Maryn McKenna

Journalist and Author

Five-fold increase in flu+MRSA deaths in kids

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I have a story up this evening at CIDRAP News about a new paper in the journal Pediatrics that analyzes the incidence of child deaths from pneumonia caused by the combination of MRSA and flu, a sad and scary development that we’ve talked about here, here and here.

(NB: CIDRAP News is the original-reporting and news-aggregation arm of the Center for Infectious Disease Research and Policy at the University of Minnesota, an infectious disease research center headed by noted epidemiologist Michael Osterholm, PhD. I have a part-time appointment there. CIDRAP News is the best-read infectious-disease website you have never heard of, with about 10 million visitors a year, and is a notable resource for news on seasonal and pandemic flu, select agents and bioterrorism, and foodborne disease.)

It is bad netiquette and not fair use to reproduce another publication’s entire story here, even if I wrote it. Here though are the highlights:

  • 166 children died of influenza in the past three seasons (2004-05, 2005-06, 2006-07) according to 39 states and 2 local health departments (86 this year in preliminary reporting)
  • The proportion of deaths from bacterial co-infection rose each year, from 6% to 15% to 34%, a five-fold increase
  • Almost all of the bacterial co-infections were staph; 64% of them MRSA
  • The rapid rise in MRSA colonization (from 0.8% of the population in 2001 to 1.5% in 2004 — that’s more than 4 million people) may be playing a role
  • And, some of these deaths could have been avoided if children had had flu shots — but overall, only 21% of under-2s and 16% of 2- to 5-year-olds get the two shots they need to be fully protected against flu.

Please click through to CIDRAP for more.

The cite is: Finelli L, Fiore A, Dhara R, et al. Influenza-associated pediatric mortality in the United States: increase of Staphylococcus aureus coinfection. Pediatrics 2008;122:805-11.

The importance of MRSA in a flu pandemic

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Constant readers will know that, in another part of my life, I write a great deal about seasonal and pandemic influenza, a subject I’ve been following since writing the first story in the American media about avian influenza H5N1 (in August 1997; find it on this page.)

And people concerned about MRSA realize that flu and MRSA have an important overlap: For decades, long before the emergence of MRSA, staph was one of the most important contributors to secondary bacterial pneumonia, which occurs after the flu virus has damaged the lung tissue and allows staph and other bacteria to take hold.

In the past few years, we’ve been reminded of this interaction because of the shocking rise in cases of necrotizing pneumonia caused by MRSA (blogged here and here). Twice in the past two years, the CDC has asked state health departments to report any cases of flu/MRSA co-infection; in the 2006-07 flu season, 22 children died from MRSA necrotizing pneumonia secondary to flu.

Comes now one of the giants of staph research to warn of an unconsidered danger of MRSA: as a contributor to deaths in a flu pandemic. Dr. Theodore Eickhoff, who wrote some of the earliest papers on hospital-acquired staph infections, has written an assessment in Infectious Disease News of two new pieces of research into deaths during the 1918 flu pandemic. Both papers contend that it was bacterial pneumonia that was the major killer in that global storm of death, and not the novel flu virus itself.

Eickhoff looks forward from those findings to consider what havoc a new pandemic could wreak in this era of massive MRSA transmission. He contends that national planning for pandemics — a huge effort and expense for the US and other governments over the past few years — has paid insufficient attention to the possibility that bacterial infection will be as significant a danger as whatever new flu has emerged:

Authors of both of these reports point out that their findings have important implications for pandemic preparedness today. U.S. preparedness policy, and indeed that of almost all other countries, has been focused on preventing or modifying influenza virus infection itself. Thus, vaccine development and anti-viral drugs (eg, neuraminidase inhibitors) have been the major efforts, and a great deal of stockpiling has already taken place. Clearly it is equally necessary to stockpile antibiotics effective against primarily community-acquired organisms causing post-influenza pneumonia today, including both MSSA and MRSA. Much more consideration needs to be given to the possible role of pneumococcal and possibly other bacterial vaccines as part of pandemic preparedness.

Disease-related Do Not Fly list?

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This is not strictly MRSA-related, but it is so striking it’s worth posting on. This morning, the Centers for Disease Control and Prevention, the US public health agency, revealed in its weekly bulletin that it has begun maintaining a “Do Not Board” list for people who are thought to be a communicable-disease risk to others.

In slightly more than a year, 33 people have been refused transportation because of the list, which is operated in conjunction with the Department of Homeland Security.

The CDC began operating the list in June 2007, shortly after tuberculosis patient Andrew Speaker flew to Europe and back despite requests by public-health authorities that he not fly; he returned via Canada, driving into the United States to evade an alert given to airlines to locate him. At the time, Speaker was thought to have extensively drug-resistant (XDR) TB, an extremely dangerous form of the disease. Later, his doctors asserted and the CDC agreed that his TB was multi-drug resistant (MDR) — still dangerous, but nowhere near as dangerous as the almost-untreatable XDR form.

Patients’ names can be placed on the list by several entities though all requests are reviewed, the CDC says:

…state or local public health officials contact the CDC Quarantine Station for their region†; health-care providers make requests by contacting their state or local public health departments, and foreign and U.S. government agencies contact the Director’s Emergency Operations Center (DEOC) at CDC in Atlanta.
To include someone on the list, CDC must determine that the person 1) likely is contagious with a communicable disease that would constitute a serious public health threat should the person be permitted to board a flight; 2) is unaware of or likely to be nonadherent with public health recommendations, including treatment; and 3) likely will attempt to board a commercial aircraft.
Once a person is placed on the list, airlines are instructed not to issue a boarding pass to the person for any commercial domestic flight or for any commercial international flight arriving in or departing from the United States. (MMWR 57(37);1009-1012)

An important point here is the phrase “would constitute a serious public health threat.” Under US law (42 USC 264), most public health functions belong to the states, but the federal government is empowered to detain and isolate or quarantine people known or suspected to have a small list of communicable diseases: cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fevers (such as Ebola), SARS, and novel strains of flu. The Do Not Board list, however, reaches beyond that list, according to the CDC bulletin:

The public health DNB list is not limited to those communicable diseases for which the federal government can legally impose isolation and quarantine; the list can be used for other communicable diseases that would pose a serious health threat to air travelers. However, to date, the list has only been used for persons with suspected or confirmed pulmonary TB, which is transmitted via the respiratory route and which has had transmission documented during commercial air travel.

Detecting and protecting against disease threats to the US is well within the CDC’s mandate. Still, this raises a huge list of questions, from how medical privacy is maintained when a patient’s name is so widely circulated, to whether healthy people with similar names will be mistaken for sick ones, to how easily people get off the list once they are deemed well.

The CDC says that, of the 33 people placed on the list in the past 15 months, 18 already have been removed. But the persistent problems with the original No-Fly list — snagging air marshals and toddlers and causing passengers to change their names — suggests that this may not be as easy to manage as the CDC thinks. It would be good to hear more about what safeguards they propose — or whether they have left that part of the issue to be handled by DHS.