Wednesday, March 20, 2013

CDC Conference 2013, Canberra, Australia - Day 2

 Day 2 of CDC 2013, the main themes were foodborne disease, vaccine preventable diseases and anti-microbial resistance.

Professor Karl Ekdahl presented the experience of setting up the European Centre for Disease Control - of great relevance given the discussion at this conference regarding the need for an Australian CDC. It is a purely technical institution with no policy role - that is left to the national centres.  It is staffed with approximately 200 personnel and has no dedicated laboratory capacity. The CDC OZ controversy continued throughout the day.

Joshua Francis presented a case of a recent tragic fatal case of Australian Bat Lyssavirus in a young boy.  He had an (uncertain) exposure to a bat 8 weeks prior to onset of illness. He presented initially with severe abdominal pain. Joshua reviewed ABL - sick injured or orphan bats have prevalence of ABLV infection of 5 - 10%, < 1% in healthy bats. Interestingly, the Milwaukee protocol, a protocol credited with the survival of 6 human cases of rabies requires the avoidance of vaccine and HRIG as these appear to hasten death in animal experiments.

Roy Chean argued for mandatory influenza vaccination of health care workers.   Patrick Cashman presented the Hunter New England LHD Vaxtracker pilot to track adverse events following influenza vaccination via a 3 day and 42 day online survey. Gary Dowse reviewed communicable disease transmission in airlines. Currently we consider that the risk of measles is mainly restricted to the same seating  row, and 2 rows forward and backward, but in this review it revealed that 45% of secondary cases fell outside this target area. Transmission occurred in 14% of flights with infectous cases.  However, follow up is not so effective - they had to follow up a mean of 27 contacts in 2 + 2 rows per flight.  Delays in notification and contacting contacts results in inablity to provide prophylaxis in many cases. Gary suggested that the current  2+2 policy is not effective, many people will be exposed to the case at other points in the travel process - such as in the boarding line or gate lounge, toilets, and baggage areas.  The working group doubt the value of following up measles cases on airlines and believe current protocols need review.

Alexis Pillsbury reviewed recent imported measles cases in NSW.  Of 43 presentations to health care facilities, they presented approximately 3 times before a diagnosis was made. Most of the transmssions occured in waiting rooms with much higher rates of transmission at EDs. Cases were rarely isolated on recognition. 16 source cases led to 36 secondary healthcare transmissions.  All secondary cases has overlap time with the source case - raising questions about the validity of the 2 hour follow up rule (i.e. consider anyone entering the same room within 2 hours of a case exiting be considered a contact).

Professor Henrik Wegener from Technical University of Denmark presented on Denmarks impressive achievements in foodborne disease control.  He emphasised that in developed countries zoonotic foodborne disease can be controlled by controlling vertical transmission. They screen pigs for salmonella at slaughter and scald the carcass with steam if elevated carriage rates. Most effective intervention is their shell egg salmonella control. 60 eggs per flock are tested and flocks eradicated or eggs heat treated and has led to massive reduction in salmonellosis. PCR testing of chicken to label it as campy free failed as only frozen chicken went down this route -the requirement to hold pending testing required freezing. However, since freezing is an excellent way to decrease campylobacter this system backfired with fresh chicken (with 100x greater campy levels) now mostly coming from the non-campy free sources. He flagged that the increasing rates of community acquired MRSA may be zoonotic. Significant campy control in chickens was achieved just through flyscreens, he said it was impossible to maintain free range chickens campy free.

The last presentation today was by Dr Abdul Ghafur, Consultant in Infectious Diseases, Apollo Hospital Chennai, India - he was a big surprise!  He had a strong and sometimes difficult to follow accent but his passion for antibiotic stewardship punched through to wake up even the most ardent multi-tasker -  the atmosphere was electric.   His recent editorial in Journal of the Association of Physicians of India “An obituary on the death of antibiotics”,( really worthwhile read) has been cited extensively internationally in journals and media. While acknowledging the crisis in resistance to gram positive bugs such as Staph, he highlighted an even greater crisis in resistance in gram negative bugs with emerging carbapenem resistance in India leaving only colistin - a single antibiotic between the world and a post antibiotic era.  He says the bacteria have won the war!

Dr Ghafur's compelling (although somewhat less animated than today) style of presentation can be see on this youtube clip:

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