Confirmed: New H7N9 Bird Flu Comes From Chickens

Reuters Health Information

Apr 25, 2013By Kate Kelland

LONDON (Reuters) Apr 25 - Chinese scientists have confirmed for the first time that a new strain of bird flu that has killed 23 people in China has been transmitted to humans from chickens.

In a study published online today in the Lancet, the scientists echoed previous statements from the World Health Organization (WHO) and Chinese officials that there is as yet no evidence of human-to-human transmission of this virus.

The H7N9 strain has infected 109 people in China since it was first detected in March. The WHO warned on Wednesday that this strain is "one of the most lethal" flu viruses and is transmitted more easily than the H5N1 strain of bird flu, which has killed hundreds around the world since 2003.

Kwok-Yung Yuen of the University of Hong Kong, who led the study, said its findings that chickens in poultry markets were a source of human infections meant that controlling the disease in these places and in these birds should be a priority.

"Aggressive intervention to block further animal-to-person transmission in live poultry markets, as has previously been done in Hong Kong, should be considered," he said.

He added that temporary closure of live bird markets and comprehensive programs of surveillance, culling, biosecurity and segregation of different poultry species may also be needed "to halt evolution of the virus into a pandemic agent."

"The evidence ... suggests it is a pure poultry-to-human transmission and that controlling (infections in people) will therefore depend on controlling the epidemic in poultry," he said.

Yuen's findings do not mean all cases of human H7N9 infection come from chickens, or from poultry, but they do confirm chickens as one source.

The WHO has said 40% of people infected with H7N9 appear to have had no contact with poultry.

Other types of birds or mammals may be acting as so called "reservoirs" of the flu virus and investigators in China are working hard to try to find out.

CASE STUDIES

Yuen's team conducted detailed case studies on four H7N9 flu patients from Zhejiang, an eastern coastal province south of the commercial hub Shanghai.

All four patients had been exposed to poultry, either through their work or through visiting poultry markets.

To find out whether there was transmission of the virus from poultry to humans, the researchers took swabs from 20 chickens, four quails, five pigeons and 57 ducks, all from six markets likely to have been visited by the patients.

Two of the five pigeons and four of the 20 chickens tested positive for H7N9, but none of the ducks or quails.

After analyzing the genetic makeup of H7N9 virus in a sample isolated from one patient and comparing it to a sample from one of the chickens, the researchers said similarities suggest the virus is being transmitted directly to humans from poultry.

The team also checked more than 300 people who had had close contact with the four patients and found that none showed any symptoms of H7N9 infection within 14 days from the beginning of surveillance. This suggests the virus is not currently able to transmit between people, they said.

But they noted that previous genetic analysis shows H7N9 has already acquired some gene mutations that adapt it specifically to being more able to infect mammals - raising the risk that it could one day spread more easily between people.

"Further adaptation of the virus could lead to infections with less severe symptoms and more efficient person-to-person transmission," the scientists wrote.

SOURCE: http://bit.ly/10Cto3
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Guidelines for Abnormal Pap Smears: Don't Always Treat

Medscape Ob/Gyn > Kaunitz on Women's Health

Andrew M. Kaunitz, MD

Apr 15, 2013

In 2012, several professional groups, including the American Society for Colposcopy and Cervical Pathology (ASCCP), issued updated guidelines on cervical cancer screening.^[1]Now, the ASCCP has updated its 2006 guidance for managing women with abnormal cervical cancer screening tests and cancer precursors, issuing 19 algorithms that address clinical scenarios ranging from women with unsatisfactory cytology to those with various grades of squamous and glandular intraepithelial neoplasia.^[2] Given the growing use of co-testing, which combines cytology with assessment for high-risk human papillomavirus (HPV), this new guidance is timely.

With these new guidelines, certain women with screening results for whom colposcopy with cervical biopsies were previously recommended should now be initially managed without colposcopy. For instance, for women ages 21-24 years with cytology indicating either atypical squamous cells of undetermined significance (ASCUS) or a low-grade squamous intraepithelial lesion (LSIL), the new guidelines do not recommend initial colposcopy. Instead, when HPV reflex testing following ASCUS cytology is negative in such women, they should resume routine screening. If the initial screen reveals ASCUS with positive HPV or LSIL, repeat cytology is recommended at 12 months.

A second algorithm that caught my attention concerns the management of women with LSIL. If LSIL is found in the course of performing co-testing, and the HPV result is negative, repeat co-testing in 1 year is now the preferred management. In contrast, if LSIL is not accompanied by an HPV test, or if such testing is positive, colposcopy is recommended.

The algorithms included in this new guidance are too complicated to memorize, so I plan to keep a copy handy where I see patients. I would like to thank Dr. Karl Smith, Director of Gynecologic Oncology at my institution, for his helpful review of this commentary
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Yearly Mammograms Still Common Despite Guidelines

Apr 23, 2013

Steven Fox

It has been more than 3 years since the US Preventive Services Taskforce (USPSTF) published controversial guidelines recommending less-frequent mammograms for breast cancer screening. The effect of those guidelines on frequency of screening appears to be negligible. At least that is the conclusion of a survey of nearly 28,000 women. The survey results arepublished online April 19 in Cancer.

Previous guidelines issued by the USPSTF had called for routine screening every 1 to 2 years in women older than 40 years. However, when the USPSTF reviewed the guidelines in 2009, they recommended against routine screening for women aged 40 to 49 years and recommended biennial screening for women aged 50 to 74 years.

The revised guidelines ignited considerable controversy, and since their publication, the American Cancer Society and other medical organizations have stuck to their recommendations that women older than 40 years get annual screenings.

To find out what effect the updated USPSTF recommendations, and the ensuing controversy, have had on screening rates, Lydia E. Pace, MD, MPH, from the Division of Women's Health, Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, and colleagues assessed National Health Interview Survey data from 27,829 women.

They focused on how often women chose to be screened, using data collected during 2005, 2008, and 2011 surveys, which provides snapshots of self-reported mammography rates before and after the updated guidelines were issued.

The researchers found that screening rates did not decrease but actually showed a nonsignificant increase.

"The overall unadjusted mammography rates increased over time and were higher in 2011 (54%) than in 2008 (52%; P = .03)," the authors write. However, the difference was not statistically significant after the researchers adjusted for other factors, including race, education, income, immigration status, and insurance level (51.9% in 2008 and 53.6% in 2011; P = .07).

The investigators saw similar results when they divided the study population by age. Among the 40- to 49-year-old women, the adjusted screening rate was 46.1% in 2008 and 47.5% in 2011 (P = .38). Among the women aged 50 to 74 years, the screening rate was 57.2% in 2008 compared with 59.1% in 2011 (P = .09).

"Among all subgroups of women examined, including women who were black, Hispanic, immigrants, less educated, low income, uninsured, or publicly insured, there were no significant decreases in screening for women ages 40 to 49 years or ages 50 to74 years from 2008 to 2011," the authors report.

They add that there may be several reasons why the survey did not show decreased screening. One may be that perhaps it is too early to detect a decline. Another possible explanation is that many providers who refer patients for screening may not agree with the new recommendations, and therefore ignore them. Finally, the researchers note, patients may be continuing to request screenings because they either disagree or do not understand the new recommendations.

Cancer. Published online April 19, 2013. Abstract

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Steven Fox

Apr 23, 2013

 It has been more than 3 years since the US Preventive Services Taskforce (USPSTF) published controversial guidelines recommending less-frequent mammograms for breast cancer screening.

The effect of those guidelines on frequency of screening appears to be negligible. At least that is the conclusion of a survey of nearly 28,000 women. The survey results arepublished online April 19 in Cancer.

Previous guidelines issued by the USPSTF had called for routine screening every 1 to 2 years in women older than 40 years. However, when the USPSTF reviewed the guidelines in 2009, they recommended against routine screening for women aged 40 to 49 years and recommended biennial screening for women aged 50 to 74 years.

The revised guidelines ignited considerable controversy, and since their publication, the American Cancer Society and other medical organizations have stuck to their recommendations that women older than 40 years get annual screenings.

To find out what effect the updated USPSTF recommendations, and the ensuing controversy, have had on screening rates, Lydia E. Pace, MD, MPH, from the Division of Women's Health, Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, and colleagues assessed National Health Interview Survey data from 27,829 women.

They focused on how often women chose to be screened, using data collected during 2005, 2008, and 2011 surveys, which provides snapshots of self-reported mammography rates before and after the updated guidelines were issued.

The researchers found that screening rates did not decrease but actually showed a nonsignificant increase.

"The overall unadjusted mammography rates increased over time and were higher in 2011 (54%) than in 2008 (52%; P = .03)," the authors write. However, the difference was not statistically significant after the researchers adjusted for other factors, including race, education, income, immigration status, and insurance level (51.9% in 2008 and 53.6% in 2011; P = .07).

The investigators saw similar results when they divided the study population by age. Among the 40- to 49-year-old women, the adjusted screening rate was 46.1% in 2008 and 47.5% in 2011 (P = .38). Among the women aged 50 to 74 years, the screening rate was 57.2% in 2008 compared with 59.1% in 2011 (P = .09).

"Among all subgroups of women examined, including women who were black, Hispanic, immigrants, less educated, low income, uninsured, or publicly insured, there were no significant decreases in screening for women ages 40 to 49 years or ages 50 to74 years from 2008 to 2011," the authors report.

They add that there may be several reasons why the survey did not show decreased screening. One may be that perhaps it is too early to detect a decline. Another possible explanation is that many providers who refer patients for screening may not agree with the new recommendations, and therefore ignore them. Finally, the researchers note, patients may be continuing to request screenings because they either disagree or do not understand the new recommendations.

Cancer. Published online April 19, 2013. Abstract

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Are Statins Worth the Diabetes Risk?

Medscape Diabetes & Endocrinology > Viewpoints

Gregory A. Nichols, PhD

Apr 08, 2013

Viewpoint

Recent studies indicating an increased incidence of diabetes associated with statins have raised concerns on 2 fronts. First, some may worry that the hyperglycemic effect of statins may put individuals at risk of developing a serious chronic disease. Indeed, a meta-analysis of previous studies found a 9% increased risk for diabetes associated with statin use. Furthermore, there appears to be a dose response with greater risk for diabetes among patients who are treated intensively with statins compared with placebo or moderate statin doses. However, few would argue that statins provide substantial cardioprotection; therefore, a second concern is that the relatively low risk of developing diabetes might cause some patients to avoid statin therapy despite being at high risk for cardiovascular events.

The current study suggests that the risk of developing diabetes is limited to patients who are already at high risk. The minor increase in blood glucose with statins may be enough to push at-risk patients across the diagnostic threshold. After all, the single strongest predictor of diabetes is hyperglycemia; the higher the glucose, the greater the risk.

 We can now be reasonably comfortable that statins increase diabetes only among people who are probably going to develop it anyway. In addition, although the present study included other important risk factors for diabetes, such as HDL cholesterol and blood pressure, the authors were unclear about whether they were controlled for in the multivariable analyses. If not, it is possible that the residual risk associated with statin therapy would be lower or nonexistent if more extensive models were constructed. In any event, even if diabetes does develop at a somewhat higher rate among high-risk statin users, there is nothing magical about the diagnosis of diabetes. Regardless of whether the patient is at high risk for diabetes or has been diagnosed, one of the primary treatment goals is to reduce the risk for complications, especially cardiovascular disease, which is best achieved with statin therapy to reduce LDL cholesterol.

Scared of Alzheimer Disease? Run From It

Medscape Cardiology 

Henry R. Black, MD

Apr 05, 2013

Hi. I am Dr. Henry Black, Clinical Professor of Internal Medicine at the New York University Langone Medical Center, former President of the American Society of Hypertension, and a member of the Center for the Prevention of Cardiovascular Disease at New York University.

One of the biggest problems we are facing now, and certainly in the future, is dementia and Alzheimer disease. It is estimated that by the time we reach our mid-80s, 15% of Americans will have that diagnosis, and the cost is well over $5 billion and likely to rise.

Everything that has been tried to reduce that risk has pretty much failed. Crossword puzzles do not help, and neither do foods or nutritional supplements. The one thing that seems to make some difference is exercise. This was evaluated very recently in an article in Annals of Internal Medicine from a group at the Cooper Institute in Dallas, Texas.^[1]

This group has been interested in the importance of exercise in cardiovascular disease assessment and prevention since 1970. They have been at it a long time and analyzed long-term effects of exercise in thousands and thousands of individuals, based on Medicare claims data. For this study, they carefully evaluated risk factors and exercise abilities with a standard protocol—how many metabolic equivalents (METs) they achieved and maximal oxygen consumption (VO₂), for example. Then they divided the groups into quintiles. The people in the highest quintile of fitness level were then compared with the people in the lowest quintile to see whether or not they developed Alzheimer disease.

The results are clear: Those in the highest quintile had a lower Alzheimer disease risk than those in the lowest quintile.

One problem with the study is the population they looked at. Almost all had a college education or more, almost all were white, and they were certainly in a higher socioeconomic stratum. How applicable is this to the general population?

Also important, however, is that they looked at midlife fitness -- not when patients were older but during midlife. The average age of the people they evaluated was about 50 years. What they found is clear: If you have a high level of fitness in your 40s, or maybe even earlier than that, your likelihood of developing Alzheimer disease later on is definitely reduced.

What is the take-home message? Don't wait until you have an event (people who had events previously were excluded); get yourself on the treadmill, put your running shoes on, row, whatever it is you want to do, but try to get your fitness level up high when you are in your 30s and 40s, because this is going to prevent you to some degree from having Alzheimer disease when you are in your 70s and 80s, or beyond, hopefully.

Some Infected With H7N9 Had No Contact With Poultry

Reuters Health Information

Apr 17, 2013

 

By Stephanie Nebehay and Sui-Lee Wee

GENEVA/BEIJING (Reuters) Apr 17 - The World Health Organization said on Wednesday that a number of people who have tested positive for a new H7N9 strain of bird flu in China appear to have had no contact with poultry, adding to the mystery about a virus that has killed 17 people to date.

WHO spokesman Gregory Hartl confirmed that "there are people who have no history of contact with poultry", after a top Chinese scientist was quoted as saying this applied to about 40% of those infected.

"This is one of the puzzles still (to) be solved and therefore argues for a wide investigation net," Hartl said in emailed comments.

Hartl an international team of experts going to China soon would include in their investigation the possibility that the virus can be spread between people, although there was "no evidence of sustained human-to-human transmission".

"It might be because of dust at the wet markets, it could be another animal source beside poultry, it could also be human-to-human transmission," he said by telephone.

Wendy Barclay, an influenza expert at Imperial College London, said it could be hard to reveal or rule out exposure to poultry - or to wild birds, which could also be a possible source of infection:

"The incubation time might be quite long, so visiting a market even 14 days before might have resulted in infection."

Hartl said two new suspected cases of possible human-to-human transmission were being investigated.

The first is a couple in Shanghai who tested positive, Hartl said, adding that the wife had died and husband was still sick. A seven-year-old girl in Beijing was the first case in the capital at the weekend and the boy next door has also tested positive, but is not showing symptoms, he said.

NUMBERS TO RISE

The WHO had previously reported two suspected family "clusters", but the first turned out to be a false alarm and the second was inconclusive.

China has warned that the number of infections, 82 so far, could rise. Most of the cases and 11 of the deaths have been in the commercial capital Shanghai.

China reported three new outbreaks to the World Animal Health Organization (OIE) this week, bringing the total number of locations to 11, the OIE said.

Poultry markets remain the focus of investigation by China and the U.N.'s Food and Agriculture Organization.

But Zeng Guang, chief scientist in charge of epidemiology at the China Disease Prevention and Control Center (CDPCC), said about 40 percent of human victims had no clear history of poultry exposure, the Beijing News reported.

The center declined to comment on state media reports saying only 10 of the 77 cases known by Tuesday had had contact with poultry.

A study published last week showed the H7N9 strain was a so-called "triple reassortant" virus with a mixture of genes from three other flu strains found in birds in Asia. One of those three strains is thought to have come from a brambling, a type of small wild bird.

"We can't rule out that this ... has passed through poultry but then been reintroduced to a wild bird population from which some spread to humans might be occurring," Barclay said.

H7N9 Human Infection of 'Public Health Significance'

Medscape News

Troy Brown

Apr 12, 2013

 A novel avian-origin influenza A (H7N9) virus circulating in China appears to be more virulent than previously observed influenza A subtype H7 viruses, according to an analysis of clinical, epidemiologic, and virologic data from 3 patients who died in March after becoming infected with the H7N9 virus.

Rongbao Gao, MD, from the National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention in China and colleagues report their findings online April 11 in the New England Journal of Medicine .

As of today, the World Health Organization reports that H7N9 has been confirmed in 43 patients and 11 have died.

The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, received a specimen of the H7N9 virus from China yesterday. On April 9, the CDC activated the Emergency Operation Center (EOC) at Level 2 (there are 3 levels, with 1 as the highest) to support the management of the emerging H7N9 situation, Sharon KD Hoskins, MPH, senior press officer at the CDC told Medscape Medical News in an email.

Researchers used real-time reverse-transcriptase-polymerase-chain-reaction assays, viral culturing, and sequence analyses to test the patients' respiratory specimens for influenza and other respiratory viruses.

Infection of poultry with influenza A subtype H7 viruses is widespread, but this subtype has not been observed in humans in Asia before now. Previously, most human infections with highly pathogenic avian influenza (HPAI) A (H7) viruses have resulted in mild illness. Transmission of H7 viruses to mammals is rare in Asia, and human infection with N9 subtype viruses has never been documented anywhere.

Fever and cough were the most common symptoms in the 3 patients, all of whom had acute respiratory distress syndrome. Their conditions deteriorated rapidly after the onset of symptoms.

One patient had no known exposure to birds in the 2 weeks before becoming ill, 1 patient worked in a market where live birds were sold but had no contact with birds (he was a butcher of pigs), and the third patient visited a chicken market 1 week before becoming ill.

Genetic sequence data indicate that the H7N9 virus may bind more easily to human receptors than avian receptors and that the virus may also be transmitted by air.

"Currently there is no vaccine available for these novel viruses, and it is not known whether the current candidate H7 vaccine viruses, of which three are North American viruses and the other three are avian viruses from 2000 in the Netherlands, may be effective," the authors write.

Diagnostic tests for the novel reassortant H7N9 viruses have been developed based on these data. The specific sequences can be found on the website of the World Health Organization (www.who.int/influenza/gisrs_laboratory/a_h7n9/en/).

'Public Health Significance'

In an accompanying perspective, Timothy M. Uyeki, MD, MPH, MPP, and Nancy J. Cox, PhD, from the Influenza Division, National Center for Immunization and Respiratory Diseases at the CDC, commented on the article, noting that this outbreak "is of major public health significance."

"The hemagglutinin (HA) sequence data suggest that these H7N9 viruses are a low-pathogenic avian influenza A virus and that infection of wild birds and domestic poultry would therefore result in asymptomatic or mild avian disease, potentially leading to a 'silent' widespread epizootic in China and neighboring countries," Drs. Uyeki and Cox write. The HPAI H5N1 virus usually causes rapid death in infected chickens.

Researchers believe the animal reservoir is birds, but many experts wonder whether the virus might also infect pigs, "another common reservoir for zoonotic infections," they write.

The viral sequence data also suggest antiviral resistance to the adamantanes and susceptibility to neuraminidase inhibitors, and continued surveillance is needed to determine if this is significant. Oral oseltamivir or inhaled zanamivir should be given to patients with suspected or confirmed H7N9 as soon as possible, Drs. Uyeki and Cox write.

Clinicians should be alert to the development of secondary bacterial infections and treat with antibiotics as appropriate, they write.

"The coming weeks will reveal whether the epidemiology reflects only a widespread zoonosis, whether an H7N9 pandemic is beginning, or something in between," Drs. Uyeki and Cox conclude.

Cervical Cancer Screening: 'We Can Do Less'

Zosia Chustecka

Apr 09, 2013

 

Unnecessary testing for cervical cancer in women younger than 21 years and in those who have had a hysterectomy is costing about $850 million annually in the United States. It also poses clear risks without documented benefit.

So conclude Nancy Morioka-Douglas, MD, MPH, and Paula Adams Hillard, MD, both from Stanford University in California, in a viewpoint published online April 8 in JAMA Internal Medicine.

"Cervical cancer screening is a prime example of where we can do less without compromising the health of our patients," writes Michael LeFevre, MD, MSPH, from the University of Missouri in Columbia, in an accompanying invited commentary.

The extent of this unnecessary testing was highlighted earlier this year in a report from the Centers for Disease Control and Prevention, as reported at the time by Medscape Medical News.

Drs. Morioka-Douglas and Hillard and Dr. LeFevre explore in some detail the use of the Papanicolaou (Pap) test in 2 populations: women younger than 21 years and women who have had a hysterectomy. They point out that the guidelines of numerous professional organizations, as well as the US Preventive Services Task Force, recommend against such testing.

Testing Against Guidelines

Drs. Morioka-Douglas and Hillard explain that screening women younger than 21 years is not recommended for several reasons. Cervical cancer is rare in adolescents, and abnormal cervical cytologic findings related to human papillomavirus (HPV) infection are common in this group, they note. Screening these women leads to unnecessary testing and treatments for lesions that would spontaneously regress, and treatments are associated with risks, they add.

Nevertheless, it is being carried out. They estimate that 4.7 million women younger than 21 years have an annual Pap test in the United States. They calculate that this unnecessary testing costs approximately $500 million per year (using a laboratory fee of $103 per Pap test, based on 2011 Medicare fee schedules). This does not include the cost of additional testing to investigate positive screening results.

Guidelines also recommend against Pap testing in women who have had a hysterectomy for a benign condition. However, such testing is being carried out in about 3 million women per year (about 1 million of whom are older than 65 years), Drs. Morioka-Douglas and Hillard note. They estimate that this costs approximately $350 million per year, not including the cost of additional investigations.

"Swimming Upstream"

Even when the cost issue is left out of the debate, Pap testing in these 2 populations can result in more harm than good, writes Dr. LeFevre.

He acknowledges that it is hard to get physicians to do less testing and patients to accept less testing. It is like "swimming upstream," he adds.

The forces to do more are powerful, and with screening, so often the mantra is "if we can save even 1 life, it is worth it," he notes.

There are also liability concerns; the failure to diagnose a problem that later causes significant morbidity or mortality is a leading cause of litigation, he points out. "Are there comparable lawsuits for overuse of medical testing?" he asks rhetorically.

Testing More Frequent Than Recommended

Even in women who meet the recommended criteria for cervical cancer screening, there is evidence that more testing than is recommended is being carried out.

Results from a survey of 2087 primary care physicians, published online April 8 as a research letter, show that most would recommend testing earlier than the 3-year interval that is now recommended for women 30 years and older with a negative test result for oncogenic HPV and a concurrent normal result on Pap testing.

"Primary care providers consistently reported that they would recommend Pap testing sooner than recommended by guidelines, especially after normal cotesting results," the research letter concludes.

JAMA Intern Med. Published online April 8, 2013. Viewpoint, Invited commentary, Research letter