gordana Derado, PhD, and epidemiologist Chris Edens, PhD – used surveillance data to investigate the incidence of LD in the U.S. over time. They compared LD incidence in 2018 with average incidence between 1992 and 2002. The incidence data, from over 80,000 LD cases, were age-standardized using the 2005 U.S. standard population as the reference.

The researchers analyzed LD data reported to CDC by the 50 states, New York City, and Washington, D.C., through the National Notifiable Diseases Surveillance System. They performed regression analysis to identify the optimal year when population parameters changed, and for most analyses, they compared 1992-2002 data with 2003-2018 data.
 

Legionnaires’ disease up in various groups

• The overall age-standardized average incidence grew from 0.48 per 100,000 people during 1992-2002 to 2.71 per 100,000 in 2018 (incidence risk ratio, 5.67; 95% confidence interval, 5.52-5.83).
• LD incidence more than quintupled for people over 34 years of age, with the largest relative increase in those over 85 (RR, 6.50; 95% CI, 5.82-7.27).
• Incidence in men increased slightly more (RR, 5.86; 95% CI, 5.67-6.05) than in women (RR, 5.29; 95% CI, 5.06-5.53).
• Over the years, the racial disparity in incidence grew markedly. Incidence in Black persons increased from 0.47 to 5.21 per 100,000 (RR, 11.04; 95% CI, 10.39-11.73), compared with an increase from 0.37 to 1.99 per 100,000 in White persons (RR, 5.30; 95% CI, 5.12-5.49).
• The relative increase in incidence was highest in the Northeast (RR, 7.04; 95% CI, 6.70-7.40), followed by the Midwest (RR, 6.13; 95% CI, 5.85-6.42), the South (RR, 5.97; 95% CI, 5.67-6.29), and the West (RR, 3.39; 95% CI, 3.11-3.68).

Most LD cases occurred in summer or fall, and the seasonal pattern became more pronounced over time. The average of 57.8% of cases between June and November during 1992-2002 grew to 68.9% in 2003-2018.

Although the study “was hindered by incomplete race and ethnicity data,” Mr. Barskey said, “its breadth was a strength.”
 

Consider legionella in your diagnosis

In an interview, Paul G. Auwaerter, MD, a professor of medicine and the clinical director of the Division of Infectious Diseases at Johns Hopkins University School of Medicine, Baltimore, said he was not surprised by the results. “CDC has been reporting increased incidence of Legionnaires’ disease from water source outbreaks over the years. As a clinician, I very much depend on epidemiologic trends to help me understand the patient in front of me.

“The key point is that there’s more of it around, so consider it in your diagnosis,” he advised.

“Physicians are increasingly beginning to consider Legionella. Because LD is difficult to diagnose by traditional methods such as culture, they may use a PCR test,” said Dr. Auwaerter, who was not involved in the study. “Legionella needs antibiotics that differ a bit from traditional antibiotics used to treat bacterial pneumonia, so a correct diagnosis can inform a more directed therapy.”

“Why the incidence is increasing is the big question, and the authors nicely outline a litany of things,” he said.

The authors and Dr. Auwaerter proposed a number of possible contributing factors to the increased incidence:

• an aging population
• aging municipal and residential water sources that may harbor more organisms
• racial disparities and poverty
• underlying conditions, including diabetes, end-stage renal disease, and some cancers
• occupations in transportation, repair, cleaning services, and construction
• weather patterns
• improved surveillance and reporting

“Why Legionella appears in some locations more than others has not been explained,” Dr. Auwaerter added. “For example, Pittsburgh always seemed to have much more Legionella than Baltimore.”

Mr. Barskey and his team are planning further research into racial disparities and links between weather and climate and Legionnaires’ disease.

The authors are employees of CDC. Dr. Auwaerter has disclosed no relevant financial realtionships.

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

Legionnaires’ disease (LD) in the United States appears to be on an upswing that started in 2003, according to a study from the Centers for Disease Control and Prevention.

The reasons for this increased incidence are unclear, the researchers write in Emerging Infectious Diseases.

“The findings revealed a rising national trend in cases, widening racial disparities between Black or African American persons and White persons, and an increasing geographic focus in the Middle Atlantic, the East North Central, and New England,” lead author Albert E. Barskey, MPH, an epidemiologist in CDC’s Division of Bacterial Diseases, Atlanta, said in an email.

“Legionnaires’ disease cannot be diagnosed based on clinical features alone, and studies estimate that it is underdiagnosed, perhaps by 50%,” he added. “Our findings may serve to heighten clinicians’ awareness of this severe pneumonia’s etiology, so with an earlier correct diagnosis, appropriate treatment can be rendered sooner.”

Mr. Barskey and his coauthors at CDC – mathematical statistician Gordana Derado, PhD, and epidemiologist Chris Edens, PhD – used surveillance data to investigate the incidence of LD in the U.S. over time. They compared LD incidence in 2018 with average incidence between 1992 and 2002. The incidence data, from over 80,000 LD cases, were age-standardized using the 2005 U.S. standard population as the reference.

The researchers analyzed LD data reported to CDC by the 50 states, New York City, and Washington, D.C., through the National Notifiable Diseases Surveillance System. They performed regression analysis to identify the optimal year when population parameters changed, and for most analyses, they compared 1992-2002 data with 2003-2018 data.
 

Legionnaires’ disease up in various groups

• The overall age-standardized average incidence grew from 0.48 per 100,000 people during 1992-2002 to 2.71 per 100,000 in 2018 (incidence risk ratio, 5.67; 95% confidence interval, 5.52-5.83).
• LD incidence more than quintupled for people over 34 years of age, with the largest relative increase in those over 85 (RR, 6.50; 95% CI, 5.82-7.27).
• Incidence in men increased slightly more (RR, 5.86; 95% CI, 5.67-6.05) than in women (RR, 5.29; 95% CI, 5.06-5.53).
• Over the years, the racial disparity in incidence grew markedly. Incidence in Black persons increased from 0.47 to 5.21 per 100,000 (RR, 11.04; 95% CI, 10.39-11.73), compared with an increase from 0.37 to 1.99 per 100,000 in White persons (RR, 5.30; 95% CI, 5.12-5.49).
• The relative increase in incidence was highest in the Northeast (RR, 7.04; 95% CI, 6.70-7.40), followed by the Midwest (RR, 6.13; 95% CI, 5.85-6.42), the South (RR, 5.97; 95% CI, 5.67-6.29), and the West (RR, 3.39; 95% CI, 3.11-3.68).

Most LD cases occurred in summer or fall, and the seasonal pattern became more pronounced over time. The average of 57.8% of cases between June and November during 1992-2002 grew to 68.9% in 2003-2018.

Although the study “was hindered by incomplete race and ethnicity data,” Mr. Barskey said, “its breadth was a strength.”
 

Consider legionella in your diagnosis

In an interview, Paul G. Auwaerter, MD, a professor of medicine and the clinical director of the Division of Infectious Diseases at Johns Hopkins University School of Medicine, Baltimore, said he was not surprised by the results. “CDC has been reporting increased incidence of Legionnaires’ disease from water source outbreaks over the years. As a clinician, I very much depend on epidemiologic trends to help me understand the patient in front of me.

“The key point is that there’s more of it around, so consider it in your diagnosis,” he advised.

“Physicians are increasingly beginning to consider Legionella. Because LD is difficult to diagnose by traditional methods such as culture, they may use a PCR test,” said Dr. Auwaerter, who was not involved in the study. “Legionella needs antibiotics that differ a bit from traditional antibiotics used to treat bacterial pneumonia, so a correct diagnosis can inform a more directed therapy.”

“Why the incidence is increasing is the big question, and the authors nicely outline a litany of things,” he said.

The authors and Dr. Auwaerter proposed a number of possible contributing factors to the increased incidence:

• an aging population
• aging municipal and residential water sources that may harbor more organisms
• racial disparities and poverty
• underlying conditions, including diabetes, end-stage renal disease, and some cancers
• occupations in transportation, repair, cleaning services, and construction
• weather patterns
• improved surveillance and reporting

“Why Legionella appears in some locations more than others has not been explained,” Dr. Auwaerter added. “For example, Pittsburgh always seemed to have much more Legionella than Baltimore.”

Mr. Barskey and his team are planning further research into racial disparities and links between weather and climate and Legionnaires’ disease.

The authors are employees of CDC. Dr. Auwaerter has disclosed no relevant financial realtionships.

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

Legionnaires’ disease (LD) in the United States appears to be on an upswing that started in 2003, according to a study from the Centers for Disease Control and Prevention.

The reasons for this increased incidence are unclear, the researchers write in Emerging Infectious Diseases.

“The findings revealed a rising national trend in cases, widening racial disparities between Black or African American persons and White persons, and an increasing geographic focus in the Middle Atlantic, the East North Central, and New England,” lead author Albert E. Barskey, MPH, an epidemiologist in CDC’s Division of Bacterial Diseases, Atlanta, said in an email.

“Legionnaires’ disease cannot be diagnosed based on clinical features alone, and studies estimate that it is underdiagnosed, perhaps by 50%,” he added. “Our findings may serve to heighten clinicians’ awareness of this severe pneumonia’s etiology, so with an earlier correct diagnosis, appropriate treatment can be rendered sooner.”

Mr. Barskey and his coauthors at CDC – mathematical statistician Gordana Derado, PhD, and epidemiologist Chris Edens, PhD – used surveillance data to investigate the incidence of LD in the U.S. over time. They compared LD incidence in 2018 with average incidence between 1992 and 2002. The incidence data, from over 80,000 LD cases, were age-standardized using the 2005 U.S. standard population as the reference.

The researchers analyzed LD data reported to CDC by the 50 states, New York City, and Washington, D.C., through the National Notifiable Diseases Surveillance System. They performed regression analysis to identify the optimal year when population parameters changed, and for most analyses, they compared 1992-2002 data with 2003-2018 data.
 

Legionnaires’ disease up in various groups

• The overall age-standardized average incidence grew from 0.48 per 100,000 people during 1992-2002 to 2.71 per 100,000 in 2018 (incidence risk ratio, 5.67; 95% confidence interval, 5.52-5.83).
• LD incidence more than quintupled for people over 34 years of age, with the largest relative increase in those over 85 (RR, 6.50; 95% CI, 5.82-7.27).
• Incidence in men increased slightly more (RR, 5.86; 95% CI, 5.67-6.05) than in women (RR, 5.29; 95% CI, 5.06-5.53).
• Over the years, the racial disparity in incidence grew markedly. Incidence in Black persons increased from 0.47 to 5.21 per 100,000 (RR, 11.04; 95% CI, 10.39-11.73), compared with an increase from 0.37 to 1.99 per 100,000 in White persons (RR, 5.30; 95% CI, 5.12-5.49).
• The relative increase in incidence was highest in the Northeast (RR, 7.04; 95% CI, 6.70-7.40), followed by the Midwest (RR, 6.13; 95% CI, 5.85-6.42), the South (RR, 5.97; 95% CI, 5.67-6.29), and the West (RR, 3.39; 95% CI, 3.11-3.68).

Most LD cases occurred in summer or fall, and the seasonal pattern became more pronounced over time. The average of 57.8% of cases between June and November during 1992-2002 grew to 68.9% in 2003-2018.

Although the study “was hindered by incomplete race and ethnicity data,” Mr. Barskey said, “its breadth was a strength.”
 

Consider legionella in your diagnosis

In an interview, Paul G. Auwaerter, MD, a professor of medicine and the clinical director of the Division of Infectious Diseases at Johns Hopkins University School of Medicine, Baltimore, said he was not surprised by the results. “CDC has been reporting increased incidence of Legionnaires’ disease from water source outbreaks over the years. As a clinician, I very much depend on epidemiologic trends to help me understand the patient in front of me.

“The key point is that there’s more of it around, so consider it in your diagnosis,” he advised.

“Physicians are increasingly beginning to consider Legionella. Because LD is difficult to diagnose by traditional methods such as culture, they may use a PCR test,” said Dr. Auwaerter, who was not involved in the study. “Legionella needs antibiotics that differ a bit from traditional antibiotics used to treat bacterial pneumonia, so a correct diagnosis can inform a more directed therapy.”

“Why the incidence is increasing is the big question, and the authors nicely outline a litany of things,” he said.

The authors and Dr. Auwaerter proposed a number of possible contributing factors to the increased incidence:

• an aging population
• aging municipal and residential water sources that may harbor more organisms
• racial disparities and poverty
• underlying conditions, including diabetes, end-stage renal disease, and some cancers
• occupations in transportation, repair, cleaning services, and construction
• weather patterns
• improved surveillance and reporting

“Why Legionella appears in some locations more than others has not been explained,” Dr. Auwaerter added. “For example, Pittsburgh always seemed to have much more Legionella than Baltimore.”

Mr. Barskey and his team are planning further research into racial disparities and links between weather and climate and Legionnaires’ disease.

The authors are employees of CDC. Dr. Auwaerter has disclosed no relevant financial realtionships.

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

Potential immigrants to the United States from countries with high rates of tuberculosis tend to follow through with TB tests and treatment before they travel, and their compliance helps control TB spread, according to a study published online Feb. 16, 2022, in Emerging Infectious Diseases.

“In our study of U.S.-bound immigrants in Vietnam during their required overseas medical examination prior to migration to the United States, we identified a high proportion of U.S.-bound immigrants with latent TB infection (LTBI) and offered them preventive TB treatment,” coauthor Christina R. Phares, PhD, of the Centers for Disease Control and Prevention, Atlanta, said in an interview.

“Overall, 88% of those who started treatment completed their treatment,” she said in an interview. “This is a higher treatment completion rate than has been found in many postarrival strategies in the U.S.”

“This study demonstrated that providing LTBI testing and treatment during the overseas medical examination is feasible, yields high initiation and completion rates, and should be considered as a viable strategy to address LTBI in U.S.-bound migrants,” lead author Amera Khan, DrPH, of the Stop TB Partnership in Geneva, said in an interview.

The research team began the 1-year Preventing Tuberculosis Overseas Pilot Study (PTOPS) in Vietnam in 2018 among applicants for U.S. immigrant visas. Study participants were 12 years of age or older and were undergoing required medical examinations, which included the interferon-gamma release assay (IGRA) tuberculosis blood test.

Eligible IGRA-positive participants who planned to complete their LTBI treatment before traveling to the United States were offered free 3HP (12 weekly doses of isoniazid and rifapentine). Of 5,311 people recruited into the study, 2,438 (46%) enrolled; 2,276 had an IGRA processed; and 484 (21%) tested positive. Of the 452 participants eligible for 3HP, 304 (67%) began, and 268 (88%) completed, their treatment.
 

Preimmigration strategies needed

Worldwide, TB is now the second-leading cause of death by infectious disease, behind COVID-19, Dr. Khan said. The U.S. has seen a slow, steady decline in incidence with an increasing proportion of TB found in people born outside the country.

“Approximately 70% of U.S. TB cases occur in persons born outside the U.S., with the vast majority due to reactivation of latent TB infection acquired prior to their travel to the U.S.,” she said. “To progress towards elimination TB in the U.S., we need innovative strategies to address the high burden of LTBI among immigrants.”

Jonathan E. Golub, PhD, MPH, an infectious diseases specialist and a professor of medicine, epidemiology, and international health at Johns Hopkins University, Baltimore, was not involved in the study but welcomed its results. “This study clearly shows that a predeparture screening and treatment strategy for LTBI can be successfully implemented,” he told this news organization. “While the study highlights areas of the LTBI care cascade that need improvement, the message is clear that predeparture screening and treatment has the potential to significantly impact TB rates among non–U.S.-born persons in the U.S.”

Dr. Golub went on to explain that new technologies for LTBI screening have been underutilized. “New, shorter LTBI treatment regimens provide more feasible choices for both providers and people applying for immigration visas. Combining IGRA with 3HP creates an efficient and effective strategy. This strategy had not been tested prior to the study and the results are exciting.”

Dr. Golub highlighted one important aspect of the study: that many participants started treatment in Vietnam and completed it in the U.S. “This shows that such a protocol provides needed flexibility and can be followed by the health care systems and patients,” Dr. Golub said. “If TB is to ever be eliminated in the U.S., reducing TB among non–U.S.-born persons must be prioritized.”

The rifapentine used in the study was donated by Sanofi, the drug’s manufacturer. Dr. Khan, Dr. Phares, and Dr. Golub reported no relevant financial relationships. The study was supported by a CDC Cooperative Agreement.

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

Potential immigrants to the United States from countries with high rates of tuberculosis tend to follow through with TB tests and treatment before they travel, and their compliance helps control TB spread, according to a study published online Feb. 16, 2022, in Emerging Infectious Diseases.

“In our study of U.S.-bound immigrants in Vietnam during their required overseas medical examination prior to migration to the United States, we identified a high proportion of U.S.-bound immigrants with latent TB infection (LTBI) and offered them preventive TB treatment,” coauthor Christina R. Phares, PhD, of the Centers for Disease Control and Prevention, Atlanta, said in an interview.

“Overall, 88% of those who started treatment completed their treatment,” she said in an interview. “This is a higher treatment completion rate than has been found in many postarrival strategies in the U.S.”

“This study demonstrated that providing LTBI testing and treatment during the overseas medical examination is feasible, yields high initiation and completion rates, and should be considered as a viable strategy to address LTBI in U.S.-bound migrants,” lead author Amera Khan, DrPH, of the Stop TB Partnership in Geneva, said in an interview.

The research team began the 1-year Preventing Tuberculosis Overseas Pilot Study (PTOPS) in Vietnam in 2018 among applicants for U.S. immigrant visas. Study participants were 12 years of age or older and were undergoing required medical examinations, which included the interferon-gamma release assay (IGRA) tuberculosis blood test.

Eligible IGRA-positive participants who planned to complete their LTBI treatment before traveling to the United States were offered free 3HP (12 weekly doses of isoniazid and rifapentine). Of 5,311 people recruited into the study, 2,438 (46%) enrolled; 2,276 had an IGRA processed; and 484 (21%) tested positive. Of the 452 participants eligible for 3HP, 304 (67%) began, and 268 (88%) completed, their treatment.
 

Preimmigration strategies needed

Worldwide, TB is now the second-leading cause of death by infectious disease, behind COVID-19, Dr. Khan said. The U.S. has seen a slow, steady decline in incidence with an increasing proportion of TB found in people born outside the country.

“Approximately 70% of U.S. TB cases occur in persons born outside the U.S., with the vast majority due to reactivation of latent TB infection acquired prior to their travel to the U.S.,” she said. “To progress towards elimination TB in the U.S., we need innovative strategies to address the high burden of LTBI among immigrants.”

Jonathan E. Golub, PhD, MPH, an infectious diseases specialist and a professor of medicine, epidemiology, and international health at Johns Hopkins University, Baltimore, was not involved in the study but welcomed its results. “This study clearly shows that a predeparture screening and treatment strategy for LTBI can be successfully implemented,” he told this news organization. “While the study highlights areas of the LTBI care cascade that need improvement, the message is clear that predeparture screening and treatment has the potential to significantly impact TB rates among non–U.S.-born persons in the U.S.”

Dr. Golub went on to explain that new technologies for LTBI screening have been underutilized. “New, shorter LTBI treatment regimens provide more feasible choices for both providers and people applying for immigration visas. Combining IGRA with 3HP creates an efficient and effective strategy. This strategy had not been tested prior to the study and the results are exciting.”

Dr. Golub highlighted one important aspect of the study: that many participants started treatment in Vietnam and completed it in the U.S. “This shows that such a protocol provides needed flexibility and can be followed by the health care systems and patients,” Dr. Golub said. “If TB is to ever be eliminated in the U.S., reducing TB among non–U.S.-born persons must be prioritized.”

The rifapentine used in the study was donated by Sanofi, the drug’s manufacturer. Dr. Khan, Dr. Phares, and Dr. Golub reported no relevant financial relationships. The study was supported by a CDC Cooperative Agreement.

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

Potential immigrants to the United States from countries with high rates of tuberculosis tend to follow through with TB tests and treatment before they travel, and their compliance helps control TB spread, according to a study published online Feb. 16, 2022, in Emerging Infectious Diseases.

“In our study of U.S.-bound immigrants in Vietnam during their required overseas medical examination prior to migration to the United States, we identified a high proportion of U.S.-bound immigrants with latent TB infection (LTBI) and offered them preventive TB treatment,” coauthor Christina R. Phares, PhD, of the Centers for Disease Control and Prevention, Atlanta, said in an interview.

“Overall, 88% of those who started treatment completed their treatment,” she said in an interview. “This is a higher treatment completion rate than has been found in many postarrival strategies in the U.S.”

“This study demonstrated that providing LTBI testing and treatment during the overseas medical examination is feasible, yields high initiation and completion rates, and should be considered as a viable strategy to address LTBI in U.S.-bound migrants,” lead author Amera Khan, DrPH, of the Stop TB Partnership in Geneva, said in an interview.

The research team began the 1-year Preventing Tuberculosis Overseas Pilot Study (PTOPS) in Vietnam in 2018 among applicants for U.S. immigrant visas. Study participants were 12 years of age or older and were undergoing required medical examinations, which included the interferon-gamma release assay (IGRA) tuberculosis blood test.

Eligible IGRA-positive participants who planned to complete their LTBI treatment before traveling to the United States were offered free 3HP (12 weekly doses of isoniazid and rifapentine). Of 5,311 people recruited into the study, 2,438 (46%) enrolled; 2,276 had an IGRA processed; and 484 (21%) tested positive. Of the 452 participants eligible for 3HP, 304 (67%) began, and 268 (88%) completed, their treatment.
 

Preimmigration strategies needed

Worldwide, TB is now the second-leading cause of death by infectious disease, behind COVID-19, Dr. Khan said. The U.S. has seen a slow, steady decline in incidence with an increasing proportion of TB found in people born outside the country.

“Approximately 70% of U.S. TB cases occur in persons born outside the U.S., with the vast majority due to reactivation of latent TB infection acquired prior to their travel to the U.S.,” she said. “To progress towards elimination TB in the U.S., we need innovative strategies to address the high burden of LTBI among immigrants.”

Jonathan E. Golub, PhD, MPH, an infectious diseases specialist and a professor of medicine, epidemiology, and international health at Johns Hopkins University, Baltimore, was not involved in the study but welcomed its results. “This study clearly shows that a predeparture screening and treatment strategy for LTBI can be successfully implemented,” he told this news organization. “While the study highlights areas of the LTBI care cascade that need improvement, the message is clear that predeparture screening and treatment has the potential to significantly impact TB rates among non–U.S.-born persons in the U.S.”

Dr. Golub went on to explain that new technologies for LTBI screening have been underutilized. “New, shorter LTBI treatment regimens provide more feasible choices for both providers and people applying for immigration visas. Combining IGRA with 3HP creates an efficient and effective strategy. This strategy had not been tested prior to the study and the results are exciting.”

Dr. Golub highlighted one important aspect of the study: that many participants started treatment in Vietnam and completed it in the U.S. “This shows that such a protocol provides needed flexibility and can be followed by the health care systems and patients,” Dr. Golub said. “If TB is to ever be eliminated in the U.S., reducing TB among non–U.S.-born persons must be prioritized.”

The rifapentine used in the study was donated by Sanofi, the drug’s manufacturer. Dr. Khan, Dr. Phares, and Dr. Golub reported no relevant financial relationships. The study was supported by a CDC Cooperative Agreement.

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