Beating Back the Norovirus Devil

Well, many of us have sick feelings in our stomachs these days. It's norovirus season and the media is filled with the usual scary reports - "hard to get rid of" and "schools closing" - that generally provide non-specific information about how to prevent transmission in your home. The CDC does have useful information online and in graphic form (below). So, with homage to Maryn McKenna's excellent book about CDC's EIS, I offer my tips for beating norovirus in your home.

A bit of background on why I've put forth these recommendations: We've had three episodes of likely norovirus cases in our home since my initial norovirus post in 2013 and zero cases of transmission. Below is my 2017 case report with steps we took to prevent transmission.

Approximately 3 weeks ago, we had a group of five 10 yo kids at our house for a party. At some point, one of the kids started feeling sick and spit up a bit in our trash can and then while trying to get  to the bathroom vomited in our family room and near our front door before finally making it to a toilet. Thus, we had 3+ areas to decontaminate and 7 at-risk people we needed to protect. We immediately sent the other kids to the lower level, donned gloves and began the clean-up procedures.

1) We made sure that the sick child stayed in or near the bathroom and also made sure he closed the lid prior to flushing the toilet and poured a cup of bleach into the toilet before we flushed the toilet again. Once the child was picked up by their parent, we put the bathroom off limits.

2) We quickly blotted up the emesis in the living room and front hall with towels, being careful to not spray the virus. We then washed all of the towels twice in the hottest water setting and dried them until practically burnt (humor).

3) We removed all glasses, plates, silverware, xbox controllers and other things the child might have touched from circulation. The things we could wash in the dishwasher were washed 3 times and we used the drying cycle (which we usually don't use).

4) We used these bleach wipes (Clorox 35309 Healthcare Bleach Germicidal Wipe), which have activity vs norovirus, twice on each hard surface (bathroom, floor, XBox controller) to make sure we achieved adequate contact time.

5) For soft surfaces, that couldn't be laundered, we used (Clorox Healthcare Hydrogen Peroxide Spray) after first testing that it was color safe on our carpet.

6) And we enforced strict hand hygiene in the house for the next few days, using only soap and water.

Hope this helps - be careful out there.

Note: I have no financial relationship with amazon or clorox - that's just where I purchased the cleaning supplies and Ms. McKenna's book.

A shock to the system

Back in April of 2011, in a blog post about the VA MRSA Initiative, I wrote:

“It seems that HAIs are falling across the VA system, probably as a result of an important culture change, and improved application of so-called "horizontal" approaches to infection prevention. Bravo to the VA!”

Of course, in addition to praising the VA, I called into question the one “vertical” component of the MRSA initiative (MRSA screening/isolation) based upon the dramatic reductions in VRE and C. difficile that accompanied the intervention, and the evidence that very little of the reported MRSA reduction could have been due to reduced MRSA transmission.

Thanks to Michi Goto and colleagues, we now have even more evidence that the MRSA Initiative coincided with a fundamental shift in infection prevention in the VA healthcare system. Their recently published CID paper adds hospital-onset Gram-negative bacteremia to the list of HAIs that saw significant reductions after the MRSA Initiative was implemented (see graph above). I will outsource most of the rest of this blog post to Maryn McKenna and Marc Bonten, please read their excellent analyses.

Marc ends his blog post by observing that “we still don’t know how” the VA achieved these HAI reductions—in particular, we don’t know the relative importance of the most expensive, resource-intensive aspect of the program (MRSA screening). As someone who served as a VA hospital epidemiologist during the implementation of the initiative, I’ll give my completely unsupported, data-free opinion: the MRSA screening was both unnecessary and essential to the VA’s success. 

Unnecessary because the HAI reductions, as Marc’s group demonstrated, were not achieved via the prevention of bacterial transmission that MRSA screening/isolation seeks to achieve. 

Essential because it served as a “shock to the system” within the VA. The complexity of implementing any universal screening and isolation program requires multidisciplinary buy-in, major investments in laboratory and infection prevention resources (in the VA system, funding for molecular detection and funding of a new “MRSA coordinator” position, essentially an extra infection preventionist). It’s this kind of system-wide investment that can change the culture, moving basic infection control practice higher on everyone’s priority list. 

We should be very surprised if any complicated, resource-intensive, universal screening intervention (including, now, universal C. difficile screening) doesn't move the needle in a quasi-experimental (before-after) study design.  We also shouldn't be surprised when that same intervention fails to impress in cluster-randomized trials, as we've seen with MRSA screening in STAR*ICU, REDUCE MRSA, MOSAR, etc.

When antibiotics don't work any more: Maryn McKenna's TED Talk

Maryn McKenna is a public health journalist whose stories, books and posts have been important for explaining antibiotic resistance to those not already immersed in its study. Her TED talk from last spring just became available - well worth the listen. If you want to read more, head over to her 'new' blog at National Geographic: Phenomena: Germination.

We're in the post-antibiotic age

We're so very lucky to have lived in the "age of antibiotics."  However, most of us were neither alive nor cognizant prior to 1943, so we don't have a concept of the morbidity and mortality prevented by antibiotics. In some regards, this pre-1943 period is the future we're facing.  Author and science journalist Maryn McKenna has a wonderful article up on medium.com where she discusses this post-antibiotic past and future using a touching story of her great uncle along with facts such as "one out of every six recipients of new hip joints would die" without antibiotics. She also discussed this article on yesterday's CBC "Sunday Edition" radio broadcast (audio available here).

As if we need other things to add to our phobia lists, there's a new case-report published in JAC last Friday of an elderly Spanish woman with chronic renal disease and recurrent UTIs. She initially presented with pyelonephritis caused by a susceptible E coli. However, after 1 week of therapy she developed sepsis and renal failure that was unresponsive to meropenem and died. MDR E Coli was isolated, which was resistant to all tested antibiotics except fosfomycin, tigecycline and tetracycline. Further analysis identified numerous resistance and virulence genes (see figure above). Importantly, the authors state that this is "the first report of the co-production of KPC-3, VIM-1, SHV-12, OXA-9 and CMY-2 in a unique clinical multiresistant E. coli isolate."

With air pollution, it's risky to breathe and with water pollution it's risky to drink. I guess now it's risky to pee.

h/t Christina Vandenbroucke-Grauls

IDWeek 2013: Media, Social Media, and Open Access

One of the great things about sitting on the planning committee of a national meeting is the ability to put together sessions that are a bit "outside the box" if you will.  During the planning of IDWeek 2013, I had the opportunity to attend the ScienceOnline2013 Conference in Raleigh where I reconnected with Maryn McKenna and met Jonathan Eisen. I thought that many of the concepts that the science journalists (McKenna) and scientists (Eisen and Smith) discussed at ScienceOnline were directly applicable and perhaps urgently needed by the public health community that attends IDWeek. Specifically, I felt that public health was a little too heavy on the "health" and a little too light on the "public." So I worked with my colleagues on the planning committee, including Scott Fridkin and Dan Diekema, to craft a session that focused on three major methods for selling public health science to the public.

The first important topic was open-access publication. If the public and journalists don't have access to your science because it's buried behind a paywall, then it doesn't even exist.  The second topic was social media, which is a method by which scientists and public health practitioners can communicate their science or policies directly to the public including science journalists. Finally, we needed a speaker to help explain how best to interact with journalists to communicate our science and messages. So, we were very lucky to have Jonathan Eisen, Tara Smith and Maryn McKenna speak at our session at IDWeek earlier this month in San Francisco.

There are several sources available for those of you interested in the session's content:

Jonathan Eisen wrote a nice post describing the entire session and also created a Storify (a collection of live tweets associated with the session) covering all three talks, both of which you can read here at one of his blogs. He's also posted his slides on slideshare.

Tara Smith posted her slides on social media at Figshare. She also posted the slides from her excellent S. aureus in animals talk, which you can access through her blog.

MRSA vs Man vs MRSA: CA-MRSA and Vaccines

Maryn McKenna has a new Nature Feature on Robert Daum's early CA-MRSA report and his vaccine development efforts.  The article spans the period 1995 to present and discusses old and new vaccines, including Daum's  T_H17-targeted approach.  A nugget I didn't know is that Daum had an 18-month struggle with JAMA editors prior to publication of his early description of CA-MRSA cases in pediatric patients.  The article is now considered to be an early warning of the epidemic.  Probably shouldn't rely on publications in academic journals for early warning signals.  What are you waiting for?  Head on over there for the full read.

Source: Maryn McKenna: Vaccine Development: Man vs MRSA, Nature 01 Feb 2012

Science Friday (the 13th): TDR-TB

Maryn McKenna (@marynmck) of Superbug fame will be on Science Friday (Hour 1: 2-3pm ET) tomorrow to discuss Totally Drug-Resistant TB.  She has had some very informative posts recently on the topic, including discussion of the two earliest known patients in Italy who died in 2003.  She also reports on the latest twelve TDR-TB cases in a single Indian hospital and points us to an ahead-of-print letter in CID posted in December that discusses the diagnosis and care of the first four of these patients in India.  Turn on, tune in...


Superbug post #2: Earliest Cases of TDR-TB
Superbug post #1: Latest Cases of TDR-TB in India

(Eli @eliowa)

Funding for antibacterial resistance research. Not so much.

At least no funding for ESCKAPE pathogen research

I just got back from attending the World HAI Forum in Annecy and the 1st ICPIC meeting in Geneva.  Both great meetings.  I will share my thoughts on the implications of ICPIC in a later post.

Last year at IDSA, Roy (Trip) Gulick stated that there are now 10,000 possible ART combinations for HIV treatment.  When he said that, I instantly got a sinking feeling in my gut.  Right now, there are many people colonized and infected with resistant bacteria for which we have NO EFFECTIVE THERAPY.  Sorry for shouting.  Think about the MDR-Acinetobacter or NDM-1 strains that are circulating.  Pretty soon we won't even have effective therapy for community UTIs.

As I thought about why this might be, I looked for the federal funding picture for antibacterial resistance research, but there were no published data.  So, we found the numbers ourselves.  I presented the data last week and Marin McKenna kindly described our findings at the World HAI Forum on her Wired Superbug blog.  She did a much better job describing our research findings than I could have.  If you're interested in reading about how much NIH/NIAID spends on antibacterial resistance research, head on over to her blog...

UPDATE:  We published these findings in the first batch of articles in the ARIC journal, see: Kwon et al. 2012 ARIC

NDM-1 in a US Military Hospital



source: wikipedia

Maryn McKenna has an interesting take on the MMWR report of NDM-1 in a US military hospital in Afghanistan. The patient had NDM-1 containing Providencia stuartii in a blood isolate collected early in 2011. This is the first case of NDM-1 in P. stuartii and in a US military hospital.  The parallels she draws to previous Acinetobacter infections in military hospitals are interesting. However, I'm not sure you can compare a specific species (Acinetobacter) to a plasmid-borne metallo-ß-lactamase (NDM-1), which can hop from species to species.

Either way, we will eventually need to beef up surveillance, infection prevention research and antibacterial drug discovery.  GNRs are not going away. I suspect the worldwide response to the many MDR-bacterial threats is going to require a significant reorganization and renewed focus (e.g. 1940s and 1950s) on how we fund these efforts. The days of nickel and diming these efforts, are coming to a close...

SUPERBUG - now in paperback

We've posted several times (here and here) on Maryn McKenna's homage to MRSA.  Head on over to Maryn's Wired Science Superbug blog to hear more about the book.  It's too bad that there is a new C. difficile PCR out. Now the world is conspiring to turn C. diff into the new superbug leaving poor old MRSA in the dust.  I have a sneaking feeling that MRSA doesn't read the news though, so I would imagine that it won't change its behavior too much.

Maryn McKenna visits Iowa City (and 1957 Cleveland)

McKenna's latest book

We've written before about Maryn McKenna, who is the author of Superbug, a journalist and a blogger.  After PepsiGate tore through ScienceBlogs, she had to relocate her blog to here and finally here, so I wanted to make sure you all could still find her.  She writes extensively about antibiotic resistance and other infectious diseases at Wired - she knows her science, which is rare among journalists, and she's a wonderful storyteller too.  Check out her latest post on the pre-publication NDM-1 EID papers.

Maryn was on the UI campus today and spoke at a UI College of Public Health conference on MRSA; she gave a wonderful history of resistant Staphylococcus aureus and MRSA. She even mentioned in passing the important conference in Cleveland on November 14, 1957.

Do you know that conference?  This conference was sponsored by 15 organizations including the AMA with ACP, ACS, AHA, ACOG, AAP, VA, CDC, USPHS, FDA and APHA among others. The presentations and discussions at this conference led to the development of a national program for the eradication of S. aureus in hospitals and to the following recommendations for the AMA trustees:

1. That every hospital establish a responsible officer or committee charged with the investigation and control of infections within that hospital and with the institution of procedures and practices designed to prevent such infections.

2. That encouragement and funds be channeled into scientific research concerning the etiology and epidemiology and the immune relationships of pyogenic staphylococci, their relationships to the defensive cells of the body and the mechanism of their mutability to drug and antibiotic resistance.

The AMA trustees approved this within one month and referred it to the Joint Commission, which in the spring of 1958 added #1 above to the requirements for hospitals seeking accreditation. Thus we have these people, groups and S. aureus to thank for infection control programs as we know them today. I wonder if we need a similar conference now on MDR-Gram negatives?

Reference: Wise RI, et al. Reviews of Infect Dis, Nov-Dec 1989

Question: Why was the conference in Cleveland?

Perhaps because Charles Henry Rammelkamp, Jr., M.D was there. He was well known for his work demonstrating the impact of a sulfonamide derivatives on staphylococci and reporting the first penicillin-resistant strain of staphylococcus. He also contributed to the understanding of the epidemiology of staphylococci in nurseries and the role of coagulase in the evolution of staphylococcal disease.  Not sure if that's why, but seems like a good enough reason to me.

Good move Maryn McKenna

We have written often on conflicts of interest. So, I've been following the recent "problems" over at ScienceBlogs.com closely. Quick story is that 2 weeks ago the editors there added a Food Frontiers blog completely funded and written by PepsiCo. I think internist PalMD said it best:

"It could be argued that since it is clearly announced that the content is PepsiCo's, that transparency is maintained, but it's not. Readers of the other 70-odd blogs at Sb expect independent content in the center column. What's more, Sb is indexed by Google News. As a news outlet, we should be held to a high standard. If the SEED management can't see what's wrong with this, this may be an insoluble problem."

PalMD left and returned to his old site as did Maryn McKenna. Many other great bloggers have left too. It must have been a difficult decision to leave the collective, but it is a good one.

PalMD's White Coat Underground (link) and PalMD's full comments (here)
McKenna's Superbug blog (link)
The Guardian's take (here)
Our COI posts (here)