- Email: [email protected]
Mycobacterium abscessus in people with cystic fibrosis: considerations for psychosocial care
Comment
seriously and to propose and fund measures that do not threaten the livelihood of the farmer. As the EU starts to promote the circular economy (COM/2014/0398),11 there is a strong case to reduce ammonia emissions as part of innovation to increase economy-wide nitrogen use efficiency. European nitrogen pollution losses have a fertiliser value of about €20 billion per year based on the European nitrogen assessment12 and a fertiliser price of about €0·80/kg nitrogen. This points to a major business opportunity to improve emission reduction and recycling technologies that further strengthen the case for revision of the national emission ceilings. *Bert Brunekreef, Roy M Harrison, Nino Künzli, Xavier Querol, Mark A Sutton, Dick J J Heederik, Torben Sigsgaard Institute for Risk Assessment Sciences and Julius Center for Health Sciences and Primary Care UMCU, Utrecht University, PO Box 80178, 3508 TD Utrecht, Netherlands (BB, DJJH); National Centre for Atmospheric Science, School of Geography, Earth and Environmental Sciences, University of Birmingham, Birmingham, UK (RMH); Department of Environmental Sciences/Center of Excellence in Environmental Studies, King Abdulaziz University, Jeddah, Saudi Arabia (RMH); Swiss Tropical and Public Health Institute Basel, Switzerland and University of Basel, Basel, Switzerland (NK); Institute of Environmental Assessment and Water Research (IDAEA-CSIC), Barcelona, Spain (XQ); Natural Environment Research Council (NERC) Centre for Ecology and Hydrology, Edinburgh Research Station, Bush Estate, Penicuik, EH26 0QB, UK (MAS); and Department of Public Health, Aarhus University, Aarhus, Denmark (TS) [email protected]
We declare no competing interests. 1
2
3 4
5
6
7
8
9 10
11 12
EC. Proposal for a Directive of the European Parliament And Of The Council on the reduction of national emissions of certain atmospheric pollutants and amending Directive 2003/35/EC. Brussels: European Commission, 2013. Hendriks C, Kranenburg R, Kuenen J, et al. The origin of ambient particulate matter concentrations in the Netherlands. Atmos Environ 2013; 69: 289–303. WHO. Review of evidence on health aspects of air pollution—REVIHAAP Project. Bonn: WHO Regional Office for Europe, 2013. Hoek G, Brunekreef B, Verhoeff A, van Wijnen J, Fischer P. Daily mortality and air pollution in the Netherlands. J Air Waste Manage Assoc 2000; 50: 1380–89. Ostro B, Hu J, Goldberg D, et al. Associations of mortality with long-term exposures to fine and ultrafine particles, species and sources: results from the California Teachers Study Cohort. Environ Health Perspect 2015; 123: 549–56. Chen S-Y, Lin Y-L, Chang W-T, Lee C-T, Chan C-C. Increasing emergency room visits for stroke by elevated levels of fine particulate constituents. Sci Total Environ 2014; 473: 446–50. Megaritis AG, Fountoukis C, Charalampidis PE, Pilinis C, Pandis SN. Response of fine particulate matter concentrations to changes of emissions and temperature in Europe. Atmospheric Chemistry and Physics 2013; 13: 3423–43. Van Grinsven HJM, Holland M, Jacobsen BH, Klimont Z, Sutton MA, Willems WJ. Costs and benefits of nitrogen for Europe and implications for mitigation. Environmental Science & Technology 2013; 47: 3571–79. Paulot F, Jacob DJ. Hidden Cost of U.S. agricultural exports: particulate matter from ammonia emissions. Environ Sci Technol 2014; 48: 903–08. Amann M, Heyes C, Kiesewetter G, Schopp W, Wagner F. Complementary impact assessment on interactions between EU air quality policy and climate and energy policy. Brussels: EPRS/European Parliamentary Research Service, 2014. IPEX. Document COM/2014/0398. http://www.ipex.eu/IPEXL-WEB/ dossier/document/COM20140398.do (accessed Sept 30, 2015). European Nitrogen Assessment. www.nine-esf.org/ENA-Book (accessed Sept 30, 2015).
Mycobacterium abscessus in people with cystic fibrosis: considerations for psychosocial care See Editorial page 823
832
Mycobacterium abscessus is a multiresistant, nontuberculous mycobacteria that infects increasing numbers of people with cystic fibrosis worldwide. It is associated with a rapid deterioration in lung function and increased rates of morbidity and mortality.1 Although some patients with cystic fibrosis and M abscessus infection undergo successful lung transplantation, postoperative complications can occur. There is evidence of shared strains among patients with cystic fibrosis and global dissemination,2 although mechanisms of transmission remain unclear. The results from the first study with next-generation sequencing of M abscessus strains suggested acquisition occurred
in hospital and outpatient settings, but attempts to isolate M abscessus from these environments were unsuccessful.3 Conversely, there was no evidence of transmission between patients in another study.4 Despite this difference in findings, the focus of UK guidelines5 is on the reduction of patient-to-patient transmission in health-care settings by advocating routine screening and enhanced segregation practices. Since the mid-1990s, people with cystic fibrosis have been segregated from each other to prevent cross infection with harmful bacteria (primarily Pseudomonas aeruginosa and Burkolderia cepacia complex). Much has been written about the emotional effect of these www.thelancet.com/respiratory Vol 3 November 2015
Comment
infection-control practices and associated psychological symptoms. However, the ability to tolerate an uncertain future and high burden of care becomes more psychologically challenging for patients with both cystic fibrosis and M abscessus infection (or infection with other bacteria, such as meticillin-resistant Staphylococcus aureus). Cystic fibrosis teams can offer additional support that includes addressing the risks of poor adherence to eradication efforts, the emotional effect of perceived further segregation and the introduction of barrier nursing, and patients living with increased uncertainty about their future. M abscessus is difficult to treat and a recent Cochrane review found no eligible studies on antibacterial management.6 The review recommended continued adherence to existing American Thoracic Society guidance for intense multidrug treatment, lasting at least 12 months, when common side-effects include diarrhoea, nausea, stomach pain, reduced appetite, and headaches, with less frequent side-effects mimicking or exacerbating psychological distress (eg, anxiety, agitation, and fatigue).7 Adherence is often a problem for people with cystic fibrosis and can be the main cause of treatment failure, poor health outcomes, and reduced quality of life. It is particularly suboptimum when treatment is complex, time-consuming, intrusive, and does not result in an immediate benefit. Because existing treatment protocols for M abscessus include many additional treatments, it is crucial that adherence is assessed before treatment commences and patients are provided support throughout the treatment. The emotional effect of living with M abscessus for people with cystic fibrosis might be substantial because of the associations between disease severity and psychological problems.8 Patients colonised with M abscessus who respond poorly to antimicrobials might re-appraise previously held assumptions about future treatment options (eg, transplantation). They might also have to review their life choices (eg, those related to work, leisure, or family planning) and face difficult choices about segregation outside of hospital (eg, contact with siblings or friends with cystic fibrosis). Patients and relatives largely support segregation strategies as being necessary.9 However, people with cystic fibrosis and infectious diseases reported that such measures increased stress, anxiety, and depression, and feelings of isolation, loneliness, anger, neglect, and www.thelancet.com/respiratory Vol 3 November 2015
Panel: Key psychological strategies for enhancing treatment protocols for Mycobacterium abscessus in patients with cystic fibrosis Working with patients and health-care teams • Effective communication through the adoption of an interactive style for information giving and assessing patient’s knowledge and concerns is needed. Patients should be regularly informed of their infection status and teams need to reinforce the rationale for infection control measures • How information about M abscessus is shared with the centre’s entire patient group needs to be balanced to ensure that patients are well informed • Clear and consistent messages need to be provided about M abscessus and information about how the risks of infection and transmission are being minimised is important, particularly because patients often communicate with each other through social media. Working with the multidisciplinary team: • The multidisciplinary staff should have awareness of the potential psychological effects of isolation and help patients and their relatives manage these effects. • Minimising boredom and maximising safe methods of social contact are essential for facilitating good psychological adjustment. Helping to establish structure in patients’ daily lives and ensuring resources are available to allow enjoyable activities are important. Working with patients and their families: • Psychologists should take a lead role in supporting teams in anticipating distress by assessing patients with cystic fibrosis before attempts to eradicate M abscessus infection. This support should include consideration of anxiety and depression (in patients and parents or other key carers), adherence rates (with particular attention given to electronic data), patients’ beliefs about illness and treatment, quality of life, and social support networks and resources • Ensure psychological follow-up and intervention and enhance support systems or adjust care plans, as needed. • In view of the need for regular sputum sampling, assist with obtaining induced sputum samples in young children who might find the procedure distressing.
abandonment.9,10 They also expressed their feelings of boredom and loss of control, and perceptions that segregation inhibited communication and information sharing while in hospital. Risk factors associated with adverse psychological reactions include poor knowledge, lack of meaningful activity, and uncertainty about and inconsistency in the implementation of infection control measures.9,10 Although patients with M abscessus infection and cystic fibrosis are not experiencing segregation for the first time, even more stringent measures and ongoing uncertainty about transmission and treatment success, might lead to increased perceptions of stigmatisation. In one of the first UK centres to implement enhanced infection control measures, assessment of patients’ experiences showed that they valued information about the rationale for changes to care and the opportunity for discussion with 833
Comment
their health-care providers. Although most individuals thought the changes were acceptable, some people reported psychological distress associated with the anticipated threat of the changes, particularly about their existing coping strategies and place in the cystic fibrosis community. Despite the concerns, most individuals adjusted to the changes and learnt to trust new systems of care.11 More than a third of parents of children and teenagers with cystic fibrosis have symptoms of anxiety above the clinical threshold.8 Although the specific causes of these problems need further examination, they are likely to include identification of new bacterial growth requiring eradication. Parental awareness of environmental acquisition of bacteria (eg, Pseudomonas aeruginosa) can lead to exaggerated perceptions and misunderstandings of risk and consequences, in turn leading to limitations being placed on children’s activities, often to the detriment of the quality of life of the child.10 Amelioration of the psychological effects of colonising M abscessus is likely to facilitate improvements in psychological health, quality of life, and adherence to eradication protocols. Considerations for doing so, and other intervention strategies, are outlined in the panel. In conclusion, M abscessus is a significant threat to patients with cystic fibrosis. Treatment protocols are complex, lengthy, and add extra demands to an already onerous therapeutic routine. Assessment of the psychological wellbeing of patients is likely to enhance treatment effectiveness. More stringent segregation measures, in place for the foreseeable future, could challenge patients’ existing coping strategies. Enhancing communication and information provision and giving consistent messages can reduce the effect of these. Many patients with chronic M abscessus infection commence lifelong maintenance treatment, which requires readjustment of their expectations for long-term health and future treatment options. Raising awareness of the psychological
effects, identifying distress, and providing appropriate treatment are important factors to address. Vanessa Shearing, *Alistair J A Duff, Miles Denton Leeds Teaching Hospitals NHS Trust, Department of Clinical and Health Psychology, Fielding House, St James’ University Hospital, Beckett Street, Leeds, W Yorks LS97TF, UK (AJAD); Leeds Teaching Hospitals NHS Trust, Department of Microbiology, Old Medical School, Leeds General Infirmary, Leeds, UK (MD); and Papworth Hospital NHS Foundation Trust, Papworth Everard Cambridge, UK (VS) alistair.duff[email protected] AJAD reports personal fees from Vertex Pharmaceuticals, Chiesi Pharmaceuticals, Forest Laboratories, Novartis Pharmaceuticals, Roche, Mylan EPD/BGP Products, and Profile Pharma, outside of the submitted work. MD reports consultancy fees from Profile Pharma and speaker’s fees from Forest Laboratories, outside of the submitted work. VS declares no competing interests. 1 2
3
4
5
6
7
8
9 10
11
Bar-On O, Mussaffi H, Mei-Zahav M, et al. Increasing non-tuberculous mycobacteria infection in cystic fibrosis. J Cyst Fibros 2015; 14: 53–62. Tettelin H, Davidson R, Agrawal S, et al. High-level relatedness among Mycobacterium abscessus subspecies massiliense strains from widely separated outbreaks. Emerg Infect Dis 2014; 20: 364–71. Byrant J, Grogono D, Greaves D, et al. Whole-genome sequencing to identify transmission of Mycobacterium abscessus between patients with cystic fibrosis: a retrospective cohort study. Lancet 2013; 381: 1551–60. Harris K, Underwood A, Kenna D, et al. Whole-genome sequencing and epidemiological analysis do not provide evidence for cross-transmission of Mycobacterium abscessus in a cohort of pediatric cystic fibrosis patients. Clin Infect Dis 2015; 60: 1007–16. Cystic Fibrosis Trust. Mycobacterium abscessus. Suggestions for infection prevention and control (interim guidance-October 2013). Report of the Cystic Fibrosis Trust Mycobacterium abscessus Infection Control Working Group. CF Trust 2013. https://www.cysticfibrosis.org.uk/media/381091/ CC15%20-%20NTM%20guidelinesv2.pdf (accessed Oct 9, 2015). Waters V, Ratjen F. Antibiotic treatment for nontuberculous mycobacteria lung infection in people with cystic fibrosis. Cochrane Database Syst Rev 2012; 12: CD010004. Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Resp Crit Care Med 2007; 175: 367–416. Quittner A, Goldbeck L, Abbott J et al. Prevalence of depression and anxiety in patients with cystic fibrosis and parent caregivers: results of The International Depression Epidemiological Study across nine countries. Thorax 2014; 69: 1090–97. Russo K, Donnelly M, Reid AJM. Segregation – the perspectives of young patients and their parents. J Cyst Fibros 2006; 5: 93–99. Ullrich G, Wiedau-Görs S, Steinkamp G, Bartig H, Schulz W, Freihorst J. Parental fears of Pseudomonas infection and measures to prevent its acquisition. J Cyst Fibros 2002; 1: 122–30. Shearing V, Offord E, Haworth C, Floto A. Evaluating the psychological impact of newly implemented infection control measures for the nontuberculous mycobacterium Mycobacterium abscessus. J Cyst Fibros 2014; 13: S113.
Preventing pneumococcal infections in older adults Published Online October 23, 2015 http://dx.doi.org/10.1016/ S2213-2600(15)00365-3
834
After approval of the 13-valent pneumococcal conjugate vaccine (PCV13) in adults by the European Medicines Agency and the Food and Drug Administration, decisionmaking bodies in Europe and the USA deferred issuing recommendations for PCV13 use in older adults until
more data were available for crucial missing information identified in cost-effectiveness analyses of adult vaccination strategies.1 These included data for the efficacy of PCV13 against nonbacteraemic pneumococcal pneumonia and the effect of herd protection from www.thelancet.com/respiratory Vol 3 November 2015
seriously and to propose and fund measures that do not threaten the livelihood of the farmer. As the EU starts to promote the circular economy (COM/2014/0398),11 there is a strong case to reduce ammonia emissions as part of innovation to increase economy-wide nitrogen use efficiency. European nitrogen pollution losses have a fertiliser value of about €20 billion per year based on the European nitrogen assessment12 and a fertiliser price of about €0·80/kg nitrogen. This points to a major business opportunity to improve emission reduction and recycling technologies that further strengthen the case for revision of the national emission ceilings. *Bert Brunekreef, Roy M Harrison, Nino Künzli, Xavier Querol, Mark A Sutton, Dick J J Heederik, Torben Sigsgaard Institute for Risk Assessment Sciences and Julius Center for Health Sciences and Primary Care UMCU, Utrecht University, PO Box 80178, 3508 TD Utrecht, Netherlands (BB, DJJH); National Centre for Atmospheric Science, School of Geography, Earth and Environmental Sciences, University of Birmingham, Birmingham, UK (RMH); Department of Environmental Sciences/Center of Excellence in Environmental Studies, King Abdulaziz University, Jeddah, Saudi Arabia (RMH); Swiss Tropical and Public Health Institute Basel, Switzerland and University of Basel, Basel, Switzerland (NK); Institute of Environmental Assessment and Water Research (IDAEA-CSIC), Barcelona, Spain (XQ); Natural Environment Research Council (NERC) Centre for Ecology and Hydrology, Edinburgh Research Station, Bush Estate, Penicuik, EH26 0QB, UK (MAS); and Department of Public Health, Aarhus University, Aarhus, Denmark (TS) [email protected]
We declare no competing interests. 1
2
3 4
5
6
7
8
9 10
11 12
EC. Proposal for a Directive of the European Parliament And Of The Council on the reduction of national emissions of certain atmospheric pollutants and amending Directive 2003/35/EC. Brussels: European Commission, 2013. Hendriks C, Kranenburg R, Kuenen J, et al. The origin of ambient particulate matter concentrations in the Netherlands. Atmos Environ 2013; 69: 289–303. WHO. Review of evidence on health aspects of air pollution—REVIHAAP Project. Bonn: WHO Regional Office for Europe, 2013. Hoek G, Brunekreef B, Verhoeff A, van Wijnen J, Fischer P. Daily mortality and air pollution in the Netherlands. J Air Waste Manage Assoc 2000; 50: 1380–89. Ostro B, Hu J, Goldberg D, et al. Associations of mortality with long-term exposures to fine and ultrafine particles, species and sources: results from the California Teachers Study Cohort. Environ Health Perspect 2015; 123: 549–56. Chen S-Y, Lin Y-L, Chang W-T, Lee C-T, Chan C-C. Increasing emergency room visits for stroke by elevated levels of fine particulate constituents. Sci Total Environ 2014; 473: 446–50. Megaritis AG, Fountoukis C, Charalampidis PE, Pilinis C, Pandis SN. Response of fine particulate matter concentrations to changes of emissions and temperature in Europe. Atmospheric Chemistry and Physics 2013; 13: 3423–43. Van Grinsven HJM, Holland M, Jacobsen BH, Klimont Z, Sutton MA, Willems WJ. Costs and benefits of nitrogen for Europe and implications for mitigation. Environmental Science & Technology 2013; 47: 3571–79. Paulot F, Jacob DJ. Hidden Cost of U.S. agricultural exports: particulate matter from ammonia emissions. Environ Sci Technol 2014; 48: 903–08. Amann M, Heyes C, Kiesewetter G, Schopp W, Wagner F. Complementary impact assessment on interactions between EU air quality policy and climate and energy policy. Brussels: EPRS/European Parliamentary Research Service, 2014. IPEX. Document COM/2014/0398. http://www.ipex.eu/IPEXL-WEB/ dossier/document/COM20140398.do (accessed Sept 30, 2015). European Nitrogen Assessment. www.nine-esf.org/ENA-Book (accessed Sept 30, 2015).
Mycobacterium abscessus in people with cystic fibrosis: considerations for psychosocial care See Editorial page 823
832
Mycobacterium abscessus is a multiresistant, nontuberculous mycobacteria that infects increasing numbers of people with cystic fibrosis worldwide. It is associated with a rapid deterioration in lung function and increased rates of morbidity and mortality.1 Although some patients with cystic fibrosis and M abscessus infection undergo successful lung transplantation, postoperative complications can occur. There is evidence of shared strains among patients with cystic fibrosis and global dissemination,2 although mechanisms of transmission remain unclear. The results from the first study with next-generation sequencing of M abscessus strains suggested acquisition occurred
in hospital and outpatient settings, but attempts to isolate M abscessus from these environments were unsuccessful.3 Conversely, there was no evidence of transmission between patients in another study.4 Despite this difference in findings, the focus of UK guidelines5 is on the reduction of patient-to-patient transmission in health-care settings by advocating routine screening and enhanced segregation practices. Since the mid-1990s, people with cystic fibrosis have been segregated from each other to prevent cross infection with harmful bacteria (primarily Pseudomonas aeruginosa and Burkolderia cepacia complex). Much has been written about the emotional effect of these www.thelancet.com/respiratory Vol 3 November 2015
Comment
infection-control practices and associated psychological symptoms. However, the ability to tolerate an uncertain future and high burden of care becomes more psychologically challenging for patients with both cystic fibrosis and M abscessus infection (or infection with other bacteria, such as meticillin-resistant Staphylococcus aureus). Cystic fibrosis teams can offer additional support that includes addressing the risks of poor adherence to eradication efforts, the emotional effect of perceived further segregation and the introduction of barrier nursing, and patients living with increased uncertainty about their future. M abscessus is difficult to treat and a recent Cochrane review found no eligible studies on antibacterial management.6 The review recommended continued adherence to existing American Thoracic Society guidance for intense multidrug treatment, lasting at least 12 months, when common side-effects include diarrhoea, nausea, stomach pain, reduced appetite, and headaches, with less frequent side-effects mimicking or exacerbating psychological distress (eg, anxiety, agitation, and fatigue).7 Adherence is often a problem for people with cystic fibrosis and can be the main cause of treatment failure, poor health outcomes, and reduced quality of life. It is particularly suboptimum when treatment is complex, time-consuming, intrusive, and does not result in an immediate benefit. Because existing treatment protocols for M abscessus include many additional treatments, it is crucial that adherence is assessed before treatment commences and patients are provided support throughout the treatment. The emotional effect of living with M abscessus for people with cystic fibrosis might be substantial because of the associations between disease severity and psychological problems.8 Patients colonised with M abscessus who respond poorly to antimicrobials might re-appraise previously held assumptions about future treatment options (eg, transplantation). They might also have to review their life choices (eg, those related to work, leisure, or family planning) and face difficult choices about segregation outside of hospital (eg, contact with siblings or friends with cystic fibrosis). Patients and relatives largely support segregation strategies as being necessary.9 However, people with cystic fibrosis and infectious diseases reported that such measures increased stress, anxiety, and depression, and feelings of isolation, loneliness, anger, neglect, and www.thelancet.com/respiratory Vol 3 November 2015
Panel: Key psychological strategies for enhancing treatment protocols for Mycobacterium abscessus in patients with cystic fibrosis Working with patients and health-care teams • Effective communication through the adoption of an interactive style for information giving and assessing patient’s knowledge and concerns is needed. Patients should be regularly informed of their infection status and teams need to reinforce the rationale for infection control measures • How information about M abscessus is shared with the centre’s entire patient group needs to be balanced to ensure that patients are well informed • Clear and consistent messages need to be provided about M abscessus and information about how the risks of infection and transmission are being minimised is important, particularly because patients often communicate with each other through social media. Working with the multidisciplinary team: • The multidisciplinary staff should have awareness of the potential psychological effects of isolation and help patients and their relatives manage these effects. • Minimising boredom and maximising safe methods of social contact are essential for facilitating good psychological adjustment. Helping to establish structure in patients’ daily lives and ensuring resources are available to allow enjoyable activities are important. Working with patients and their families: • Psychologists should take a lead role in supporting teams in anticipating distress by assessing patients with cystic fibrosis before attempts to eradicate M abscessus infection. This support should include consideration of anxiety and depression (in patients and parents or other key carers), adherence rates (with particular attention given to electronic data), patients’ beliefs about illness and treatment, quality of life, and social support networks and resources • Ensure psychological follow-up and intervention and enhance support systems or adjust care plans, as needed. • In view of the need for regular sputum sampling, assist with obtaining induced sputum samples in young children who might find the procedure distressing.
abandonment.9,10 They also expressed their feelings of boredom and loss of control, and perceptions that segregation inhibited communication and information sharing while in hospital. Risk factors associated with adverse psychological reactions include poor knowledge, lack of meaningful activity, and uncertainty about and inconsistency in the implementation of infection control measures.9,10 Although patients with M abscessus infection and cystic fibrosis are not experiencing segregation for the first time, even more stringent measures and ongoing uncertainty about transmission and treatment success, might lead to increased perceptions of stigmatisation. In one of the first UK centres to implement enhanced infection control measures, assessment of patients’ experiences showed that they valued information about the rationale for changes to care and the opportunity for discussion with 833
Comment
their health-care providers. Although most individuals thought the changes were acceptable, some people reported psychological distress associated with the anticipated threat of the changes, particularly about their existing coping strategies and place in the cystic fibrosis community. Despite the concerns, most individuals adjusted to the changes and learnt to trust new systems of care.11 More than a third of parents of children and teenagers with cystic fibrosis have symptoms of anxiety above the clinical threshold.8 Although the specific causes of these problems need further examination, they are likely to include identification of new bacterial growth requiring eradication. Parental awareness of environmental acquisition of bacteria (eg, Pseudomonas aeruginosa) can lead to exaggerated perceptions and misunderstandings of risk and consequences, in turn leading to limitations being placed on children’s activities, often to the detriment of the quality of life of the child.10 Amelioration of the psychological effects of colonising M abscessus is likely to facilitate improvements in psychological health, quality of life, and adherence to eradication protocols. Considerations for doing so, and other intervention strategies, are outlined in the panel. In conclusion, M abscessus is a significant threat to patients with cystic fibrosis. Treatment protocols are complex, lengthy, and add extra demands to an already onerous therapeutic routine. Assessment of the psychological wellbeing of patients is likely to enhance treatment effectiveness. More stringent segregation measures, in place for the foreseeable future, could challenge patients’ existing coping strategies. Enhancing communication and information provision and giving consistent messages can reduce the effect of these. Many patients with chronic M abscessus infection commence lifelong maintenance treatment, which requires readjustment of their expectations for long-term health and future treatment options. Raising awareness of the psychological
effects, identifying distress, and providing appropriate treatment are important factors to address. Vanessa Shearing, *Alistair J A Duff, Miles Denton Leeds Teaching Hospitals NHS Trust, Department of Clinical and Health Psychology, Fielding House, St James’ University Hospital, Beckett Street, Leeds, W Yorks LS97TF, UK (AJAD); Leeds Teaching Hospitals NHS Trust, Department of Microbiology, Old Medical School, Leeds General Infirmary, Leeds, UK (MD); and Papworth Hospital NHS Foundation Trust, Papworth Everard Cambridge, UK (VS) alistair.duff[email protected] AJAD reports personal fees from Vertex Pharmaceuticals, Chiesi Pharmaceuticals, Forest Laboratories, Novartis Pharmaceuticals, Roche, Mylan EPD/BGP Products, and Profile Pharma, outside of the submitted work. MD reports consultancy fees from Profile Pharma and speaker’s fees from Forest Laboratories, outside of the submitted work. VS declares no competing interests. 1 2
3
4
5
6
7
8
9 10
11
Bar-On O, Mussaffi H, Mei-Zahav M, et al. Increasing non-tuberculous mycobacteria infection in cystic fibrosis. J Cyst Fibros 2015; 14: 53–62. Tettelin H, Davidson R, Agrawal S, et al. High-level relatedness among Mycobacterium abscessus subspecies massiliense strains from widely separated outbreaks. Emerg Infect Dis 2014; 20: 364–71. Byrant J, Grogono D, Greaves D, et al. Whole-genome sequencing to identify transmission of Mycobacterium abscessus between patients with cystic fibrosis: a retrospective cohort study. Lancet 2013; 381: 1551–60. Harris K, Underwood A, Kenna D, et al. Whole-genome sequencing and epidemiological analysis do not provide evidence for cross-transmission of Mycobacterium abscessus in a cohort of pediatric cystic fibrosis patients. Clin Infect Dis 2015; 60: 1007–16. Cystic Fibrosis Trust. Mycobacterium abscessus. Suggestions for infection prevention and control (interim guidance-October 2013). Report of the Cystic Fibrosis Trust Mycobacterium abscessus Infection Control Working Group. CF Trust 2013. https://www.cysticfibrosis.org.uk/media/381091/ CC15%20-%20NTM%20guidelinesv2.pdf (accessed Oct 9, 2015). Waters V, Ratjen F. Antibiotic treatment for nontuberculous mycobacteria lung infection in people with cystic fibrosis. Cochrane Database Syst Rev 2012; 12: CD010004. Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Resp Crit Care Med 2007; 175: 367–416. Quittner A, Goldbeck L, Abbott J et al. Prevalence of depression and anxiety in patients with cystic fibrosis and parent caregivers: results of The International Depression Epidemiological Study across nine countries. Thorax 2014; 69: 1090–97. Russo K, Donnelly M, Reid AJM. Segregation – the perspectives of young patients and their parents. J Cyst Fibros 2006; 5: 93–99. Ullrich G, Wiedau-Görs S, Steinkamp G, Bartig H, Schulz W, Freihorst J. Parental fears of Pseudomonas infection and measures to prevent its acquisition. J Cyst Fibros 2002; 1: 122–30. Shearing V, Offord E, Haworth C, Floto A. Evaluating the psychological impact of newly implemented infection control measures for the nontuberculous mycobacterium Mycobacterium abscessus. J Cyst Fibros 2014; 13: S113.
Preventing pneumococcal infections in older adults Published Online October 23, 2015 http://dx.doi.org/10.1016/ S2213-2600(15)00365-3
834
After approval of the 13-valent pneumococcal conjugate vaccine (PCV13) in adults by the European Medicines Agency and the Food and Drug Administration, decisionmaking bodies in Europe and the USA deferred issuing recommendations for PCV13 use in older adults until
more data were available for crucial missing information identified in cost-effectiveness analyses of adult vaccination strategies.1 These included data for the efficacy of PCV13 against nonbacteraemic pneumococcal pneumonia and the effect of herd protection from www.thelancet.com/respiratory Vol 3 November 2015