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Highlights from the 21st ECCMID and 27th ICC
Newsdesk
Highlights from the 21st ECCMID and 27th ICC The 21st annual European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) and the 27th International Congress of Chemotherapy (ICC), held as a joint meeting May 7–10, in Milan, Italy, brought together more than 8500 infectious disease experts. The growing problem of antibiotic resistance featured prominently in the meeting’s programme. Other notable topics included neglected and emerging infectious diseases, vaccines, and new diagnostic tests. Rino Rappuoli (Novartis Vaccines & Diagnostics, Siena Italy) received this year’s award for excellence in clinical microbiology and infectious diseases. The award was given in recognition of his work on vaccine manufacture and his characterisation of the non-toxic mutant of diphtheria toxin (CRM197) that is now used as a carrier protein in many conjugate vaccines.
H1N1 pandemic—the aftermath
Jiuguang Wang
Although the subject did not attract the crowds it did at ECCMID 2 years ago, fascinating data have emerged following the 2009–10 influenza H1N1 pandemic. Jake Dunning (Imperial College London, UK) reported that the UK 2010–11 winter influenza season, which was dominated by the pandemic strain of influenza A H1N1 plus some
The ECCMID–ICC joint conference was held in Milan May 7–10, 2011
430
influenza B, was more severe than were the two pandemic waves in 2009. National data for influenza hospitalisations since the end of the pandemic are not available; however, Dunning stated that admissions for influenza to the four hospitals of the Imperial College Healthcare NHS Trust in west London were substantially greater in 2010–11 than during both pandemic waves. Furthermore, there were 602 PCR-confirmed influenzarelated deaths nationwide in 2010–11 versus 457 in 2009. As in the 2009 pandemic, the latest influenza wave disproportionally affected younger adults and children—the average age of patients admitted to hospital was 41 years. The 2010–11 H1N1 is genetically very similar to the original pandemic strain, with no unique mutations associated with severity of disease. Jens Lundgren (University of Copenhagen, Denmark) also reported that among isolates of pandemic H1N1 virus sequenced as part of the Flu 002 and Flu 003 research programmes, there was no distinct genetic pattern associated with severity. Lundgren concluded that pandemic H1N1 is not a particularly virulent virus and shows no geographical or temporal trends in virulence. Thomas Bénet (Hopital Edouard Herriot, Lyon, France; abstract O239) described a case–control study designed to investigate whether vaccination of health-care workers protected patients from hospitalacquired influenza. On hospital units where 35% or more of staff were vaccinated, patients were less likely to acquire influenza. However, the study was small (11 patients and 44 controls) and done before the 2009 pandemic. Dunning noted that uptake of the vaccine against pandemic H1N1 among UK health-care workers had reached 40% by March 2010, but has since fallen to below 20% for the subsequent seasonal influenza vaccine, despite the comparative severity of the 2010–11 epidemic. Emergence of
oseltamivir resistance was rare among pandemic influenza H1N1 isolates from patients treated with this antiviral drug according to Timothy Barkham (Tan Tock Seng Hospital, Singapore; abstr O240). Among 94 patients with PCR-confirmed pandemic H1N1, treated with oseltamivir, and isolated until the virus was no longer detected, the His275Tyr mutation indicating oseltamivir resistance was detected in only one.
Elusive cure for sepsis Mortality from sepsis remains worryingly high (USA 30%, EU 36%) despite decades or research into treatment. Eritoran, an inhibitor of Toll-like receptor 4, looked promising in phase 2 trials, but gave disappointing results in a phase 3 randomised controlled trial, as reported by Steven Opal (Memorial Hospital of Rhode Island, RI, USA). In the ACCESS trial, around 2000 patients with clear criteria for sepsis, evidence of infection, and APACHE II scores from 21–37, from 150 centres worldwide were randomised to eritoran or placebo. Unfortunately, treatment gave no difference in the primary endpoint of day 28 all-cause mortality, and most secondary endpoints were not met either. Opal speculated the reasons for trial failure could have included patient heterogeneity, patients too sick or not sick enough, or the timing or dose of treatment.
Antifungal drugs In a symposium, Bart-Jan Kullberg (Radboud University, Nijmegen, Netherlands) and John Rex (AstraZeneca, London, UK) discussed the use of azoles and candins for fungal infections. Two of the most lively topics were azole resistance in Aspergillus spp in the Netherlands and the treatment of Candida glabrata. Resistance to azoles, conferred by a mutation in cyp51A, might be a consequence of use of azoles in the agriculture since the early 1990s. www.thelancet.com/infection Vol 11 June 2011
Newsdesk
For C glabrata, American guidelines support the use of echinocandin; and transition to fluconazole or voriconazole is not recommended without confirmation of isolate susceptibility. For the treatment of ocular candidiasis, both American and European guidelines support the use of fluconazole and voriconazole. Both guidelines suggest caution with candins.
Visceral leishmaniasis Jorge Alvar (WHO, Geneva, Switzerland; abstr S322–S324) reported on visceral leishmaniasis (VL). The vector-borne disease is endemic in 88 countries in the tropics, subtropics, and Mediterranean basin. Every year an estimated 500 000 new cases of VL occur worldwide, and mortality from VL is surpassed only by that of malaria among protozoal diseases. The burden is greatest in the tropics, but Europe’s Mediterrean countries had an average of 875 cases
each year from 2004 to 2008. No global strategy exists to manage VL. Traditional treatment with pentavalent antimony has become ineffective. Miltefosine is the first oral drug against visceral leishmaniasis. Phase 1 and 2 clinical trials described by Shyam Sundar (Banaras Hindu University, Varanasi, India) reported that miltefosine at the dose of 100 mg given daily for 4 weeks can achieve cure rates of 94%. Licensed in 2002, its big limitations are adherence and teratogenicity (it cannot be given in pregnancy). Amphotericin is a polyene antibiotic and at dose of 0·75–1·0 mg/kg per day it cures more than 97% of patients at 6 months. Liposomal amphotericin B is one of the most exciting developments. With the recommended dose of 10 mg/kg the cost per vial in India is $18 and the treatment is less expensive than the conventional treatment with amphotericin-B deoxycholate.
Escherichia coli infection and drug resistance in chickens Stefan Borjesson and colleagues (National Veterinary Institute, Uppsala, Sweden; abstr 1279) reported how meat imported to Sweden from South America is a potential source for extended-spectrum β-lactamase (ESBL) producing Escherichia coli. 115 samples, 36 South American and 79 European, from imported fresh, tenderised, and frozen chicken meat were collected in retail stores and outlets during 2009 and 2010. 92% of meat from South America was positive for E coli compared with 19% from Europe. Resistance to chloramphenicol (four isolates) and florfenicol (one) were found only in isolates from South American meat. Chicken meat from South America had a much higher prevalence of ESBL-producing E coli than did that from Europe.
Raffaella Bosurgi, John McConnell
Infectious disease surveillance update Chikungunya in New Caledonia 17 cases of Chikungunya virus infection have been reported for the first time in New Caledonia since March, 2011. An epidemy has not been declared. 16 of 17 cases were confined to the port town of Noumea, but the one case outside this town might indicate the spread of the disease. The state of Polynesia is implementing health surveillance, with distribution of brochures to flight passengers departing from Noumea containing information about symptoms. A mosquito control programme has also been implemented with aircarfts departing from Noumea being sprayed with insecticides.
Mumps in UK Outbreaks of mumps have been reported in two universities in the northwest of England. Since February 2011, 47 students at the www.thelancet.com/infection Vol 11 June 2011
University of Central Lancashire and 35 at the University of Manchester were infected. Students in the area have been advised by the UK Health Protection Agency to check if they have had the full mumps, measles, and rubella vaccine, since full protection is only attributed to two doses of the vaccine.
Rubella in Taiwan Since 2011, 34 cases of rubella have been reported in Taiwan. Most cases (25) were contracted abroad, mainly in Vietnam, where almost 1000 cases have been reported so far this year. Officials of the Taiwan Centres for Disease Control (CDC) have advised people who haven’t previously caught the disease to get vaccinated if they are planning to travel to southeast Asia. Foreign workers and exchange students will have to show their immunisation certificates before entering Taiwan.
Wild poliovirus in CÔte d’Ivoire An outbreak of wild poliovirus (WPV) type 3 has been reported in CÔte d’Ivoire, for the first time in the country since 2000. The three new cases reported so far this year are genetically linked to WPV3 detected in 2008 in northern Nigeria. The country’s highest priority is to stop the transmission of WPV3 and to maintain high population immunity to WPV1 across west Africa. In 2008–09, an outbreak of WPV1 was recorded in CÔte d’Ivoire. Two rounds of supplementary immunisation activities were planned for March 25, 2011, and April 29, 2011 in 15 countries across west Africa. Supplementary immunisation could not be done in CÔte d’Ivoire in March because of the difficult political situation in the country.
For more on chikungunya in New Caledonia see http://apex. oracle.com/pls/ otn/f?p=2400:1001:674479108 843189::NO::F2400_P1001_ BACK_PAGE,F2400_P1001_ PUB_MAIL_ID:1010,88117 For more on mumps in UK see http://www.bbc.co.uk/news/ uk-england-lancashire-13295418 For more on rubella in Taiwan see http://www.icrt.com.tw/ newsroom_news_detail. php?newsId=10666 For more on wild poliovirus in CÔte d’Ivoire see http://www. who.int/csr/don/2011_04_21a/ en/index.html
Olaya Astudillo 431
Highlights from the 21st ECCMID and 27th ICC The 21st annual European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) and the 27th International Congress of Chemotherapy (ICC), held as a joint meeting May 7–10, in Milan, Italy, brought together more than 8500 infectious disease experts. The growing problem of antibiotic resistance featured prominently in the meeting’s programme. Other notable topics included neglected and emerging infectious diseases, vaccines, and new diagnostic tests. Rino Rappuoli (Novartis Vaccines & Diagnostics, Siena Italy) received this year’s award for excellence in clinical microbiology and infectious diseases. The award was given in recognition of his work on vaccine manufacture and his characterisation of the non-toxic mutant of diphtheria toxin (CRM197) that is now used as a carrier protein in many conjugate vaccines.
H1N1 pandemic—the aftermath
Jiuguang Wang
Although the subject did not attract the crowds it did at ECCMID 2 years ago, fascinating data have emerged following the 2009–10 influenza H1N1 pandemic. Jake Dunning (Imperial College London, UK) reported that the UK 2010–11 winter influenza season, which was dominated by the pandemic strain of influenza A H1N1 plus some
The ECCMID–ICC joint conference was held in Milan May 7–10, 2011
430
influenza B, was more severe than were the two pandemic waves in 2009. National data for influenza hospitalisations since the end of the pandemic are not available; however, Dunning stated that admissions for influenza to the four hospitals of the Imperial College Healthcare NHS Trust in west London were substantially greater in 2010–11 than during both pandemic waves. Furthermore, there were 602 PCR-confirmed influenzarelated deaths nationwide in 2010–11 versus 457 in 2009. As in the 2009 pandemic, the latest influenza wave disproportionally affected younger adults and children—the average age of patients admitted to hospital was 41 years. The 2010–11 H1N1 is genetically very similar to the original pandemic strain, with no unique mutations associated with severity of disease. Jens Lundgren (University of Copenhagen, Denmark) also reported that among isolates of pandemic H1N1 virus sequenced as part of the Flu 002 and Flu 003 research programmes, there was no distinct genetic pattern associated with severity. Lundgren concluded that pandemic H1N1 is not a particularly virulent virus and shows no geographical or temporal trends in virulence. Thomas Bénet (Hopital Edouard Herriot, Lyon, France; abstract O239) described a case–control study designed to investigate whether vaccination of health-care workers protected patients from hospitalacquired influenza. On hospital units where 35% or more of staff were vaccinated, patients were less likely to acquire influenza. However, the study was small (11 patients and 44 controls) and done before the 2009 pandemic. Dunning noted that uptake of the vaccine against pandemic H1N1 among UK health-care workers had reached 40% by March 2010, but has since fallen to below 20% for the subsequent seasonal influenza vaccine, despite the comparative severity of the 2010–11 epidemic. Emergence of
oseltamivir resistance was rare among pandemic influenza H1N1 isolates from patients treated with this antiviral drug according to Timothy Barkham (Tan Tock Seng Hospital, Singapore; abstr O240). Among 94 patients with PCR-confirmed pandemic H1N1, treated with oseltamivir, and isolated until the virus was no longer detected, the His275Tyr mutation indicating oseltamivir resistance was detected in only one.
Elusive cure for sepsis Mortality from sepsis remains worryingly high (USA 30%, EU 36%) despite decades or research into treatment. Eritoran, an inhibitor of Toll-like receptor 4, looked promising in phase 2 trials, but gave disappointing results in a phase 3 randomised controlled trial, as reported by Steven Opal (Memorial Hospital of Rhode Island, RI, USA). In the ACCESS trial, around 2000 patients with clear criteria for sepsis, evidence of infection, and APACHE II scores from 21–37, from 150 centres worldwide were randomised to eritoran or placebo. Unfortunately, treatment gave no difference in the primary endpoint of day 28 all-cause mortality, and most secondary endpoints were not met either. Opal speculated the reasons for trial failure could have included patient heterogeneity, patients too sick or not sick enough, or the timing or dose of treatment.
Antifungal drugs In a symposium, Bart-Jan Kullberg (Radboud University, Nijmegen, Netherlands) and John Rex (AstraZeneca, London, UK) discussed the use of azoles and candins for fungal infections. Two of the most lively topics were azole resistance in Aspergillus spp in the Netherlands and the treatment of Candida glabrata. Resistance to azoles, conferred by a mutation in cyp51A, might be a consequence of use of azoles in the agriculture since the early 1990s. www.thelancet.com/infection Vol 11 June 2011
Newsdesk
For C glabrata, American guidelines support the use of echinocandin; and transition to fluconazole or voriconazole is not recommended without confirmation of isolate susceptibility. For the treatment of ocular candidiasis, both American and European guidelines support the use of fluconazole and voriconazole. Both guidelines suggest caution with candins.
Visceral leishmaniasis Jorge Alvar (WHO, Geneva, Switzerland; abstr S322–S324) reported on visceral leishmaniasis (VL). The vector-borne disease is endemic in 88 countries in the tropics, subtropics, and Mediterranean basin. Every year an estimated 500 000 new cases of VL occur worldwide, and mortality from VL is surpassed only by that of malaria among protozoal diseases. The burden is greatest in the tropics, but Europe’s Mediterrean countries had an average of 875 cases
each year from 2004 to 2008. No global strategy exists to manage VL. Traditional treatment with pentavalent antimony has become ineffective. Miltefosine is the first oral drug against visceral leishmaniasis. Phase 1 and 2 clinical trials described by Shyam Sundar (Banaras Hindu University, Varanasi, India) reported that miltefosine at the dose of 100 mg given daily for 4 weeks can achieve cure rates of 94%. Licensed in 2002, its big limitations are adherence and teratogenicity (it cannot be given in pregnancy). Amphotericin is a polyene antibiotic and at dose of 0·75–1·0 mg/kg per day it cures more than 97% of patients at 6 months. Liposomal amphotericin B is one of the most exciting developments. With the recommended dose of 10 mg/kg the cost per vial in India is $18 and the treatment is less expensive than the conventional treatment with amphotericin-B deoxycholate.
Escherichia coli infection and drug resistance in chickens Stefan Borjesson and colleagues (National Veterinary Institute, Uppsala, Sweden; abstr 1279) reported how meat imported to Sweden from South America is a potential source for extended-spectrum β-lactamase (ESBL) producing Escherichia coli. 115 samples, 36 South American and 79 European, from imported fresh, tenderised, and frozen chicken meat were collected in retail stores and outlets during 2009 and 2010. 92% of meat from South America was positive for E coli compared with 19% from Europe. Resistance to chloramphenicol (four isolates) and florfenicol (one) were found only in isolates from South American meat. Chicken meat from South America had a much higher prevalence of ESBL-producing E coli than did that from Europe.
Raffaella Bosurgi, John McConnell
Infectious disease surveillance update Chikungunya in New Caledonia 17 cases of Chikungunya virus infection have been reported for the first time in New Caledonia since March, 2011. An epidemy has not been declared. 16 of 17 cases were confined to the port town of Noumea, but the one case outside this town might indicate the spread of the disease. The state of Polynesia is implementing health surveillance, with distribution of brochures to flight passengers departing from Noumea containing information about symptoms. A mosquito control programme has also been implemented with aircarfts departing from Noumea being sprayed with insecticides.
Mumps in UK Outbreaks of mumps have been reported in two universities in the northwest of England. Since February 2011, 47 students at the www.thelancet.com/infection Vol 11 June 2011
University of Central Lancashire and 35 at the University of Manchester were infected. Students in the area have been advised by the UK Health Protection Agency to check if they have had the full mumps, measles, and rubella vaccine, since full protection is only attributed to two doses of the vaccine.
Rubella in Taiwan Since 2011, 34 cases of rubella have been reported in Taiwan. Most cases (25) were contracted abroad, mainly in Vietnam, where almost 1000 cases have been reported so far this year. Officials of the Taiwan Centres for Disease Control (CDC) have advised people who haven’t previously caught the disease to get vaccinated if they are planning to travel to southeast Asia. Foreign workers and exchange students will have to show their immunisation certificates before entering Taiwan.
Wild poliovirus in CÔte d’Ivoire An outbreak of wild poliovirus (WPV) type 3 has been reported in CÔte d’Ivoire, for the first time in the country since 2000. The three new cases reported so far this year are genetically linked to WPV3 detected in 2008 in northern Nigeria. The country’s highest priority is to stop the transmission of WPV3 and to maintain high population immunity to WPV1 across west Africa. In 2008–09, an outbreak of WPV1 was recorded in CÔte d’Ivoire. Two rounds of supplementary immunisation activities were planned for March 25, 2011, and April 29, 2011 in 15 countries across west Africa. Supplementary immunisation could not be done in CÔte d’Ivoire in March because of the difficult political situation in the country.
For more on chikungunya in New Caledonia see http://apex. oracle.com/pls/ otn/f?p=2400:1001:674479108 843189::NO::F2400_P1001_ BACK_PAGE,F2400_P1001_ PUB_MAIL_ID:1010,88117 For more on mumps in UK see http://www.bbc.co.uk/news/ uk-england-lancashire-13295418 For more on rubella in Taiwan see http://www.icrt.com.tw/ newsroom_news_detail. php?newsId=10666 For more on wild poliovirus in CÔte d’Ivoire see http://www. who.int/csr/don/2011_04_21a/ en/index.html
Olaya Astudillo 431