EH 2_2016

© adriaticfoto / Shutterstock.com © r.classen / Shutterstock.com INFECTION CONTROL ECCMID highlights why MMR infections are emerging viral illnesses Clostridium difficile remains a difficult foe Measles, mumps, rubella threaten youngsters Fresh insight into an old pathogen Report: Jane MacDougall, Paris Explaining the reason why measles, mumps and rubella were present- ed in the same session as viruses such as Ebola and Zika, during the 2016 ECCMID meeting, infectious disease specialist Dr Guillaume Béraud, from the Centre Hospitalier Universitaire de Poitiers, said this was an ‘organisational short cut on the part of the ECCMID organisers, or we could reconsider our opin- ion of these ‘common and benign childhood’ viral infections. Because, since the introduction of vaccination in the 1960s, these can certainly no longer be considered as “common and benign”.’ ‘Also, and this is of particular impor- tance,’ he stressed, ‘one effect of widespread vaccination – which has been extremely effective but has not, of course, achieved 100% cover- age – is that these viruses have not, unlike smallpox, been eradicated. To do so, we’d need to reach 95% vaccine coverage. This has had an interesting impact on the spread of these viruses, none of which has an animal reservoir, they can only sur- vive by infecting humans, and this is why their spread has slowed down. ‘From a modelling point of view, we can see that the circulation of the viruses is slower than in the pre-vaccine era, therefore the popu- lation being infected has changed. The population now at risk to get infected is no more children, but teens and young adults. Why? Because, in addition to the shift in age of onset due to a slower viral circulation, these are the generation that socialise the most and therefore are the most likely to come into contact with the virus and, if they have not been vaccinated, develop the disease. Report: Anja Behringer Hospital-acquired Clostridium diffi- cile infection (CDI) is on the rise. Symptoms range from non-typical mild diarrhoea that can develop into pseudomembranous colitis up to a toxic megacolon, which often leads to death. Not only are there are hardly any efficient antibiotics nowadays, the use of antibiotics has turned out to be a significant risk factor in the spread of CDI. Since CDI occurs in many coun- tries, rich and poor, an international team of researchers, supported by the German state of Lower Saxony, compared the incidence of CDI in countries with different levels of antibiotics use. When patients carry the bacte- rium upon admission to the hospital and the infection develops during the patient’s hospital stay, the body not only has to fight the original disease, which was the cause for the hospital admission, but also CDI. Particularly older and immune-com- promised patients are at risk: the extended hospital stay also trans- lates into a considerable increase in treatment costs. CDI furthermore has a high recurrence rate and can develop into a chronic disease because most antibiotics destroy healthy as well as harmful bacteria, which can cause allergies, autoim- mune, metabolic or psychological disorders, with the latter ones rarely diagnosed as being tied to the status of the colon. According to the Robert Koch Institute, every year around 65 mil- lion adults worldwide suffer some form of gastrointestinal disease. While only one third of the people affected consult a doctor, those who do seek treatment should be aware of the risks associated with antibiot- ics. The German Gastroenterological Society (DGVS) points out that anti- biotics themselves can cause diar- rhoea and recommends limiting their use to certain cases, such as shigella or salmonella infections. While antibiotics do cure diseases they can cause long-term damage to the enteric flora – not to mention environmental damage. For hospital therapy the DGVS Guideline recommends judicious use of antibiotics and strict com- pliance with hygiene rules. In par- ticularly severe cases, the patient must be isolated – with unavoidable additional staff and treatment costs. Despite many warnings from physi- cians there are only a few pharma- ceuticals left whose efficacy has not been wasted by over-prescription. These drugs of last resort are lim- ited to particularly severe cases. Understandably pharmaceutical companies are urged to develop new antibiotics. However, the call goes largely unheeded despite steadily progressing research. Obviously in the future an antibiotic has to attack the specific pathogen rather than damaging the entire microbiota. Indeed, an active ingredient for targeted use against Staphylococcus aureus already exists. In Europe, the influx of young migrants may well increase pressure on the pharmaceutical companies to intensify efforts – particularly since the Zika virus, for example, is spreading without a vaccine or a therapy in sight. ‘One important downside of catch- ing measles, mumps or rubella, when older, is that the disease is much more severe than in a younger person (<5 year old). These cases are often much more serious, with far more risk of sequelae and, in the worst case scenario, mortality and therefore, from this perspective these can certainly be considered as new emerging viral diseases.’ Why, if adequate vaccination exists, is there resurgence? In France vaccination has been rec- ommended for all children since 1985 and is 100% reimbursed by Social Security. The MMR vaccine requires two doses to be given before the age of 24 months. However, vac- cination is not obligatory and there- fore a number of children each year either receive only one, or no dose of vaccine, which enables the virus to propagate. ‘The actual vaccine coverage (which is highly variable by region) never exceed 90% for the first dose and 85% for the second dose, with much lower coverage for some departments, which is far too low for herd immunity to be protec- tive (>90-95% is required). Therefore outbreaks can and do occur, par- ticularly in areas where coverage is lowest, such as in south-east France. With continued suboptimal cover- age the risk of epidemics can be easily be modelled – and are a real threat for 2016. Why are vaccination rates low? ‘The reasons for low vaccine uptake are multiple and complicated. One very real problem is because vac- cination has been so successful for so long, the potential seriousness of these illnesses has been forgotten and people do not consider protec- tion against them as a priority. ‘Also, of course, there is the anti- vaccine lobby, which is extremely articulate and convincing in its argu- ments and can sway a parent who has fears about vaccine safety. Of course the importance of vaccine safety is now primordial as the fear of the disease is so low. ‘As a profession, healthcare provid- ers need to learn to communicate our message to the public in an equally meaningful way, we need to learn what triggers a mother to have her baby vaccinated. It most certain- ly is not the highly scientific data that excites us, and our colleagues!’ In this 21st century, why are these viral diseases potentially dangerous? ‘These diseases are entirely prevent- able by vaccine. The vaccines we have are very effective and provide immunity for life and, therefore, no research has been directed towards specific antiviral therapy for mea- sles, mumps or rubella. Today, our standard of care for patients with these infections is much as it was in the 1950s and ’60s, when epidem- ics were frequent in the under 5s, meaning standard symptom control; fluids, rest, control of fever etc. This also means that, with the more severe cases we are seeing, we have no real therapeutic options, hence the real probability of serious com- plications.’ How might the cases in France affect European neighbours? ‘This problem is not unique to France; many other EU countries have low vaccine coverage, for example, the United Kingdom and Germany. The adolescent popula- tion also travels to other countries in groups. ‘We had a good example of how this helps virus spread last year. A group of school children from Alsace vis- ited Berlin and contracted measles from the children with whom they had exchanged. ‘Fortunately, for France, Alsace is a region with higher than average vaccine coverage and the number of cases soon petered out. This was fortunate because our modelling shows quite clearly how, in another region, an epidemic could easily have broken out. Measles is a highly contagious virus.’ How can this resurgence be stopped? Dr Béraud: ‘Only by vaccination; we need to work together to eradi- cate these viruses. It should be pos- sible, but will require a concerted effort from parent groups, health- care professionals and governments working together, which is not as easy as it sounds.’ Dr Guillaume Béraud, at the Centre Hospitalier Universitaire de Poitiers, Poitiers, France, recently completed his PhD, which focuses on mathematical modelling of the spread of infectious diseases. For this he worked in two centres – EA 2694 ‘Epidemiology and healthcare quality assessment’ in Lille, France and the Centre for Statistics in the Institute for Biostatistics and Statistical Bioinformatics at Hasselt University in Hasselt, Belgium. In a European Hospital interview before his presentation at ECCMID 2016, Infectious Disease Specialist Dr Guillaume Béraud spoke of the results from his modelling of the three ‘childhood’ diseases, measles, mumps and rubella. 14 EUROPEAN HOSPITAL  Vol 25 Issue 2/16

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