The week in review: June 3-9, 2012
MedWire News: This week's featured stories include a detective story about finding the source of a salmonella outbreak, a study showing home telemonitoring fails to reduce hospitalizations or costs in elderly patients with multiple comorbidities, the finding that one in 10 younger vets lack health insurance, the fall and rise of an STI, and an update on the cancer drug shortage.
Salmonellosis outbreak hatches in poultry facility
A multistate outbreak of salmonellosis has been linked to contact with poultry from a single hatchery ("Hatchery C"), reported Nicholas Gaffga (Centers for Disease Control and Prevention, Atlanta, Georgia, USA) and colleagues in the New England Journal of Medicine.
They investigated an outbreak of human Montevideo salmonella infection that was first reported in three people in Colorado in 2005. All three reported exposure to chickens or ducks purchased in agricultural feed stores prior to their illness.
The same strain of Salmonella enterica was then isolated in four other states, spreading to 316 confirmed patients in 43 states by December 2011. Through the use of questionnaires, patients and their caretakers were asked about contact with live poultry during the week before onset of illness, purchase of poultry, their knowledge of salmonella transmission, and if they were informed at the time of purchase.
Fifty-four percent of the 316 patients were aged 5 years or younger. In all, 122 patients had handled live poultry before their illness, and a trace-back investigation of the poultry in 59 patients' homes found that 81% had originated at Hatchery C.
In 2006, Hatchery C began a facility overhaul that included improved biosecurity, the introduction of biologic surveillance for salmonella, and implementation of a vaccination program for all adult chickens. A spot check by investigators in October 2007 noted 58 isolates of the outbreak strain, and an additional 14 isolates were found in 200 samples collected in 2008 and 2009.
The investigators surmised that the persistence of the salmonella strain may be due to the fact that Hatchery C has a closed breeding facility, with no birds from outside flocks.
Nice try, telemonitoring
Home telemonitoring of elderly patients with multiple illnesses does not lead to fewer hospitalizations or emergency department (ED) visits or reduced mortality, according to the results of a randomized controlled trial published in Archives of Internal Medicine.
Paul Takahashi (Mayo Clinic, Rochester, Minnesota, USA) and colleagues hypothesized that home telemonitoring could be beneficial in elderly patients with multiple chronic conditions.
They randomly assigned 205 patients, aged 60 years or older and at high risk for hospitalization owing to factors including comorbid conditions (stroke, dementia, heart disease, diabetes mellitus, and chronic obstructive pulmonary disease), to receive usual care or a telemonitoring device that had videoconferencing capability and several peripheral measures. Baseline characteristics did not differ between groups.
The patients given telemonitoring devices had symptoms and biometrics assessed daily, and the recorded data were downloaded to a website reviewed by the investigators. A registered nurse was available for phone calls or videoconferences if there were any alerts. Those in the usual care group had access to primary care physicians and specialists as well as the ED and urgent care facilities.
A greater proportion of patients given telemonitoring had ED visits and hospital admissions than those given usual care (63.7 vs 57.3%). The telemonitoring group also had a significantly greater mortality rate. No significant differences in hospitalizations were noted between the groups.
The investigators note that the trial enrollment was small and the patients' ethnicity was fairly homogenous. In addition, patients given usual care had access to a tertiary care hospital and case management programs for treatment of diabetes and heart failure.
Takahashi and colleagues conclude that in addition to the potential increase in some adverse events with home telemonitoring, there are also "potentially greater costs for support and equipment. This implies that investments in telemedicine may not provide better outcomes in its current delivery of case management."
One in 10 younger vets uninsured
One in 10 nonelderly US veterans does not have health insurance and does not take advantage of Department of Veterans Affairs medical services, according to a report released by the Robert Wood Johnson Foundation.
The 2010 American Community Survey sampled more than 129,000 nonelderly veterans, identified as those aged 19 to 64 years who had ever served on active duty but are no longer serving. The Urban Institute, which ran the survey, examined rates of uninsurance among these veterans and their families at both the national and state levels and their access to care, among other parameters.
The uninsurance rate among the veterans surveyed was 10.5%, considerably less than the 17.9% uninsurance rate among the general nonelderly US population. Rates varied significantly across states, from a low of 4.3% in Massachusetts to a high of 17.3% in Montana.
Compared with their insured counterparts, uninsured veterans are younger, have lower formal education levels, are more likely to be unemployed or working part-time, and are less likely to report any service-related disabilities.
The survey found that 41.2% of uninsured veterans have unmet medical needs and 39.5% have unmet dental needs, with over a third reporting delaying care due to healthcare costs. About 55% of uninsured family members also reported unmet medical needs.
Based on the expanded income range under the 2010 Affordable Care Act (ACA), almost 50% of uninsured veterans would qualify for Medicaid. This could provide, the Institute notes, "new routes to health insurance coverage for veterans and their family members." Currently, only about 10% are Medicaid-eligible. However, this change will not address uninsured veterans' unmet dental needs, as dental coverage is not part of the ACA.
Old scourge finds new customers
Drug-resistant gonococcal infections are making an unwelcome comeback, according to a report from the World Health Organization.
Gonorrhea resistant to cephalosporins ‑ the antibiotics of last resort against the sexually transmitted infection ‑ have been reported in Australia, France, Japan, Norway, Sweden, the UK, and other countries, the WHO notes.
The infectious organism, Neisseria gonorrhoeae, can acquire antimicrobial resistance across antibiotic classes, allowing it to gain both genetic and phenotypic resistance to several different anti-infective drug classes simultaneously, according to the WHO "Global action plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoeae."
The plan calls for campaigns to increase the awareness of the correct use of antibiotics by both patients and healthcare providers, with particular targeting of messages to at-risk populations, including men who have sex with men, and sex-trade workers.
It also calls for systematic surveillance and verification of treatment failures, with particular emphasis on countries with high rates of gonococcal and HIV infections and other STIs; prevention, diagnosis, and adequate treatment; improved regional laboratory networks for culturing gonoccoci; research into molecular methods for detecting antimicrobial resistance; and research into developing effective alternative treatment regimens for gonoccocal infections.
Methotrexate? Sorry, fresh out
Cancer drug shortages in the USA are beginning to decline, although ongoing difficulties obtaining certain chemotherapy drugs mean cancer patients are not out of the woods yet, according to the Food and Drug Administration (FDA).
In late October, the White House issued an executive order asking drug manufacturers to give the FDA an early warning of potential disruptions in the drug supply, and it appears to have worked: In 2012 alone, FDA has taken action to prevent at least 50 shortages, according to Sandra Kweder (FDA Office of New Drugs, Rockville, Maryland). Although the supply chain problems are beginning to diminish, oncologists remain concerned that they may not be able to get adequate supplies of several common chemotherapeutic agents, nearly all of which are generic. The list includes 5-fluorouracil, nitrogen mustard, and the taxane paclitaxel. Ironically, although a methotrexate shortage has been resolved, sodium bicarbonate needed to deliver high-dose methotrexate is now in short supply, said ASCO president Michael Link (Stanford University, California).
Reasons for the shortages vary, but they are usually attributable to manufacturing problems, such as contamination of sterile injectable compounds with glass particles, metal shavings, or other impurities.
The FDA has asked Congress to authorize creation of "user fees" for generic drugs that the agency says could help speed approval of generic drug review, cutting the average time from the current 2-plus years down to a relatively speedy 6‑10 months.
By Neil Osterweil