Lancet: Public Response To The H1N1 Pandemic Of 2009

 

 

# 6610

 

 

During the opening months of the 2009 H1N1 pandemic – before a vaccine was available – about the only advice that public health departments could offer was that people practice good flu hygiene.

 

The CDC’s Action Steps released in September, 2009.

 

1. Get your family vaccinated for seasonal flu and 2009 H1N1 flu.
2. Cover your mouth and nose with a tissue when you cough or sneeze.  If you don’t have a tissue, cough or sneeze into your elbow or shoulder; not into your hands.
3. Practice good hand hygiene by washing your hands often with soap and water, especially after coughing or sneezing.
4. Stay home if you or your child is sick for at least 24 hours after there is no longer a fever or signs of a fever (without the use of fever-reducing medicine). Keeping sick students at home means that they keep their viruses to themselves rather than sharing them with others.

 

And variations of this advice was promoted pretty much worldwide, including this NHS promotion in the UK:

 

 

While many people did adopt these practices, many did not.  In September of 2009 I wrote of my own encounter with with an unrepentant public sneezer in a blog called  `Being A Sneeze Guard’.

 

And in a blog called And Yet, They Still Call It Wellington, we looked at a New Zealand study that found poor flu hygiene compliance during the 2009 pandemic.

 

Today, The Lancet has published a review of flu compliance that has garnered a good deal of press overnight, particularly in Britain, where compliance was less than sterling.

 

Public response to the 2009 influenza A H1N1 pandemic: a polling study in five countries

Dr Gillian K SteelFisher PhD , Robert J Blendon ScD , Johanna RM Ward MSc , Robyn Rapoport MA , Emily B Kahn PhD , Katrin S Kohl MD

 

 

Although the full text is behind a pay wall, the Fergus Walsh with the  BBC has a report with some of the details.

 

Britons 'kissed through swine flu'

(Excerpt)

Researchers at Harvard School of Public Health in Boston questioned nearly 5,000 people. Just 25% of British people surveyed said they more frequently coughed or sneezed into their elbow or shoulder during the pandemic compared with 82% in Mexico and 84% in Argentina. Some 53% of Britons said they washed their hands or used hand sanitizer more frequently, compared with 89% in Argentina, and 72% in Japan and the US.

 

Just 2% of Britons said they avoided hugging or kissing family or friends compared with 46% of those questioned in Mexico and 21% in the US.

(Continue . . .)

 

 

It wasn’t just the general public displaying a cavalier attitude during the pandemic - something I wrote about in Hand Hygiene Among Doctors Exposed. That concerned an observational study conducted at two scientific conferences on the hand washing habits of doctors.

 

The first was the 26th Meeting of the Scandinavian Society on Antimicrobial Chemotherapy (SSAC) in Tromsø, Norway, and second took place at the International Congress on Antimicrobial Agents and Chemotherapy (ICAAC) in San Francisco, CA.

 

Both took place in September 2009, during the height of the pandemic.

 

Observers stationed in the men’s and women’s restrooms kept track of the hand washing compliance among the men and women (mostly infectious disease specialists) attending these conferences.

 

The results, while better than others we’ve seen among the general public, were still less than comforting.

 

The study appeared in the  AJIC (American Journal of Infection Control) and was called:

 

Do as I say, not as I do: Handwashing compliance of infectious diseases experts during influenza pandemic

Anu Kantele, MD, PhD, Mari Kanerva, MD, PhD, Mikko Seppänen, MD, PhD, Jussi Sutinen, MD, PhD, Kirsi Skogberg, MD, PhD, Laura Pakarinen, MD, Iiro H.S. Jääskeläinen, MD, Inko Aho, MD, Asko Järvinen, MD, PhD, Taru Finnilä, MD Jukka Ollgren, PhD

 

The bottom line was that in San Francisco only 69% of the men were observed to wash with soap and water, and 86% of the women. Results from the conference in  Tromsø, Norway conference were even more disturbing, with just 38% of the men, and 84% of the women using soap and water.

 

You’ll find a lot more on this subject in Giving Germs A Helping Hand, which looked at low handwashing compliance among doctors and other healthcare providers.

 

To try to encourage better hand hygiene among health care providers, the CDC has a hand hygiene website  with  many resources, including a link to a new iPad/iPhone application called iScrub.

 

»» Read More

Lancet: Estimating Global 2009 Pandemic Mortality

 

 

# 6505

 

 

Sounding a bit like a broken record, during the first 12 months of the 2009 pandemic I wrote repeatedly on our inability to accurate count – or even estimate – the number of H1N1 flu deaths in the United States and around the globe.

 

Just a few of those posts include:

 

Dead Reckoning

The Tip Of The Iceberg

When No Number Is Right

Apples, Oranges, And Influenza Death Tolls

 

The CFR, or case fatality ratio is generally seen as the most important statistic in any pandemic, and yet it is often the hardest to quantify. This number is the percentage of people who, once infected, die (either directly or indirectly) as a result of that infection.

 

While that may seem a simple enough task , the truth is that even during a `normal’ flu season the CDC can only estimate the number of deaths in the United States related to influenza.

 

The problem is, influenza can provoke or exacerbate many other medical problems. Influenza can obviously lead to pneumonia and death, but it has also been linked to heart attacks, strokes (CVAs), and other potentially fatal health crises.

   

Most of the time, the attending doctor signs the death certificate and puts down the most immediate or obvious cause of death.  If influenza was a factor, it rarely is noticed or noted.

 

The official numbers we get from the CDC, the World Health Organization, and from individual countries are almost always referred to as `the tip of the iceberg’, or as in the graphic below, the tip of the pyramid.

 

 

And this is the best we can do in developed countries, where the majority of people have at least some access to medical care and where governments make an attempt to maintain public health records and death registries.

 

For much of the rest of the world, these are luxuries that are too often unavailable.

 

As an example, in November of 2009, in Zhong Nanshan On China’s Death Toll, one of the real heroes of the 2003 SARS epidemic, openly questioned the low number of deaths being reported out of China.

 

The truth is, in many countries, no one was counting the dead. 

 

In South Africa, where nearly 1,000 AIDS/HIV deaths occur each day, no one was looking to see if flu was a factor.  No one had the time, and it simply wasn’t in the budget.  

 

The `official’ death toll, as reported by the World Health Organization was roughly 18,000 deaths globally,  but the WHO offered this disclaimer:

 

The reported number of fatal cases is an under representation of the actual numbers as many deaths are never tested or recognized as influenza related. – World Health Organization.

 

Unfortunately, the mainstream media often reported the low official number of deaths without adequately explaining the acknowledged gaps in the data, leading many to believe that the 2009 pandemic was a damp squib.

 

The CDC stopped counting H1N1 influenza deaths in the summer of 2009, realizing that their official tally was more misleading that helpful.

 

In November of that year, they released their first estimate of the number of U.S. pandemic flu infections, hospitalizations, and deaths (see  CDC Releases Revised Hospitalization & Death Estimates), where they estimated that between about 2,500 and 6,000 2009 H1N1-related deaths occurred between April and October 17, 2009.

 

Two months later (see CDC Updates Estimates Of Infections, Hospitalizations, and Deaths From H1N1) the the CDC updated their estimates to carry through to the 12th of December. Their mid-range estimates were of 55 million infections and 11,160 deaths in the US from H1N1 since April of 2009.

 

Today, a study appears in The Lancet that attempts to estimate the number of global H1N1 deaths during the first year of the pandemic, and it comes up with a number than runs between 15 and 30 times higher than reported to the WHO.

Estimated global mortality associated with the first 12 months of 2009 pandemic influenza A H1N1 virus circulation: a modelling study

Dr Fatimah S Dawood MD , A Danielle Iuliano PhD, Carrie Reed DSc , Martin I Meltzer PhD , David K Shay MD, Po-Yung Cheng PhD, Don Bandaranayake MBBS , Robert F Breiman MD , W Abdullah Brooks MD , Philippe Buchy MD , Daniel R Feikin MD, Karen B Fowler DrPH , Aubree Gordon PhD , Nguyen Tran Hien MD , Peter Horby MBBSl, Q Sue Huang PhD , Mark A Katz MD , Anand Krishnan MBBS , Renu Lal PhD , Joel M Montgomery PhD , Kåre Mølbak MDo, Richard Pebody MBBS, Anne M Presanis PhD , Hugo Razuri MD , Anneke Steens MSc , Yeny O Tinoco DVM , Jacco Wallinga PhD , Hongjie Yu MDr, Sirenda Vong MD , Joseph Bresee MD , Dr Marc-Alain Widdowson VetMB

Findings

We estimate that globally there were 201 200 respiratory deaths (range 105 700—395 600) with an additional 83 300 cardiovascular deaths (46 000—179 900) associated with 2009 pandemic influenza A H1N1. 80% of the respiratory and cardiovascular deaths were in people younger than 65 years and 59% occurred in southeast Asia and Africa.

 

While most of this report is behind a pay wall, the CDC - which co-authored the study -  has posted a summary on their website.

 

CDC Releases First Global Estimates of 2009 H1N1 Pandemic Mortality

June 25, 2012 -- A study published today in The Lancet Infectious Diseases Online First provides the first global estimates of how many people died as a result of the 2009 H1N1 influenza pandemic. The study, co-authored by 9 members of the CDC Influenza Division, used an improved modeling approach which resulted in an estimated range of deaths from between 151,700 and 575,400 people who perished worldwide from 2009 H1N1 virus infection during the first year the virus circulated. A disproportionate number of deaths occurred in Southeast Asia and Africa, where access to prevention and treatment resources are more likely to be limited. Study authors hope that this work can be used not only to improve how influenza deaths are estimated, but also to improve the public health response during future pandemics in parts of the world that suffer more influenza-related deaths.

 

These global estimates are more than 15 times higher than the number of laboratory-confirmed deaths reported to the World Health Organization (WHO). WHO has acknowledged for some time that official, lab-confirmed reports are an underestimate of actual number of influenza deaths. Diagnostic specimens are not always collected from people who die with influenza; for others, influenza virus may not be detectable by the time of death. Because of these challenges, modeling is used to estimate the actual burden of disease.

<SNIP>

2009 H1N1 Pandemic Hits the Young Especially Hard

This study estimated that 80% of 2009 H1N1 deaths were in people younger than 65 years of age which differs from typical seasonal influenza epidemics during which 80-90% of deaths are estimated to occur in people 65 years of age and older. To illustrate the impact of the shift in the age distribution of influenza deaths to younger age groups during the pandemic, researchers calculated the number of years of life lost due to 2009 H1N1-associated deaths. They estimated that 3 times as many years of life were lost during the first year of 2009 H1N1 virus circulation than would have occurred for the same number of deaths during a typical influenza season.

(Continue . . . )

 

 

This age shift to younger victims was frequently noted during the pandemic, and in the spring of 2010 a study appeared that found that the mean age of death from the novel H1N1 virus has been calculated to be half that of seasonal flu, or 37.4 years.

 

In terms of years of life lost (YLL), the average pandemic flu death had a many fold greater impact than the average seasonal flu fatality – often robbing decades of potential life from its victims.

 

Preliminary Estimates of Mortality and Years of Life Lost Associated with the 2009 A/H1N1 Pandemic in the US and Comparison with Past Influenza Seasons

By Cecile Viboud, Mark Miller, Don Olson, Michael Osterholm et al (5 authors)

 

 

All of which makes the impact of the 2009 pandemic – in real terms – greater than most people realize.

Today’s new estimate is unlikely to be the last word on this subject. As more data is analyzed and new mathematical models are developed, better estimates will be generated.

 

We’ll never know the true number, of course.  Some things are not directly measureable. But having more accurate estimates can go a long ways towards helping us plan for the next pandemic.

 

And as most researchers acknowledge: that isn’t a matter of `if’, it’s just a matter of `when’.

»» Read More

Lancet: 1/3rd Of Malaria Drugs Fake Or Sub-Standard

 

Credit  CDC 

 

 

# 6339

 

An eye-opening report from The Lancet today, which indicates that a large percentage of the anti-malarial drugs used in Asia and sub-Saharan Africa are either fake, or are of inferior quality.

 

Ominously, using drugs that contain too little of their intended active ingredient can contribute to pathogens developing increased and widespread resistance over time.

 

 

The problem isn’t new, but is apparently more widespread than previously thought.   The authors divided `Poor Quality’ drugs into three categories.

 

• Falsified (fraudulently manufactured with fake packaging and usually no or a wrong active pharmaceutical ingredient)
• Substandard (products resulting from poor manufacturing with no intent to deceive, usually with inadequate or too much active pharmaceutical ingredient);
• Degraded (good-quality drugs that are degraded by poor storage after leaving the factory)

 

Follow the link to the Lancet article (full access with free registration) is below.

 

Poor-quality antimalarial drugs in southeast Asia and sub-Saharan Africa

Gaurvika ML Nayyar BS , Joel G Breman MD , Paul N Newton MRCP , James Herrington PhD

Summary

Poor-quality antimalarial drugs lead to drug resistance and inadequate treatment, which pose an urgent threat to vulnerable populations and jeopardise progress and investments in combating malaria. Emergence of artemisinin resistance or tolerance in Plasmodium falciparum on the Thailand—Cambodia border makes protection of the effectiveness of the drug supply imperative.

 

We reviewed published and unpublished studies reporting chemical analyses and assessments of packaging of antimalarial drugs. Of 1437 samples of drugs in five classes from seven countries in southeast Asia, 497 (35%) failed chemical analysis, 423 (46%) of 919 failed packaging analysis, and 450 (36%) of 1260 were classified as falsified.

(Continue . . . )

 

 

A problem of longstanding, the CDC’s website has more on the problem of fake Malaria drugs, and what steps travelers should take if the must purchase medication abroad.

 

Counterfeit and Substandard Antimalarial Drugs

What Are They?

Counterfeit (fake) antimalarial or other drugs are deliberately made to look like brand name drugs. However, they may have no active ingredients, they may have less than the required amount of active ingredient, or they may contain ingredients which are not what is described on the package label. Counterfeiters tend to focus on the more expensive brands. Substandard drugs are found even among cheaper products, because some manufacturers try to avoid costly quality control and good manufacturing practices.

The quality of commercially available drugs varies greatly in malaria-endemic countries:

• The amount of the active ingredient can vary due to lack of regulations and poor quality control practices in many of these countries.
• Some pills may release very little if any drug due to poor formulation techniques.
• Chemical break-down of some drugs can occur due to poor storage conditions, especially in warm and humid tropical climates.
• Some drugs may be contaminated with other substances.
• Counterfeiters may also obtain expired drugs and repackage them with new expiration dates.

Where Do You Find Them?

Worldwide prevalence of counterfeit and substandard products is summarized in a Drug Quality Report matrix by the U.S. Pharmacopeia Drug Quality and Information (USP DQI) Program. Information on domestic (U.S.) issues regarding counterfeit and poor-quality drugs is provided by the U.S. Food and Drug Administration.

 

For example, in Cambodia in 1999, counterfeit antimalarial drugs were responsible for the deaths of at least 30 people. A 2001 survey in Southeast Asia showed that among 104 tablets presented as the antimalarial drug artesunate, 38% did not contain any artesunate.

When Buying Drugs, Take the Following Precautions

• Travelers should buy in their home country all the medicines they will need before their trip.
• Travelers should write down the drug's generic and brand names as well as the name of the manufacturer. In case they run out, they can look for the correct product.
• Make sure that the drug is in its original packaging.
• Inspect the packaging because many times poor quality printing indicates a counterfeited product.
• Be suspicious of tablets that have a peculiar odor, taste, or color, or that are extremely brittle

»» Read More

Lancet: Increasing Incidence Of Infectious Diseases In New Zealand

 

 

# 6158

 

 

Forty-three years ago (1969), Surgeon General of the United States William H. Stewart, famously (and as it turned out, prematurely) declared,  "The war against diseases has been won."

 

And for a time, it seemed he might be right.

  

With the advent of the Salk Vaccine in 1955, we finally had the tool with which to eradicate the last great childhood scourge in this country; Polio. By 1963, an early measles vaccine had been developed, and in the late 1970s significant improvements had been made in the existing mumps vaccine.

 

And the tremendous victory over smallpox – now vanquished from the planet for more than 3 decades – seemed only to prove the point.

 

A telling graphic from the MMWR of Dec 1999, Achievements in Public Health, 1900-1999: Control of Infectious Diseases shows the progress made during the 20th century in the battle against infectious diseases.

 

 

 

But this victory was short-lived. By 1996 you can begin to see the uptick in infectious disease deaths, after reaching its nadir in 1980.

 

Since Stewart’s pronouncement we’ve seen a Swine Flu  pandemic, a SARS epidemic, the return of the H1N1 virus in 1977 plus the emergence of previously unknown pathogens like HIV, Lyme Disease, Nipah, Hanta and Hendra (among others).

 

We’ve watched the global spread of MRSA, along with the recent arrival of of NDM-1 and other Carbapenemases that threaten the viability of our antibiotic arsenal.  Even Gonorrhea, once easily cured, threatens with new drug resistant strains.

 

And we’ve seen an explosion in dengue and chikungunya cases, the global persistence of malaria, along with outbreaks of Ebola, CCHF, and other exotic diseases.

 

Even old scourges, once thought on the way out, are showing new signs of life . . . like Pertussis, measles, and polio. Perhaps most troubling of all has been the emergence of increasingly drug resistant strains of tuberculosis.

 

On average –  researchers have discovered one new zoonotic threat a year over the past three decades.

 

 

Admittedly a lot of these emerging infectious diseases are predominantly found in developing, or under-developed countries.

 

Non-communicable diseases – like cancer, coronary artery disease, diabetes, and tobacco-related illnesses – are generally thought of as being the primary health threats in developed countries.

 

And in terms of total numbers, that holds true.

But infectious diseases are on the rise in the developed world, as is once again confirmed by the following report on a nationwide epidemiological survey of New Zealand from The Lancet.

 

 

The Lancet, Early Online Publication, 20 February 2012

doi:10.1016/S0140-6736(11)61780-7

Increasing incidence of serious infectious diseases and inequalities in New Zealand: a national epidemiological study

Dr Michael G Baker MBChB a, Lucy Telfar Barnard PhD a, Amanda Kvalsvig MBChB a, Ayesha Verrall MBChB a, Jane Zhang MSc a, Michael Keall PhD a, Nick Wilson MBChB a, Teresa Wall DPH b, Prof Philippa Howden-Chapman PhD a

Findings

Infectious diseases made the largest contribution to hospital admissions of any cause. Their contribution increased from 20·5% of acute admissions in 1989—93, to 26·6% in 2004—08. We noted clear ethnic and social inequalities in infectious disease risk. In 2004—08, the age-standardised rate ratio was 2·15 (95% CI 2·14—2·16) for Māori (indigenous New Zealanders) and 2·35 (2·34—2·37) for Pacific peoples compared with the European and other group. The ratio was 2·81 (2·80—2·83) for the most socioeconomically deprived quintile compared with the least deprived quintile. These inequalities have increased substantially in the past 20 years, particularly for Māori and Pacific peoples in the most deprived quintile.

Interpretation

These findings support the need for stronger prevention efforts for infectious diseases, and reinforce the need to reduce ethnic and social inequalities and to address disparities in broad social determinants such as income levels, housing conditions, and access to health services. Our method could be adapted for infectious disease surveillance in other countries.

 

Retrospective epidemiological analyses such as this one are always subject to a certain degree of error.

 

As this study is based on hospital admissions, it is likely that milder infections are under-represented. Coding errors, or the re-evaluation of original diagnosis codes based on the judgment of the reviewers, may further complicate matters.

 

The authors cite economic and social disparities as prime factors in the increase in infectious diseases.

 

Problems that are hardly unique to New Zealand. 

 

While almost 75% of their hospitalizations still come as the result of non-communicable diseases, the trend over the past two decades shows that infectious diseases are gaining ground.

 

Up by roughly 30% since 1989.

 

In the discussion section, the authors write:

 

The large increase in admissions for infectious diseases has important health and economic implications, and challenges prevailing views about the waning importance of infectious diseases. New Zealand seems to have the dual burden of rising non-infectious diseases, without having controlled the incidence of infectious disease.

 

The increase is equivalent to an additional 17 000 hospital admissions per year compared with the expected incidence, had the proportion of admissions caused by infectious diseases in 1989—93 continued to the present.

 

 

For more on this apparent pendulum swing back towards emerging infectious diseases, you may wish to revisit a blog I wrote more than a year ago called:

 

The Third Epidemiological Transition

»» Read More

Lancet: Guillain-Barré Syndrome & H1N1 Vaccine In Children

 

Photo Credit – CDC PHIL 

 

# 5928

 

 

We’ve another study – published yesterday in The Lancet- on the safety of the 2009 pandemic vaccine that looked specifically at the development of Guillain Barre Syndrome among pediatric vaccine recipients in the UK.

 

Guillain-Barre Syndrome (GBS) is a neurological disorder that gained notoriety in 1976 after it was linked to an emergency flu vaccine that was rolled out in anticipation of a `swine flu’ pandemic.

 

As it turned out, the feared pandemic never came.

 

But before the campaign was abandoned - among the 40 million people who were vaccinated - around 500 people developed GBS and 25 died.

 

While not all of those cases were likely caused by the vaccine, the incidence of Guillian-Barre Syndrome was  around 1 in every 100,000 vaccinations. Or five times the expected background rate of this disease.

 

I was a young paramedic at the time, and chronicled my part in that bit of influenza history some time ago in Deja Flu, All Over Again. 

 

In the more than 3 decades since that fiasco, there has been little or no evidence of flu shots causing Guillain-Barre Syndrome. 

 

Still, memories of 1976 linger on, and anti-vaccine activists were only too happy to recall the unfortunate events of that year as they repeatedly warned that the `2009 swine flu vaccine was deadlier than the flu’.

 

Of course, the evidence clearly showed otherwise. 

 

Surveillance and reporting systems have not found any unusual pattern of deaths in the United States attributable to the pandemic vaccine, and the oft predicted spike in Guillain-Barré syndrome (GBS) never occurred (see CIDRAP VAERS study finds H1N1 vaccine safety similar to seasonal vaccines').

 

In fact, the VAERS report cited above found 0 deaths they could link to the pandemic Vaccine. Meanwhile, during the same period the CDC estimated that at least 12,000 (mostly younger) Americans died from the flu.

 

The CDC, along with many other public health agencies, have allowed that the flu vaccine might carry with it a very low risk of developing GBS. But most years the incidence is so low (perhaps 1 in 500,000 or 1 in a million) as to be nearly impossible to measure.

 

This from the CDC’s Guillain-Barré syndrome (GBS)  Q&A page.

 

What causes GBS?

Many things can cause GBS; about two-thirds of people who develop GBS symptoms do so several days or weeks after they have been sick with diarrhea or a respiratory illness. Infection with the bacterium Campylobacter jejuni is one of the most common risk factors for GBS.

People also can develop GBS after having the flu or other infections (such as cytomegalovirus and Epstein Barr virus). On very rare occasions, they may develop GBS in the days or weeks after getting a vaccination.

 

 

Recent studies have shown that you are many times more likely to develop GBS in the weeks following an influenza infection, than you are after getting the flu vaccine (see Lancet: The Influenza - Guillain Barré Syndrome Connection).

 

The irony here is, that the flu vaccine may turn out to be the best protection against the adverse vaccine effect that people seem to fear the most.

 

Adding a bit more weight to that argument, we’ve a letter published yesterday in The Lancet that looked at children who developed Guillain-Barré syndrome or Fisher's syndrome between September, 2009, and Aug 31, 2010.

 

doi:10.1016/S0140-6736(11)61665-6

Guillain-Barré syndrome and H1N1 influenza vaccine in UK children

Christopher Verity, Lesley Stellitano, Anne Marie Winstone, Nick Andrews , Julia Stowe , Elizabeth Miller

 

During the 12 months of surveillance, 55 children in the UK were diagnosed with GBS or Fisher’s syndrome. 

 

Of those, only 3 had received the pandemic flu shot, and of those, only 1 had received the shot within 6 weeks of developing neurological symptoms – a time frame that could suggest a causal relationship to the shot.

 

Among those same 55 children, 49 showed laboratory or clinical evidence of infection in the 90 days prior to developing symptoms.

 

• 22 had respiratory infections
• 13 had gastroenteritis
• 7 had H1N1 influenza (5 laboratory-confirmed)
• 2 had seasonal influenza (1 laboratory confirmed)
• 2 had Epstein-Barr virus
• 1 had chickenpox
• and 2 had unexplained fevers

 

Which matches pretty close to the CDC GBS FAQ above that states: about two-thirds of people who develop GBS symptoms do so several days or weeks after they have been sick with diarrhea or a respiratory illness.

 

The authors conclude by stating:

 

The peak in the number of children with Guillain-Barré syndrome or Fisher's syndrome shortly after the peak of the second wave of H1N1 infection in November, 2009, might reflect this causal association (figure).

 

Given the proven effectiveness of pandemic influenza vaccine used in UK children, the vaccination programme might have had an overall protective effect against Guillain-Barré syndrome.

 

 

Another UK study I highlighted last July (see BMJ: No Substantial Link Between Flu Vaccines And Guillain-Barre Syndrome), similarly found: 

 

“Adjuvanted pandemic influenza A (H1N1) 2009 vaccines did not increase the risk of Guillain-Barré syndrome substantially, if at all.”

 

For more reassuring research on the safety profile of modern flu vaccines, you may wish to revisit the following blogs:

 

Harvard Study Reaffirms Safety Of Flu Vaccine

MJA: Safety Of Flu Shot In Young Children

NEJM: Study On China’s H1N1 Vaccine Safety

Lancet: Immunogenicity and safety Of Adjuvanted Flu Vaccines

 

While no vaccine (or drug) can be said to be 100% safe – and rare but sometimes serious adverse effects have been reported - the preponderance of evidence continues to support the scientific consensus that flu vaccines are very safe and most years, reasonably effective.

»» Read More

CIDRAP: A Comprehensive Flu Vaccine Effectiveness Meta-Analysis

 

 

 

# 5924

 

I hadn’t intended today to be a `theme’ day at AFD, but things have certainly turned out that way.  

 

I started early this morning with a study on the reduced immune response from the flu vaccine among the obese (here), and this afternoon posted a link to the on-target comments by Dr. Jody Lanard on the CDC’s recent rollout of vaccine effectiveness numbers (here).

 

For the hat trick I’ve saved the best for last.

 

A comprehensive study lead by Michael T. Osterholm, director of CIDRAP (the Center for Infectious Disease Research and Policy) at the University of Minnesota, that provides a systematic review and meta-analysis on the efficacy and effectiveness of the TIV (trivalent Inactivated Vaccines) and LAIV (Live attenuated influenza vaccine) influenza vaccines.

 

Note: Most of the time, the terms `effectiveness’ and `efficacy’ can be used interchangeably, but in the scientific world there are subtle differences.

 

Effectiveness describes how well something works under day-to-day, real-world conditions.  In the following study, it is used to gauge the results of observational studies.

 

Efficacy describes how well something performs in a more controlled setting – and here it is used to describe the results of randomized placebo-controlled clinical trials.

 

Researchers at CIDRAP, along with colleagues from  the Marshfield Clinic Research Foundation and Johns Hopkins University examined more than 5700 existing  vaccine studies going back to 1967, and found 31 that met their (admittedly strict) criteria for inclusion.

 

What they were looking for were well-mounted studies that used highly sensitive laboratory testing (RT-PCR or culture) to confirm influenza infection in its participants.

 

Since the flu vaccine cannot be reasonably be expected to protect against non-influenza respiratory illness (ie. rhinovirus, adenovirus, enteroviruses, etc.), studies that fail to do this sort testing are of considerably less value.

 

 

 

After an exhaustive examination and whittling down process, fewer than 3 dozen studies met their criteria. As a result there remain some significant gaps in the evidence.

 

For example, there were no randomized controlled trials (RTCs) showing efficacy of the TIV (trivalent Inactivated Vaccines) in those aged 2–17 years or in adults 65 years or older. 

 

Similarly, they found no RCTs showing the efficacy of the LAIV (Live attenuated influenza vaccine) for people aged 8–59 years.

 

 

In the discussion, the authors write:

 

The evidence from trials and observational studies suggests that presently available influenza vaccines can provide moderate overall protection against infection and illness, with LAIV providing a consistently higher level of protection in children aged 7 years or younger.

 

But they found the protective effects of the flu vaccine could vary considerably from one season to the next, and among different age groups. Some years, and in some cohorts, there was little evidence of protection.

 

Although some of the numbers are lower than have been commonly stated in the past, today’s flu vaccines were shown to provide a moderate level of protection. 

 

TIV showed efficacy in preventing influenza during 8 of 12  flu seasons (67%) with a combined efficacy of 59% among healthy adults (aged 18–65 years).

 

And among children aged 2-7, the LAIV proved even more protective, showing efficacy in 9 out of 12 flu seasons (75%) with a pooled efficacy of 83%. 

 

 

Beyond the numbers, which probably represent the most accurate assessment of influenza vaccine effectiveness to date, this study also highlights the folly of depending upon a vaccine technology that has changed little since the 1950s.

 

Not only does it take too long to produce an emergency vaccine in the face of a pandemic . . .  those at greatest risk from a novel influenza virus are likely to receive the least amount of benefit from today’s vaccines.

 

The study’s authors say their findings should be seen as a clarion call for the development of more effective influenza vaccines.

 

Until that can happen, and despite these lower efficacy numbers, they still recommend getting the seasonal flu vaccine.     

 

Robert Roos, News Editor for CIDRAP (which operates independently of CIDRAP’s  research and policy programs) provides a good deal more detail on all of this, including extensive remarks by Dr. Osterholm.

 

 

Strict meta-analysis raises questions about flu vaccine efficacy

Robert Roos  News Editor

Oct 25, 2011 (CIDRAP News) – A rigorous new analysis of 44 years' worth of studies is raising questions about the evidence for the effectiveness of influenza vaccines in elderly people and, for certain types of vaccines, in children and younger adults as well.

 

Applying very strict criteria to filter out potential bias and confounding, a US research team sifted more than 5,000 studies and found only 31 that they felt provided reliable evidence about the efficacy and effectiveness of flu vaccines. The findings were published online today by Lancet Infectious Diseases.

(Continue . . . )

(Cites)

Osterholm MT, Kelley NS, Sommer A, et al. Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. Lancet Infect Dis 2011 (published online Oct 25)

Kelly H, Valenciano M. Estimating the effect of influenza vaccines. (Commentary) Lancet Infect Dis 2011 (published online Oct 25)

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Lancet Perspective: Mandatory Flu Vaccination For HCWs

 

 

Photo Credit – CDC PHIL

# 5709

 

 

A perspective appears today in The Lancet by Arthur Caplan, Ph.D., who is director of the Center for Bioethics at the University of Pennsylvania, on the ethics of mandating yearly influenza vaccination for Health Care Workers (HCWs).

 

Arthur Caplan is the author and/or editor of nearly 25 books, and more than 500 journal articles. He writes a regular column on bioethics for MSNBC.com, and is a frequent guest commentator on NPR, CNN, MSNBC, and for major newspaper outlets, including the New York Times and Washington Post.

 

In 2008, Discover Magazine named him one of the 10 most influential people in science.

 

Not known for mincing words (see Arthur Caplan On `Flunking The Swine Flu Test’ for an earlier example), Caplan states that: “Vaccination is a duty that one assumes in becoming a health-care provider.”

 

He argues that the evidence overwhelmingly shows that vaccinating HCWs helps to protect patients from infection (and possible death), and that the influenza vaccine is both safe and effective.

 

Citing language common to all oaths sworn by health care professionals (Doctors, Nurses, Techs, etc.), he points out the universal concept that the interests of the patient must come first, and that all HCWs must honor the core medical principal of, “First, do no harm.”

 

Both tenets, he argues, are violated when HCWs fail to accept a yearly flu vaccination.

 

Yet every year, despite awareness campaigns and the endorsement by many medical organizations, less than half of all healthcare providers in the United States and the UK voluntarily agree to take the vaccine.

 

You can read the entire piece at the link below, after which I’ll return with more.

 

The Lancet, Volume 378, Issue 9788, Pages 310 - 311, 23 July 2011

doi:10.1016/S0140-6736(11)61156-2

Time to mandate influenza vaccination in health-care workers

 

 

 

While strongly advocating HCW influenza vaccination, the CDC has stopped short of mandating them. I blogged on this back on June 23rd, 2010  in  CDC: Proposed Influenza Infection Control Guidance.

 

Numerous professional medical organizations have adopted policies calling for mandatory vaccination of HCWs, however.  A few earlier blogs on that include:

 

APIC Calls For Mandatory Flu Vaccination For HCWs

AAP: Recommends Mandatory Flu Vaccinations For HCWs

SHEA: Mandatory Vaccination Of Health Care Workers

IDSA Urges Mandatory Flu Vaccinations For Healthcare Workers

 

While many infection control experts see this as a long overdue step in patient and co-worker protection, this is a hugely divisive issue, with many HCWs believing that it is an infringement of their rights to decide what will be injected into their bodies.

 

I’ve covered HCW’s objections to forced flu shots in the past, including:

 

HCWs: Refusing To Bare Arms

HCWs: Developing a Different Kind Of Resistance

 

 

Given that hospitalized patients are often at increased risk of serious illness or death from influenza, reasonable measures that can reduce the spread of the virus – such as improved vaccination rates and better infection control measures - are vital areas that many healthcare facilities need to review and improve.

 

In recent years an increasing number of hospitals have managed to implement mandatory flu vaccinations, including Seattle’s Virginia Mason Medical Center and BJC Heathcare of St. Louis, Missouri  (see here and here).

 

 

The Immunization Action Coalition (IAC) maintains a terrific website with extensive information on vaccines, and includes a growing `Honor Roll’ of organizations and practices that have adopted a mandatory flu shot policy (some exemptions may apply).

 

As we saw last month in SHEA: Improving HCW Flu Vaccine Uptake, some facilities are offering employees an alternative to taking the vaccine. This from a recent edition of Infection Control and Hospital Epidemiology.

 

An Alternate Approach To Improving Healthcare Worker Influenza Vaccination Rates

Lisa M. Esolen, Kimberly Kilheeney, Richard E. Merkle

 

Essentially, this approach allows HCWs with medical or ethical objections to flu vaccination to opt out and elect to wear a surgical facemask during flu season when in close contact with patients.

 

 

Increasingly, hospitals are looking at this as both a liability and an economic issue, on top of their concerns over patient welfare. 

 

Of course, legal challenges still lie ahead.

 

But love the idea, or hate it, the momentum appears to be moving in the direction of mandatory influenza vaccinations for Health Care Workers.

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Lancet Study: TB Screening

 

 

 

# 5509

 

 

The World Health Organization estimates that roughly 2 billion people – nearly 1 in 3 – are infected with the TB bacilli, and of those, 1 in 10 will develop active TB during his or her lifetime.

 

The incidence of Tuberculosis varies greatly around the world, with North America, Europe and Australia/New Zealand seeing the lowest rates, and with the highest rates found in Africa, India, and Asia.

 

(From Global TB Control Report 2010)

 

For details on declining TB rates in the United States you may wish to revisit MMWR: Tuberculosis Trends In The United States.  For a more global view, I wrote about the WHO: Global Tuberculosis Control Report 2010 last November.

 

Last year, you may recall, I highlighted the increasing rates of TB in the UK on a couple of occasions. 

 

Last July, in UK: TB Rising we looked at a report on the incidence of Tuberculosis in London, England. This from the Journal of Public Health.

Recent trends in tuberculosis in children in London

J.E.T. Ruwende, E. Sanchez-Padilla, H. Maguire,
J. Carless, S. Mandal, D. Shingadia

Abstract

Background Childhood tuberculosis (TB) represents a sentinel event of recent transmission and is an indication of the effectiveness of prevention and control interventions. We analysed the trends in the epidemiology of TB in children in London aged 0–14 years between 1999 and 2006.

 

<SNIP>

 

Conclusions Ethnicity, country of birth and age are important risk factors for development of. With an overall TB incidence in London exceeding 40/100 000, universal BCG immunization of all neonates should be considered across all London boroughs.

 

 

In October, in UK: TB `Rife’ in Birmingham, we looked at press reports out of England’s second most populous city proclaiming  UK: "Third World" rate of TB in Birmingham.

 

While nowhere near the problem that it is in many developing nations, the rate of Tuberculosis has been rising in England steadily for the past decade.

 

Part of this increase has been due to Immigrants arriving from countries where TB is more prevalent. Although new arrivals are required to have chest X-rays to screen them for TB, that only catches active TB.

 

TSKs (Tuberculin Skin Tests), are also recommended for certain age groups immigrating from specific countries. These, however, will show positive for those who have received the TB vaccine, or who have been previously exposed (but not necessarily infected), limiting their usefulness.

 

This from the BBC

20 April 2011 Last updated at 21:32 ET

TB screening 'missing most cases'

Current screening for TB in immigrants arriving in the UK is missing the majority of cases, say researchers.

 

The genesis of this media report is the following study which appears in The Lancet (free registration req.), that argues that the adoption of blood tests (interferon-γ release-assay (IGRA)) to screen specific cohorts of immigrants for latent TB is both cost effective and will result in earlier treatment for many who unknowingly are infected. 

 

 

Screening for latent tuberculosis

Current UK policy requires that all immigrants from countries with a tuberculosis incidence higher than 40 per 100,000 have a chest X-ray on arrival to check for active tuberculosis. However, very few immigrants have active tuberculosis on arrival, and many are carriers of latent tuberculosis, which often progresses to infectious active tuberculosis within a few years of arrival in the UK. An Article, by Pareek and colleagues, estimates the yields from, and cost-effectiveness of, screening for latent infection at different thresholds in relation to incidence of tuberculosis in immigrants’ countries of origin.

 

The entire (very detailed) research article is called:

The Lancet Infectious Diseases, Early Online Publication, 21 April 2011

doi:10.1016/S1473-3099(11)70069-X

Screening of immigrants in the UK for imported latent tuberculosis: a multicentre cohort study and cost-effectiveness analysis

 

The blood test in question (IGRA) are whole-blood tests that can often diagnose Mycobacterium tuberculosis infection, in both its  latent form (LTBI) and active tuberculosis (TB) disease.

 

Unlike the TST (Tuberculin Skin Test), the IGRA (aka. IGT) doesn’t give a false positive in those with prior BCG (bacille Calmette-Guérin) vaccination.

 

The CDC maintains the following FAQ sheet on the IGRA tests.  

 

In June of 2010 the CDC published via the MMWR Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium tuberculosis Infection --- United States, 2010.

 

It should be noted that the NHS’s  NICE (National Institute of Health and Clinical Excellence) updated their 2006 guidance on screening for TB in March of this year, including the use of the IGRA blood tests.

 

 

These guidelines are recommendations, and it is up to local NHS agencies to decide whether to adopt them.

 

They now have the  combined weight of this new guidance, along with the Lancet study, to consider.

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Hopefully, It’s Just A Stage They Are Going Through

 

 

 

All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.

Arthur Schopenhauer
German philosopher (1788 - 1860)

 

 

Even as evidence of the spread of the NDM-1 resistance enzyme in India grows, Indian health officials and politicians are adamant in their denials that:

 

1) a problem exists  and

2) if a problem does exist, that it is in any way unique to India.

NDM-1, or New Delhi metallo-ß-lactamase-1, is an  enzyme that can confer resistance to certain gram negative bacteria like E.coli and Klebsiella against a class of antibiotics called carbapenems.

 

Last August a Lancet Infectious Diseases article was published on its growing prevalence on the Indian sub-continent and its recent importation into the UK, US, and other countries.

 

The Lancet Infectious Diseases, Early Online Publication, 11 August 2010

doi:10.1016/S1473-3099(10)70143-2Cite or Link Using DOI

Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study

 

The immediate reaction out of India was disappointing.  Condemnation of the use of `New Delhi’ in the naming of this resistance gene, and broad denials that medical tourism to India was responsible for its spread.

 

The naming convention for pathogens typically invokes its place of discovery or emergence. 

 

In 2001 a similar gene was discovered in Brazil and was dubbed SPM-1 (Sao Paulo metallo-beta-lactamase). Another, discovered in 1999 in Italy, is called VIM (Verona integron-encoded metallo-β-lactamase), while SIM stands for Seoul imipenemase found in Korea.

 

Last August Indian officials took umbrage over the naming of NDM-1, called the claims of its emergence and spread from India a `conspiracy theory’, and rejected The Lancet paper out of hand.

 

12 August 2010 Last updated at 10:44 ET

India rejects UK scientists' 'superbug' claim

By Geeta Pandey BBC News, Delhi

India has rejected a claim by British scientists that a new superbug, resistant to even the most powerful antibiotics, has entered UK from India.

(Continue . . . )

 

The rest of the world, however, was less sanguine (see Public Health Agencies On NDM-1) regarding NDM-1’s spread..

 

 

Since that time the NDM-1 gene has been the subject of much international concern, particularly since it can be carried on a plasmid – a snippet of DNA - that has the potential to jump to other strains of bacteria.

 

Last week the original authors of the NDM-1 study came forth with new data in The Lancet that found evidence of the resistance enzyme in New Delhi’s tap water and sewage sites.

 

They also found evidence that this enzyme had been passed on to 11 other types of bacteria (see  Lancet Study: NDM-1 In New Delhi Water Supply).

 

Indian reaction to this latest paper has been swift and strong, with new denials that a problem exists, or that NDM-1 posed a public health threat in New Delhi.

 

This from The Economic Times.

 

11 Apr, 2011, 02.55PM IST,PTI

India being wrongly blamed for bacteria in drinking water

NEW DELHI: Accused of "supressing the truth" about drug resistant bacteria reportedly found in Delhi's public water supply, the Union Health Ministry today said India was being "unnecessarily and wrongly blamed" and singled out in the matter.

(Continue . . . )

 

 

Indian officials have claimed that the researchers `illegally transferred’ samples of tap water out of the country, have stated that the research was `unscientific’ and insist that the researchers are intentionally biased.

 

The stakes for Indian officials are admittedly high, as medical tourism is a profitable sector of the economy and continual discussion of emerging `superbugs’ cannot possibly enhance their medical reputation.

 

Additionally, the costs of trying to rectify deficits in New Delhi’s water and sewage systems (and those elsewhere across the nation) would be enormous and prohibitive.

 

The authors of the study remain adamant that their findings are correct, and that the Indian government is `in denial’ and suppressing information.

 

This from The Statesman.

 

India suppressing truth about NDM-1: Lancet

10 April 2011

NEW DELHI, 10 APRIL: Notwithstanding the Union government’s persistent denials of the presence of a drug-resistant bacteria in the public water system, an international health journal Lancet has charged the government with “suppressing truth” about the presence of a drug-resistant bacteria in Delhi’s public water system by “threatening” and “abusing” its own scientists. It has dubbed the government’s denial of presence of such a bacteria as “unfortunate” .

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While one could certainly debate the `sensitivity’ of naming pathogens after their place of discovery, the fact is that is a long-standing convention used worldwide (ie. West Nile Virus, St. Louis Encephalitis, Hong Kong Flu, Asian Flu,  etc.).

 

The Indian strategy of `shooting the messenger’ solves nothing, and delays in determining the scope of the problem could end up costing many lives.

 

Rather than simply maligning the researchers, now is the time for Indian officials to call for an open, independent, and outside investigation into the NDM-1 threat in India. 

 

Only then can the truth be satisfactorily determined.

 

The problem with Arthur Schopenhauer’s quotation is that it can take a long time to reach the third stage – accepting the truth as being self-evident.

 

Time, that frankly, the world can ill afford to waste.

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Lancet Study: NDM-1 In New Delhi Water Supply

 

 

# 5470

 

Released just in time for World Health Day, we’ve a fresh study that appears in The Lancet authored by Timothy Walsh, Janis Weeks , David M Livermore, and Mark A Toleman that looked for – and found – bacteria carrying the NDM-1 enzyme in New Delhi's drinking water supply.

 

NDM-1, or New Delhi metallo-ß-lactamase-1, is an  enzyme that can confer resistance to certain gram negative bacteria like E.coli and Klebsiella against a class of antibiotics called carbapenems.

 

Carbapenems are newer generation beta-lactam antibiotics (a class that includes penicillins, cephalosporins, cephamycins, and carbapenems) that are usually reserved as an antibiotic of last resort.

 

Up until recently, Carbapenems have been generally resistant to Beta-lactamases - enzymes bacteria use to breakup the ring structure of “beta-lactam” antibiotics - that renders them ineffective.

 

But in recent years a new enzyme has been spreading in India, Bangladesh, and Pakistan that helps certain types of bacteria to defeat Carbapenem antibiotics; NDM-1.

 

Although the NDM-1 enzyme has been around since about 2008, it made headlines last August when a Lancet Infectious Diseases article was published on its growing prevalence on the Indian sub-continent and its recent importation into the UK, US, and other countries.

 

Professor Timothy Walsh, along with two of the co-authors of today’s report (David M Livermore , Mark A Toleman) were among the authors of this original Lancet study.

 

The Lancet Infectious Diseases, Early Online Publication, 11 August 2010

doi:10.1016/S1473-3099(10)70143-2Cite or Link Using DOI

Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study

 

 

Since that time the NDM-1 gene has been the subject of much scientific scrutiny and enhanced surveillance, particularly since it often carried on a plasmid – a snippet of DNA - that has the potential to jump to other strains of bacteria.

 

Although most cases reported in Europe and North America have travel links to Southeast Asia, that can’t be said for all of them.

 

Last November Maryn McKenna explored the apparent community spread of the bacteria in NDM-1, the supergene: Further (community?) spread.

 

We’ve a press release on today’s study, issued by Cardiff University, that gives the highlights of the study, but the `money quote’ (emphasis mine) buried about halfway down is:

 

Resistant bacteria were found in 4 per cent of the water supplies and 30 per cent of the seepage sites. The researchers identified 11 new species of bacteria carrying the NDM-1 gene, including strains which cause cholera and dysentery.

 

The spread of the NDM-1 gene to 11 new strains of bacteria is particularly ominous news.

 

In an interview for Reuters today, co-author Mark Toleman of Britain’s Cardiff University School of Medicine stated that as many as 500,000 residents of New Dehli may be carrying the NDM-1 resistance gene in their gut flora.

 

 

Antibiotic-resistant bacteria in Indian public water supply

Disease-causing bacteria carrying the new genetic resistance to antibiotics, NDM-1, have been discovered in New Delhi's drinking water supply.

 

A Cardiff University-led team found new strains of resistant bacteria in the Indian capital, including species which cause cholera and dysentery. The findings are the first evidence of the environmental spread of NDM-1, which had previously only been found in hospitals.

 

The scientists are calling for urgent action by health authorities worldwide to tackle the new strains and prevent their global spread. The Cardiff scientists also highlight the all-round benefits of preventative measures such as better sanitation and appropriate drinking water.

 

Cardiff scientists were the first to identify the NDM-1 gene which makes bacteria resistant to a large range of antibiotics. Moreover, the NDM-1 gene is carried on mobile DNA called plasmids which can carry up to 13 other antibiotic resistance genes. While most patients with the bacteria have recently been hospitalised in India, some cases have occurred there without recent hospital treatment, prompting the team to test the wider environment.

 

Samples were taken in New Delhi from public water taps and from waste seepage, such as water pools in the street. Resistant bacteria were found in 4 per cent of the water supplies and 30 per cent of the seepage sites. The researchers identified 11 new species of bacteria carrying the NDM-1 gene, including strains which cause cholera and dysentry.  Antibiotics are used to reduce excretion of bacteria in cholera patients, and to reduce the duration and severity of dysentery. Worryingly, the identified Shigella isolate, which can carry dysentery, is resistant to all appropriate antibiotics.

 

Study leader Professor Tim Walsh, of Cardiff University's School of Medicine, said: "These are extremely worrying results. We found resistant bacteria in public water used for drinking, washing and food preparation and also in pools and rivulets in heavily-populated areas where children play. The spread of resistance to cholera and to a potentially-untreatable strain of dysentery is also a cause for extreme concern."

(Continue . . . )

 

 

Below is a link to the Lancet study, which you can read in its entirety (a free registration is required).

 

The Lancet Infectious Diseases, Early Online Publication, 7 April 2011

doi:10.1016/S1473-3099(11)70059-7Cite or Link Using DOI

 

Dissemination of NDM-1 positive bacteria in the New Delhi environment and its implications for human health: an environmental point prevalence study

Prof Timothy R Walsh PhD , Janis Weeks BS, David M Livermore PhD , Mark A Toleman PhD

 

Interpretation

The presence of NDM-1 β-lactamase-producing bacteria in environmental samples in New Delhi has important implications for people living in the city who are reliant on public water and sanitation facilities. International surveillance of resistance, incorporating environmental sampling as well as examination of clinical isolates, needs to be established as a priority.

(Continue . . . )

 

 

Antibiotics have often been called the miracle drugs of the 20th century, but almost from their inception bacteria have been evolving and finding ways to evade them. 

 

In 1940, even before penicillin could be rolled out for clinical use, the first β-lactamase (Penicillinase) was identified by researchers in a sample of Gram-negative E. coli.

 

Over the next two decades this penicillinase resistance spread to other bacteria, which required the creation of newer generations of penicillin (such as Methicillin in 1959), that were resistant to these enzymes.

 

Methicillin is no longer used (replaced by newer generation antibiotics), although we retain its name in the term MRSA (Methicillin-resistant Staphylococcus aureus), which was identified in the UK just two years after Methicillin was introduced.

 

Today, we are seeing an ever expanding array of antimicrobial resistant bacteria and a worrying lack of new drugs in the development pipeline to deal with them.

 

Which is why the World Health Organization has declared that the focus on this year’s World Health Day (April 7th) to be on this growing threat.

 

You can read more on this global observance in my blog  World Health Day 2011.

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