16 July 2013
07 July 2013
H3N2v VIRUS
Distributed via the CDC Health Alert Network
July 05, 2013, 09:00 ET (9:00 AM ET)
CDCHAN-00351
Variant Influenza Virus (H3N2v) Infections
Summary: This Health Alert Network Health Advisory provides an update on H3N2 variant virus (or “H3N2v”) activity and summarizes CDC’s updated H3N2v case definitions and recommendations for H3N2v surveillance for the summer and fall of 2013. It supersedes the last H3N2v-related HAN Health Advisory, HAN 325, which was issued August 3, 2012.
Background
The first cases of influenza A (H3N2) variant1 (H3N2v) virus infection this year were reported in June 2013. These cases were associated with exposure to swine at an agricultural fair prior to illness onset.
H3N2v viruses with the matrix (M) gene from the 2009 H1N1 pandemic virus were first detected in people in 2011 and were responsible for a multi-state outbreak in the summer of 2012 that resulted in 306 cases, including 16 hospitalizations and 1 fatality. Genetic sequencing by CDC has confirmed that H3N2v viruses isolated in June 2013 are nearly identical to those detected during summer 2012. Most cases of H3N2v identified during 2012 were associated with exposure to pigs at agricultural fairs. Agricultural fairs take place across the United States every year, primarily during the summer months and into early fall. Many fairs have swine barns, where pigs from different places come in close contact with each other and with people. These venues may allow spread of influenza viruses both among pigs and between pigs and people. Data indicate that infected pigs may spread influenza viruses even if they are not symptomatic (e.g., coughing and/or sneezing). Although instances of limited person-to-person spread of this virus have been identified in the past, sustained or community-wide transmission of H3N2v has not occurred.
Clinical characteristics of the 2012 and 2013 H3N2v cases have been generally consistent with those of seasonal influenza, and have included fever, cough, pharyngitis, myalgia, and headache. Of the 16 H3N2v hospitalized patients, most were at increased risk for complications of influenza because of age or the presence of an underlying medical condition. None of the persons ill with 2013 H3N2v infection have been hospitalized, and no deaths have occurred among them.
Rapid detection and characterization of novel influenza viruses remain important components of national efforts to prevent further cases and evaluate clinical illness associated with these viruses. As a result, clinicians are reminded to consider influenza as a possible diagnosis when evaluating patients with acute respiratory illnesses, and clinicians should consider the possibility of H3N2v in persons presenting with respiratory illness and recent swine contact or attendance at an agricultural fair. The H3N2v case definitions for 2013 (http://www.cdc.gov/flu/swineflu/case-definitions.htm) include laboratory-confirmed cases and cases under investigation for H3N2v virus infection; the probable case definition used in 2012 has been deleted.
CDC anticipates that state health departments will identify more H3N2v cases in 2013 as agricultural fair season continues. The number of cases may exceed those identified last year, and CDC recommends a surveillance strategy for 2013 designed primarily to identify increases in person-to-person transmission or clinical severity. Testing for H3N2v should focus primarily on persons with exposures known to be associated with H3N2v virus infection (e.g., fair attendance) and in settings where person-to-person transmission has been identified previously (e.g., influenza-like illness outbreaks in child-care centers). For more information on 2013 testing recommendations, please see http://www.cdc.gov/flu/swineflu/h3n2v-surveillance.htm. Novel influenza A virus infections, which include those caused by H3N2v, remain notifiable conditions in the United States, and all confirmed cases should be reported to CDC within 24 hours.
CDC continues to share information and guidance for local and state public health officials regarding the surveillance and investigation of human infections with H3N2v. This information is available at http://www.cdc.gov/flu/swineflu/h3n2v-publichealth.htm.
HEPATITIS A VIRUS : ITALIAN FROZEN BERRIES (redcurrent, black-,blue- raspberries)
HEPATITIS A - EU (05): (ITALY) FROZEN BERRIES
*********************************************
A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases
Date: Thu 4 Jul 2013
Source: Eurosurveillance Edition 2013, 18(27) [summ., edited]
Ongoing outbreak of hepatitis A in Italy
----------------------------------------
[Byline: Rizzo C, Alfonsi V, Bruni R, Busani L, Ciccaglione AR, De
Medici D, Di Pasquale S, Equestre M, Escher M, Montaño-Remacha MC,
Scavia G, Taffon S, Carraro V, Franchini S, Natter B, Augschiller M,
Tosti ME, the Central Task Force on Hepatitis]
Since January 2013, an unusual increase in hepatitis A cases has been
detected in northern Italy. A total number of 352 cases were reported
to the integrated surveillance system between January 2013 and the end
of May 2013, and this represents a 70 percent increase compared to the
same period of the previous year [2012]. The outbreak is ongoing and
the public health authorities are continuing their investigations to
establish the transmission vehicle and to control the outbreak.
From 1 Jan 2013 to 31 May 2013 a total of 352 cases of hepatitis A
were reported to the Italian national surveillance system,
corresponding to a 70 percent, 54 percent, and 34 percent increase in
HAV [hepatitis A virus] notifications compared to the same period in
2012, 2011 and 2010, respectively. Here we describe the
epidemiological features of the cases and the investigation of the
outbreak.
Surveillance of hepatitis A in Italy
------------------------------------
Hepatitis A is a notifiable disease in Italy. According to the
national legislation, laboratory-confirmed cases of hepatitis A virus
(HAV) infection are reported by clinicians to the local health units
(LHUs) which are responsible for the epidemiological investigation.
From the LHUs, notifications are sent to the regional health
authorities (RHAs) and from here to the Ministry of Health. However,
the routine notification system does not collect information on risk
groups and risk factors associated with hepatitis A and there is an
important delay in the transmission of the data [1]. For this reason,
in 1984, a specific sentinel surveillance system for acute viral
hepatitis (SEIEVA -- Sistema Epidemiologico Integrato Epatiti Virali
Acute) was set up in parallel with the official notification system in
Italy [2]. Data included in the SEIEVA system provide insight into the
risk factors associated with the disease. Data collected by SEIEVA are
provided by LHUs, which participate on a voluntary basis. A case is
defined as a person with an acute illness including symptoms
clinically compatible with hepatitis A, such as fever, fatigue,
nausea, vomiting, abdominal pain, dark urine and jaundice, and
positive for IgM anti-HAV. Cases are interviewed using a standardised
online questionnaire collecting socio-demographic, clinical and
laboratory information, and information on possible risk factors
(shellfish consumption, contact with a jaundice case, travel to an
endemic area, child attending daycare in the household, intravenous
drug use in the last 6 months). After the alert issued by the northern
European countries about a possible association between the hepatitis
A cases and frozen berries [3], the consumption of mixed frozen
berries was included as another possible risk factor in the SEIEVA
questionnaire at the end of April 2013.
As of 31 May 2013, 76 percent of the Italian LHUs (139/181)
participate in the SEIEVA. The participating LHUs are distributed all
over the country and cover 70 percent of the population. Data were
adjusted considering the total population of the LHUs' catchment
areas.
Epidemiological situation of hepatitis A in Italy
-------------------------------------------------
In recent decades, the epidemiological pattern of hepatitis A has
changed. Italy is considered to be at low/intermediate endemicity for
HAV [2,4]. The improved health and sanitary conditions have favored a
progressive decrease of the infection rate in children, and a major
shift of the population at risk, with the highest incidence reported
in young adults. Outbreaks were described in 1996-1997 and 2004 mainly
in southern Italian regions (Apulia and Campania) and were related to
the consumption of contaminated raw shellfish [5,6]. From 1997, when
the incidence was 19 per 100 000 population [2] to date, a decreasing
trend in the incidence of HAV has been observed, to 1.1 cases, 0.7 and
0.8 per 100 000 population in 2010, 2011, and 2012, respectively [7].
The 2013 hepatitis A outbreak in Italy
--------------------------------------
From 1 Jan 2013 to 31 May 2013 a total number of 352 cases of
hepatitis A were reported to SEIEVA surveillance system, corresponding
to a 70 percent, 54 percent and 34 percent increase in HAV
notifications compared to the same period in 2012, 2011 and 2010,
respectively. The highest increase in the number of cases was observed
in 7 northern Italian regions (Trento and Bolzano, Emilia-Romagna,
Lombardy, Friuli Venezia Giulia, Piedmont, and Veneto) that accounted
for 193/352 (55 percent) of the total cases recorded in 2013. In these
7 regions, the cumulative incidence was 2.66 per 100 000 population in
the 5-month reference period. Another region that showed an increase
in the number of cases in 2013 is Apulia, in southern Italy, which
recorded a 22 percent increase in the number of cases in 2013; 77 of
the 352 cases were reported from this region.
The mean age of cases was 35 years (range: 2-63 years) and the median
was 39 years; 23 cases (12 percent) were recorded in children under 14
years. The cases were equally distributed among men and women: 55
percent of the cases were men and 45 percent were women. A total of
159 persons were hospitalised, with the majority of hospitalised cases
in the age group of 35-54 years. As of 31 May 2013, no acute liver
failures and deaths occurred; 4 cases had been vaccinated against
hepatitis A, with one dose within the 3 weeks before the onset of
symptoms, so these were not considered vaccine failures.
With regard to the risk factors, among those who answered the
questionnaire (193 cases), 3 percent (7/193) reported to have
travelled to Egypt, 17 percent (33/193) reported to have eaten raw
seafood and 20 percent (37/193) mixed berries in the 6 weeks before
the symptom onset. When considering risk factors distribution after
the end of April [2013] (date of introduction of the question on the
consumption of frozen mixed berries), the majority of cases (37 of 46)
reported having consumed frozen mixed berries.
Description of the 2013 hepatitis A outbreak in the provinces of
Trento and Bolzano
---------------------------------------------------------------------------
In May 2013, Germany, the Netherlands and Poland reported through the
Epidemic Intelligence Information System for food- and waterborne
diseases (EPIS-FWD) and the Early Warning and Response System (EWRS)
15 cases of HAV infection associated with a ski holiday in the
autonomous provinces of Trento and Bolzano (northern Italy). The
sequencing of the VP1-region of these 5 Italian isolates, from Trento
province, showed 100 percent nucleotides homology with those isolated
from 2 German and one Dutch case [8].
After the EPIS and EWRS notifications, a retrospective epidemiological
investigation started in the provinces of Trento and Bolzano,
contacting cases notified through the regional notification system.
For the epidemiological investigation, a confirmed case was defined as
a person resident in the provinces of Trento and Bolzano with an acute
illness including symptoms clinically compatible with hepatitis A,
such as fever, fatigue, nausea, vomiting, abdominal pain, dark urine
and jaundice, and identified as positive for IgM anti-HAV after 1 Jan
2013.
Between 1 Jan and 31 May 2013, 31 cases of HAV infection were notified
in the province of Trento (a 13-fold, 19-fold and 6-fold increase
approximately, compared to the same period in 2012, 2011, and, 2010
respectively). The 1st case reported the onset of symptoms on 2 Feb
2013 and the most recent case was identified on 31 May 2013. Most of
the cases had the onset of symptoms in May 2013 (15 cases).
In the province of Bolzano, 7 cases were reported in the same period.
The epidemic curve of the 38 confirmed HAV infection cases in these 2
provinces shows the evolution of the outbreak over time and suggests a
common vehicle of transmission.
In these 2 provinces, the mean age of the cases was 36.3 years (range:
3-63 years) and the median was 38.5 years. Men were more represented
than women (24 versus 14). A total of 31 persons were hospitalised and
the majority of them were 35 to 54 years old. There was only one case
vaccinated and this case was reported from the province of Trento;
however, this case had been vaccinated with one dose within the 3
weeks before the onset of symptoms, so this was not considered a
vaccine failure. Preliminary epidemiological investigation for the
identification of risk factors and common exposures focused on
consumption of contaminated food as no epidemiological link between
the cases could be confirmed. The only common food consumed by all
cases was mixed berries or food containing mixed berries (cakes).
Serum samples were collected during the acute phase of the disease
from 5 of the 38 cases, all from the Trento province. The sequence of
the VP1/2A region of the HAV 1A virus obtained from all of them (with
GenBank accession number KF182323) showed a 100 percent nucleotides
homology with sequences of the isolates from the German and Dutch
cases.
Investigation of food items implicated
--------------------------------------
The preliminary epidemiological investigation in the provinces of
Trento and Bolzano showed that the only common food consumed by
different cases was mixed berries or food containing mixed berries
(cakes). Moreover, the hypothesis was strongly supported by the
results of an epidemiological investigation conducted in a family
cluster in Veneto region. Part of the mixed berries (redcurrant,
blackberries, raspberries, blueberries) that the cases indicated to
have eaten within the period of time compatible with the onset of
clinical symptoms were still available and were sampled. The analysis
for HAV detection in the sample of mixed berries provided positive
results. As a consequence, on 17 May 2013, the Italian Ministry of
Health (which is the food safety authority at national level)
communicated these findings through the European Rapid Alert System
for Food and Feed (RASFF). Following these preliminary positive
results, the surveillance of these food items was intensified. More
samples of berries were collected throughout the country once they
were identified as potential risk factors, and 2 sampled berries in
Trento were found positive for HAV. On 30 May 2013, 2 additional RASFF
notifications were issued to inform about new HAV findings in frozen
mixed berries from Italy. Environmental investigations have been done
on the mixed frozen berries suppliers of raw material in 6 different
countries. Results on samples collected are pending at the time of the
present rapid communication.
Control measures
----------------
On 23 May 2013 the Ministry of Health (the General Direction for
Prevention together with the food safety authority) published a note
for RHAs in order to enhance surveillance and awareness of HAV
recommending to report within 24 hours any new HAV cases, to collect
additional epidemiological information on risk factors associated, and
perform virus genotyping and sequencing from all new cases. In
addition to the recommendation mentioned above, a case-control study
in the regions that experienced the highest increase of cases was
planned, in order to support the hypothesis of berries as a source of
infection, to find other potential risk factors and to identify
appropriate control measures. The National Institute of Health
(Istituto Superiore di Sanita, ISS) is responsible for the
coordination of the virological and epidemiological investigations,
and of the case-control study.
Moreover, after the positive results on the sampled frozen mixed
berries from different regions, the Ministry of Health started the
tracing back of this food item. The investigation identified a dealer
that received consignments of berries from different countries (mix
made in Italy, with raw material from Bulgaria, Canada, Poland, and
Serbia).
Following the RASFF notification from the Ministry of Health, regions
recalled the lots that were identified positive for HAV and advised
the population through the website of the Ministry of Health regarding
the use of the leftover frozen mixed berries. Trace back
investigations on food are ongoing for each new case notified. The
European Centre for Disease Prevention and Control (ECDC) performed a
rapid risk assessment that was published on 16 Apr 2013 [8].
Discussion
----------
Preliminary analysis of the case interviews on possible risk factors
associated with the ongoing outbreak identified consumption of frozen
mixed berries (redcurrant, blackberries, raspberries, blueberries) as
a potential vehicle of infection. The hypothesis that they could be
implicated is strongly supported by the detection of HAV virus in a
sample of frozen mixed berries. The surveillance on these frozen mixed
berries together with other food items potentially carrying the HAV
(vegetables, seafood, and other food reported as potential risk
factors by cases in the epidemiological investigation), has been
intensified, to provide a clear picture of the distribution of the
contaminated items and the risk of exposure through these.
A total of 7 sequences of HAV genotype 1A isolated from cases in
different countries (the Netherlands, Germany and Italy) and in
different laboratories showed a 100 percent similarity. The genotype
and the sequence of the virus isolated in the Italian outbreak is
different from the currently ongoing outbreak with frozen berries as a
suspected vehicle described in northern European countries and in the
United States].
--
Communicated by:
ProMED-mail
[Remarkably, a 3rd outbreak of hepatitis A virus infection is
described above to supplement the outbreaks in 4 Nordic countries of
the European Union and several states in North America. Again, mixed
frozen berries are implicated as the source of the outbreak. Hepatitis
genotype 1a is implicated in the Italian outbreak in contrast to the
Nordic countries and US outbreaks where the agent is hepatitis A virus
genotype 1b. In contrast to the other 2 outbreaks, in the Italian
outbreak hepatitis A virus was recovered directly from the frozen
berries product.
Frozen mixed berries are now being revealed as a previously
unrecognised vehicle of hepatitis A virus infection. By their nature
these soft fruits are frozen to enable them to be marketed far from
their sites and time of production. The eastern Mediterranean region
appears to be the source of at least some of these products.
Harvesting berried soft fruits is a labour-intensive occupation which
increases the risk of transmission of infectious agents. The habit of
the mixing of different berried fruits increases the risk, since some
fruits require a greater amount of handing than others. - Mod.CP
A HealthMap/ProMED-mail map can be accessed at:
.]
29 June 2013
USA(Miami): Dr. Augusto SARMIENTO: FUNCTIONAL FRACTURE BRACING (FFB)
Dr.Sarmiento: FFB is a system of nonsurgical care for certain long- bone fractures based on the proposition that immobilization of joints above and below a fracture is not essential for healing, and that the resulting physiologically induced motion at the fracture site is conducive to the formation of a stronger callus.
Body Cast Editor: How has functional fracture bracing evolved from its inception?
Dr. Sarmiento: Experiences with the PTB prosthesis for the below-the-knee amputee developed in the early 1960s,
which successfully eliminated the traditional thigh corset, prompted me to suspect that a below-the-knee cast molded
like the prosthesis could be successfully used in the treatment of tibial diaphyseal fractures, where the proximal fragment would be the equivalent of the stump and shortening would be prevented. The initial results were encouraging, but soon I realized that neither the indented patellar tendon nor the molded tibial condyles were major weight-bearing
contributors. The soft tissues surrounding the fractured bones were the structures that prevented shortening above
the one present at the initial injury. A degree of shortening that does not increase with the introduction of graduated
weight-bearing ambulation.
Therefore, the name PTB commonly used to describe the cast is wrong. Further experiences with the short-leg functional cast led to the construction of a brace that gave freedom of motion of the ankle joint, as well.
Following subsequent clinical and laboratory investigations, the concept was extended to other bones, such as the humerus, forearm, isolated fractures of the ulna, the femoral shaft, tibial nonunions, and Colles' fractures. The results were mixed, so much that the use of the system was discontinued for fractures of both bones of the forearm, open tibial fractures and the femur. Advances in the surgical treatment of these fractures fully justified their dismissal. Similarly, the intramedullary nailing of fractures has made this approach a successful one in the management of many tibial fractures, particularly in those with unacceptable initial shortening or uncorrectable angulation.
UK: NURSING MEDICATION ERRORS in NHS HOSPITALS
From UK DAILY MAIL
Saturday, Jun 29 2013 12PM 16°C 3PM 20°C 5-Day Forecast
One in three diabetes patients 'are given the wrong medication while in hospital'
A third of patients in England and Wales experienced a 'medication error' during a five week audit
The audit found that 61 patients had developed life threatening ketoacidosis during a hospital stay
Charity Diabetes UK says it is 'appalling' that anybody should develop the preventable condition
By Daily Mail Reporter
PUBLISHED: 00:49 GMT, 27 June 2013 | UPDATED: 07:52 GMT, 27 June 2013
Worrying: A third of patients in hospitals in England and Wales experienced a 'medication error' during the five-day National Diabetes Inpatient Audit (file picture)
Worrying: A third of patients in hospitals in England and Wales experienced a 'medication error' during the five-day National Diabetes Inpatient Audit (file picture)
One in every three diabetic patients are given the wrong medication while in hospital, a new report suggests.
A third of patients in hospitals in England and Wales experienced a 'medication error' during the five-day National Diabetes Inpatient Audit.
The audit, conducted last September, also found that 61 patients developed a life-threatening but preventable complication due to poor care.
Charity Diabetes UK said it is 'appalling' that any patients should develop diabetic ketoacidosis during a hospital stay.
The audit, which examined data from 13,400 patients, also found that a fifth of patients suffered from hypoglycaemia while in hospital.
Bridget Turner, director of policy and care improvement at Diabetes UK, said: 'It is appalling that some people with diabetes are being so poorly looked after in hospitals that they are being put at risk of dying of an entirely preventable life-threatening condition.
'Even a single case of diabetic ketoacidosis developing in hospital is unacceptable because it suggests that insulin has been withheld from that person for some time.
'The fact that this is regularly happening raises serious questions about the ability of hospitals to provide even the most basic level of diabetes care.
'In every aspect of hospital diabetes care that this report shines a light on, the picture that emerges is profoundly disturbing.
Read more: http://www.dailymail.co.uk/health/article-2349313/One-diabetes-patients-given-wrong-medication-hospital.html#ixzz2XbmK7OG7
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26 June 2013
PERSONALIZED (PRIVATE) vs GUIDELINE (STATE) MEDICINE
ONLINE FIRST
Personalized Medicine vs Guideline-Based Medicine
Published online
May 27, 2013
Two
philosophical approaches to the implementation of optimal health care
are emerging—the use of evidence-based guidelines and the application of
personalized (or “precision”) medicine. Even though both approaches
have important merits, they both also can present conflicting priorities
that must be reconciled before they can be best leveraged.
Evidence-based
guidelines are generated based on the body of clinical data available
for a particular question. The highest level of evidence assigned in a
guideline is based on multiple randomized controlled clinical trials. In
general, randomized clinical trials have specific inclusion and
exclusion criteria designed to represent a population broad enough and
sufficiently enriched to attain a requisite number of end points and
demonstrate a statistically and clinically significant difference in
outcome. Subgroup analyses (both those that are prespecified and other
post hoc analyses) are often performed to identify characteristics
within the study population that are associated with greater benefit
from the intervention, with no benefit, or even with harm. Yet these
analyses are accompanied by warnings that findings should be cautiously
interpreted.1
24 June 2013
UK AVITA MEDICAL : RECELL spray-on skin
About ReCell
ReCell is a stand-alone, rapid, autologous cell harvesting,
processing and delivery technology that enables surgeons and clinicians
to treat skin defects using the patient's own cells in a regenerative
process.Developed as an 'off the shelf' kit, ReCell enables a thin split thickness biopsy, taken at the time of the procedure, to be processed into an immediate cell population for delivery onto the surface of the treatment area using a highly efficient, easy-to-use proprietary 'spray-on' application process. Tissue collection, cell segregation and preparation of the cell suspension takes approximately 20-30 minutes in total during which time the treatment area is prepared. Once processed, the cell suspension is available for immediate use and can cover a treatment area up to 80 times the area of the donor biopsy.
ReCell enables the delivery of keratinocytes, melanocytes, fibroblasts and Langerhans cells harvested from the epidermal-dermal junction for application onto a wound surface in order to promote rapid and effective healing.
ReCell has been clinically demonstrated to accelerate healing, minimize scar formation, eliminate tissue rejection and reintroduce pigmentation into hypopigmented areas.
ReCell has been designed for use in a wide variety of wound, plastic, reconstructive, burn and cosmetic procedures including burns and scalds, donor sites, glabrous injuries, mild to moderate scars, hypopigmentation (hypopigmented scars, iatrogenic hypopigmentation and Vitiligo) and in aesthetic rejuvenation procedures.
As the ReCell technology enables cell processing at the site of treatment without the use of specialised laboratory staff, the process is both cost and time efficient.
Advantages include:
· Minimisation of donor site size and depth with concomitant reduction in complications, morbidity and healing time.
· Improved wound healing time and scar quality.
· Repopulation of melanocytes to reduce hypopigmentation.
· On-site processing for immediate application.
· Increased viability through immediate harvest and application.
· Ability to be processed by clinician and not require specialised laboratory staff.
REPORTED IN UK DAILY MAIL
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