Plague debrief: what really happened in the July 2014 Gansu case of pneumonic plague?

by Michael Woodhead
In July 2014 a case of pneumonic plague was widely reported in the media.

The victim was a 38-year old shepherd who caught the infection from a marmot (the usual carriers of the infection) after it was caught by his dog. At the time it was widely reported that the town of Yumen (near Jiayuguan) where he was treated, had been put into lockdown. None of the 30,000 residents were allowed to leave town and more than 150 close contacts were kept under observation in quarantine. It looks like Chinese authorities did the right thing - but only after a fatal delay in the initial diagnosis. A new report published by the local infection control team gives more details of the case.

Dr Ge Pengfei and colleagues say that the man contracted the Yersinia pestis infection from an infected marmot after it was caught by his dog on 11 July. He skinned the marmot for its pelt and fed the meat to his dogs. Two days later the shepherd started to develop respiratory symptoms and went into a nearby village to seek treatment. However, when he first went to the local clinic on 15 July he was mis-diagnosed as having a simple respiratory tract infection and given just a prescription for an antibiotic (clindamycin) and some anti-inflammatories. When his condition worsened later that day he was seen by doctors at the hospital in Yuman, who diagnosed pneumonia on x-ray and they gave him an ineffective antibiotic, cefoperazone, and more anti-inflammatory treatment.

It was only later that night when the man's condition deteriorated further and he started coughing up blood that throat swabs were taken, which showed the presence of the characteristic Yersinia bacilli when tested. Doctors then gave the man the recommended treatment of IV streptomycin, but this was too late and probably did more harm than good in the rapidly advancing conditions of the infection. Streptomycin must be used with great care in advanced plague because it cases the Y. pestis bacteria to burst (lysis) and release large amounts of the endotoxin that causes septic shock. This is what happened in the case of the Gansu shepherd, whose quickly deteriorated in the early hours of 16 July and he died at 5am.

The infection control team said they also detected Yersinia infection in the man's sister in law and in two patients who had been in close contact with him at the hospital. These people were among the 150 close contacts subject to quarantine and to preventive treatment with streptomycin. This containment strategy worked, as none of the close contacts developed full blown pneumonic plague.

The infection control team said them man may have survived if his infection has been detected earlier. However, the village clinic and hospital had only limited medical facilities, and the plague was only picked up when cultures were examined under a microscope.

They said that local clinics in areas such as Gansu where plague is present (on average there is one case per year in the region) should be alert for the early signs of the infection - and be prepared to take a careful history to see if there has been any contact with potential sources such as marmots and infected dogs. Despite the death of the patient, they said the incident had shown that quarantine and antibiotic prophylaxis procedures for contacts were effective.

"Doctors need to improve awareness and ask about contact history for the possibility of plague infection to avoid misdiagnosis," they recommended.

International Journal of Infectious Diseases.

Drug resistant bacteria - just how much of a problem are they in a typical Chinese hospital?

by Michael Woodhead
With broad spectrum antibiotics easily available over the counter in China  - and the Chinese cultural expectation of an antibiotic as the magic bullet for every viral fever - it's not surprising that drug resistance is a major problem in the PRC. 
But just how common is the problem for a typical provincial hospital? The rather worrying answer is quite a big problem. A study carried out in the Liaocheng People's Hospital in Shandong has found that one in three bacteria samples obtained from around the hospital were multi-drug resistant. Researchers at the hospital took almost 10,600 microbial samples from around the hospital and found that  33.4% were multi-drug resistant pathogens such as ESBLs producing E. coli and A. baumannii. The blackspots for resistant bacteria were in surgical departments and the intensive care department. Samples obtained from respiratory and secretions were the greatest source of resistant bacteria. The obvious consequences of these multi-drug resistant bacteria are treatment failure, longer hospital stays, increased mortality, and higher hospitalisation costs. As the authors conclude, their findings show the need for much greater attention to antibiotic resistance, especially from respiratory cases and surgical wounds.

China's best case scenario for an Ebola outbreak: 3000 deaths

by Michael Woodhead

With more than 600,000 annual passenger arrivals from Africa and a poor to non-existent public health infrastructure in most parts of the country, China faces  a very real risk of an Ebola outbreak. That the verdict of infectious disease specialists who have modelled what will happen if a person with Ebola lands in China and is not detected immediately.

Dr Chen Tianmu and colleagues from the Changsha Center for Disease Control and Prevention have used data from previous Ebola outbreaks overseas and also from outbreaks of dengue and HIV viruses in China to model the likely spread of the infection before it can be brought under control. They modelled several different scenarios based on different levels of infectivity of the virus and different levels of detection and containment.

They based their calculation on the fact that there were 524,900 African visitors and 112,966 Chinese returning from Africa each year in China. Based on current distribution of Ebola Virus Disease and the rates of carriage in Africa, they estimated that 0.04%–0.16% of these arriving passengers in China (255–1021 people) may carry Ebola. Even if an optimistic assumption is made that only 1% of them slip through the entry-exit inspection and only 1% of these are not picked up by further reporting and monitoring follow ups, this would still mean 3-10 Ebola virus carriers could be at large in China.

The researchers noted that China lacks a primary care system and most sick patients go direct to hospitals that are overcrowded and where Ebola patients might spread the virus to others. China also has limited public health reporting and surveillance systems for much of the country, and it would therefor be possible that cases of Ebola virus could be misdiagnosed and slip though the net until the patient became symptomatic and infectious.

The researchers then calculated that the likely impact of such 'index cases' spreading the Ebola infection to others would be outbreaks of Ebola in China affecting between 6000-10,000 people. With a likely fatality rate of around 50% this would mean a severe mortality burden for China, they wrote.

Writing in Travel Medicine and Infectious Diseases, they said the lack of Ebola testing facilities in China and poor infection control practices would further encourage the spread of the infection, they predicted. Other factors, such as the lack of quality control on blood transfusions (as seen with outbreaks of HIV and hepatitis) would also increase the risk of spreading Ebola in China, they warned.

"Even if a good surveillance and monitoring system is implemented at immigration, an effective and efficient local medical response system involving primary health care providers and awareness of the general public is necessary to minimise the risk of an Ebola Virus outbreak due to other unknown sources," they suggested.

In China's hospitals, one in three doctors have latent tuberculosis infection

by Michael Woodhead
It's an avoidable occupational hazard that Chinese doctors could well do without: tuberculosis. 

A  study carried out in a general hospital in Henan has found that one in three healthcare staff have latent tuberculosis infection. The figures are even worse for a nearby infectious diseases hospital where almost 60% of doctors had latent tuberculosis infection.

First some clarification: as the CDC points out:

Persons with latent TB infection do not feel sick and do not have any symptoms. They are
infected with M. tuberculosis, but do not have TB disease. The only sign of TB infection is a
positive reaction to the tuberculin skin test or TB blood test. Persons with latent TB infection
are not infectious and cannot spread TB infection to others. Overall, without treatment, about 5 to 10% of infected persons will develop TB disease at some time in their lives.

So, people with latent TB do not pose a serious risk to patients, but they themselves face a high risk of developing active tuberculosis disease.

In the study of 712 healthcare workers at a 1600-bed general hospital and a 600-bed infectious diseases hospital in Zhengzhou, researchers found that the tuberculin skin test-positive prevalence was 34% in the general hospital and 58% in the infectious disease hospital.

Dr Zhou Feng and colleagues who did the study said that health staff faced high risks of tuberculosis if they worked with infected people, such as those with HIV who often have co-infection with tuberculosis. Rates of infection were also highest in staff with longer years of working in the hospitals, presumably due to greater duration of exposure to risk.

Writing in PLOS One they said many staff did not use personal protective equipment such as  face masks and N95 respirators when working with infectious patients, despite this being recommended in guidelines.

Another problem with detecting and treating tuberculosis in healthcare workers was the low rate of tuberculin skin testing for the infection: many healthcare workers refused testing, and the most effective testing kits were too expensive for many Chinese hospitals. The findings also highlighted the limitations of the regular chest X-rays used to screen workers for active tuberculosis disease.

As the authors conclude - more emphasis is needed on observing and adhering to basic infection control and prevention practices in Chinese hospitals:

"Comprehensive guidelines should be developed for different types of medical institutions to reduce tuberculosis transmission and ensure the health of healthcare workers," they suggest.

China's answer to Ebola: a lethal haemorrhagic fever that kills 20,000 people a year

by Michael Woodhead

Like many other countries, China has gone into a hysterical spin about the threat posed by Ebola virus disease.

Authorities have dusted off the useless thermal scanners last used in the avian flu outbreaks, and have started screening passengers arriving at from Africa at Chinese airports. And despite the World Health Organization saying that China does not need to be overly concerned about the disease, authorities have been issuing stern warnings to health workers about being vigilant for Ebola and also looking with suspicion on the African expats living in cities such as Guangzhou. The irony is that China has seen its own counterpart of Ebola virus disease, a killer disease that has been increasing dramatically in the last two years.

But first some background: Ebola is a haemorrhagic fever, caused by the Ebola virus, which belongs to the  Filoviridae family of RNA viruses. The virus comes from apes and bats and is only transmitted between humans by body fluids such as blood and saliva - in Africa it has been spread by hunters cutting up meat from infected animals, and spread to healthcare workers and close relatives to touch the dead bodies of Ebola victims at traditional African funerals. In the latest outbreak there have been 1323 confirmed and suspected cases of Ebola reported, and 729 deaths. That's a mortality rate of 55% according to my calculator.

What to make then of China's recent little remarked but lethal cases of haemorrhagic fever? In April, Dr Du Hong and colleagues from the Center for Infectious Diseases, Tangdu Hospital, Xian, described the horrific symptoms of some of the 356 patients who had been treated at their hospital for  "hemorrhagic fever with renal syndrome" (HFRS),  a disease caused by Hantavirus that is spread by rats (or more specifically in their droppings, which may become aerosolised and spread to anyone working near where rats have been active).

The symptoms are similar to Ebola: fever, circulatory collapse with hypotension, hemorrhage, but also with acute kidney failure (hence the name renal syndrome). The difference between Ebola and HFRS is that the Hantavirus disease has a death rate of 'only' 40%. For China, which has had about 50,000 cases of HFRS annually, that means about there have been, at a conservative estimate, 20,000 deaths from Hanta virus every year. Makes the 730 Ebola deaths in Africa look fairly insignificant doesn't it? And as with Ebola, there is no treatment or vaccine for Hantavirus, only supportive care.

And that's not all. China has other types of haemorrhagic fever. This month The Lancet carries a report of the emergence of one, known as "severe haemorrhagic fever with thrombocytopenia". This is a viral disease spread by ticks, caused by the SFTS phlebovirus in the Bunyaviridae family. According to Dr Liu Quan and colleagues from the State Key Laboratory of Veterinary Etiological Biology, Lanzhou, SFTS was first reported in 2010 and has since been found in 11 provinces of China, with about 2500 reported cases, and an average case-fatality rate of 7%. That's about 175 deaths. As the study authors say with some understatement: "The disease has become a substantial risk to public health".

China is the epicentre for Hantavirus haemorrhagic fever in the world, but it is not the only country affected. The disease is also seen in Europe and the US - a Denver man died of the infection just this week. But with tens of thousands of Chinese people dying every year from this terrible haemorrhagic disease, perhaps China ought to worry more about curbing Hantavirus - and the rats that carry it - rather than panicking over the threat from an African outbreak of Ebola.

Dysentery in China - the good news and the bad news

by Michael Woodhead
Dysentery is one of those disease most westerners associate with 'the olden days' - or the Third World. 
Bacillary dysentery, also known as Shigellosis, is the severe gastro disease of poor hygiene, spread by faecal contamination. Ten years ago dysentery was still relatively common in Guangzhou, but a new report shows the city has brought rates of the disease down with a co-ordinated campaign to detect and manage cases and prevent further outbreaks. In 2006 the city had about 12 cases of dysentery per 100,000 population - so for a city of 8.5 million people that's more than a thousand cases a year. To tackle the infection, the city health department implemented the "Intestinal Infectious Disease Surveillance, Prevention and Control Program" (IIDSPCP). This means that once a patient is suspected as having Bacillary dysentery, public health workers target their household with preventive measures such as quarantine, disinfection, and good personal hygiene practices mandatorily implemented by local government. This program has seen the rate of dysentery cut to around 2 per 100,000. Good news so far. However, public health staff say dysentery still remains a problem in the poorest families - as judged by the high rates among children who do not attend school. They now account for the largest group of patients with dysentery.
This social group - usually migrant workers from the poor inland provinces - is China's new underclass. As the report notes: "They are usually lacking in adequate sanitation, with low health risk awareness, and more likely to have exposure to contaminated food or water. It has been reported that compared to the other group, the school-age children not attending school have higher incidence in many infectious diseases such as hand-food-mouth disease, infectious diarrhea, and hepatitis A."
Interestingly, the other high risk group for dysentery is young people aged the people aged 20-44 years - perhaps because they take part in more social activities, have more chance to contact with Shigella patients or carriers, and have more leisure time, and finance to travel and thus more likely to have exposure to Shigellosis.
As the report authors conclude: "more effort should be made to enhance health education about dysentery and monitoring/targeting at school-age children not attending school ... .as well as establish strategies for prevention of the disease in China."

Seven China medical news snippets for Thursday 13 March

1. Antivirals at kindergarten
Children at a kindergarten in Xian have been treated with an antiviral without the knowledge of their parents. Parents were furious to discover their children were dosed with moroxydine thee days a week supposedly as prophylaxis to prevent viral infections, at the direction of a doctor who was only licensed to practice in Guangdong.

2. Private health eyes China profits
Private healthcare operator Concord Medical says it sees huge potential in the Chinese health system reforms. The group already owns 144 medical centres and the Chang'an Hospital in Xi'an, and is now building three high-end specialty cancer hospitals in Guangzhou, Beijing and Shanghai.

3. Stroke risk with high normal BP
Cardiologists in Guangzhou have shown that pre-hypertension (systolic BP of 120-140mmHg) is a risk factor for stroke. Their research showed that low range hypertension increased stroke risk by 44%, according to the meta-analysis published in the journal Neurology this week.

4. Needlestick risks in Chinese hospitals
Doctors and nurses in Chinese hospitals face high risks of blood-borne infections because of poor needlestick injury prevention practices, a study has found. Doctors faced a high risk of infections from suturing needle accidents while nurses often had needlestick injuries with syringes and IV infusion sets,w ith an average of two injuries per year, a study in the American Journal of Infection Control showed.

5. Medical article fraud
A doctor in Hainan has been jailed for eight years for fraud after it was discovered he wrote 11 medical articles and dissertations for others. The doctor charged about 12,000 yuan for each article.

6. Knee OA undiagnosed
Knee osteoarthritis is common among elderly people in Guangzhou but often goes undiagnosed and untreated. A study of elderly inpatients at a city hospital found the prevalence rate of knee arthritis was 10% in males and 38% in females. Only about half of patients were aware they had arthritis, and among these only 77% had adequate treatment.

7. Dust full of carcinogens
Inhabitants of Guangzhou are exposed to toxic levels of arsenic and chromium in PM2.5 particle in dust, a study has found. Using hair analysis, researchers from Sun Yat-sen University, Guangzhou found that Guangzhou residents had high and carcinogenic levels of accumulated metals and other toxic elements.

China medical news for Sunday 2 February

Cosmetic procedures a high risk for hepatitis C
Chinese people are more likely to contract hepatitis C from a cosmetic and beauty treatments than from medical procedures or blood transfusion, a study from Jilin shows.
Researchers found that hepatitis C rates had increased rapidly in Yanbian, Jilin, more than doubling from  2007 to 2011. Unexpectedly, they found that cosmetic treatments conferred the higest risk - almost five fold higher than control groups. Having someone esle in the family with HCV was also a high risk for infection, presumably through sexual transmission between spouses, the researchers said. Writing in PLOS One, the researchers for the Capital Medical University, Beijing, said cosmetic treatments had become popular in recent years and there was a risk of viral infection with procedures that broke the skin such as shaving and ear piercing.

Atherosclerosis defined in stroke
Intracranial atherosclerosis (ICAS) is the most common vascular lesion in patients with cerebrovascular disease in China, a study  has shown. Researchers at the Tiantan Hospital in Beijing assessed 2864 consecutive patients who experienced an acute cerebral ischemia and found the prevalence of ICAS was 47%. Patients with ICAS had more severe stroke at admission and stayed longer in hospitals compared with those without intracranial stenosis. According to the study in Stroke, after 12 months, recurrent stroke occurred in 3.3% of patients with no stenosis, in 3.8% for those with 50% to 69% stenosis, in 5.2% for those with 70% to 99% stenosis, and in 7.3% for those with total occlusion.

STI risk high for men who visit prostitutes
Men who have unprotected sex with prostitutes are at high risk of HIV and syphilis, Guangxi research has shown. A study of more than 100 men who visited prostitutes found a high rate of unprotected sex (84%). The overall prevalence of HIV, hepatitis C and syphilis was 1.9%, 1.0% and 18.4%, respectively, according to the study published in Sexually Transmitted Infections.

Parasite problems on the Tibetan plateau
Worm parasites are an endemic problem for Tibetans, especially nomadic herders, a study has found.
Echinococcosis affects more than 380,000 people on the Tibet-Qinghai plateua, is spread by dogs and cattle, and is often picked up from drinking groundwater, according to a study by Chinese researchers. Those most at risk include the old and female in particular. Writing in Infectious Diseases of Poverty, the researchers said control of the parasites should focus on deworming both owned and stray dogs and health education activities n Tibetan language.

China's medical news for Friday 31 January

Breast milk contains high levels of DDT
Breastfeeding mothers in Zhejiang have high levels of DDT in their milk, a study has shown. Researchers said the high levels of DDT found in breast milk were in excess of safe limits and showed that human milk was "grossly polluted". The DDT was thoght to come from seafood in the diet, the researchers said in the journal Environment International.

Shanghai obesity myth dispelled
Shanghai researchers have dispelled the concept of 'metabolically healthy obese'. In a study of more than 211,000 people over 40 i 25 areas of China they showed that  obesity was a risk factor for  CHD regardless of the presence or absence of insulin resistance. The findings are published in the International Journal of Cardiology.

Zinc levels linked to naughty children
Low zinc levels have been linked to behavioural problems in pre-school children in China. A study conducted in 1314 children in Jintan, Jiangsu found that low zinc levels were significantly associated with increased reports of total behavior problems. Living in the suburbs was associated with increased internalizing problems, while higher mother’s education and being female were associated with decreased externalizing problems, the study in the journal Nutrients found.

N95 face masks prove effective

A study of the effectiveness of N95 masks in Beijing has found that they are protective against bacterial colonization, co-colonization and viral-bacterial co-infection. The clinical trial of 1441 hospital staff found the rate of bacterial colonization was 2.8% with N95 mask users, 5.3% in medical mask users  and 7.5% in staff who did not wear any mask. Co-infections of bacteria and/or a virus  occurred in up to 3.7% of healthcare workers and were significantly lower in N95 wearers, the study in Preventive Medicine showed. (NB: See our earlier story that found N95 masks were a poor fit for Chinese faces).

Medicine costs and hospitals

The Economist has an article explaining why China's hospitals are dependent on revenue from drug sales for their financial viability. The magazine says efforts to reduce corruption will be difficult until the system is reformed, as hospital derive 40% of income from commissions on medicines and medical products.

China has psychotherapy boom

Mental disorders have traditionally been a taboo subject in China, but SBS reports that a reality television show Psychological Sessions has been captivating audiences across China. And a researcher says there is now a 'psychotherapy-boom' in China as people have become aware of modern-day stresses and the need for treatment. 

Women don't get a fair go in health

Women face medical discrimination in China as they appear to have lower rates of treatment than men, a study suggests. Published in the International Journal for Equity in Health, the study finds that women have lower rates of hospital admission than men for the same conditions. Women also have lower rates of investigations and shorter hospital stays compared to their male equivalents.

Seven important items of medical research from China

N95 masks don't work for Chinese faces
The specialised N95 face masks used to protect against infections such as influenza are not shaped to fit Chinese faces and most would fail to prevent transmission because of poor fit and leakage, tests by Wuhan researchers have shown. Evaluation tests on ten different types of N95 mask found that only two performed within acceptable limits to prevent transmission of infections. Performance of some masks was better when users were trained and they were specially fitted, the study in PLOS One showed.
"This study indicated that widely used N95 filtering facepiece respirators in China didn't fit well and can't provide desired protection for respirator users," the researchers concluded.

Malaria from Africa now a problem in China
Malaria has been virtually eliminated in China but doctors now face the problem of treating malaria in Chinese workers who have returned from Africa. In Jiangsu there have been 918 malaria cases and six deaths in the last decade due to malaria imported from other countries. The imported cases make up 12% of all malaria cases and account for all malaria deaths, according to researchers from the Jiangsu Institute of Parasitic Diseases, Wuxi, writing in the Malaria Journal.

No cardiovascular treatment for many Chinese patients
Two out of three Chinese people with cardiovascular disease are still going untreated, a major study has found. Data from of 512,891 Chinese adults showed that 5% had a history of cardiovascular disease. However, of these only 35% had been treated with any cardiovascular medicine for secondary prevention such as statins, antiplatelet drugs or antihypertensives. The findings from a team from Oxford and Beijing universities, are published in the International Journal of Cardiology.

Shenzhen women have high rates of HPV
More than one in ten women in Shenzhen are have HPV serotypes that put them at risk of cervical cancer, researchers say. A study of 4, 413 women measured HPV infection rates and the prevalance was 14%. The high risk HPV types 16 and 18 that are likely to cause cervical cancer were found in 3.5% of women and 1.27% of women, according to the study published in the Asia Pacific Journal of Cancer Prevention.

Avian H7N9 flu virus on way to mutation
The H7N9 influenza virus is genetically much more diverse than previously thought, suggesting that it is reassorting and closer to mutating into a pandemic virus, researchers from the Jiangsu Provincial Center for Disease Control and Prevention, have shown. They report their findings in Nature.

Medical teacher burnout
Staff at medical colleges in China have high rates of burnout, a study from Shanxi shows. Staff who had a love of teaching and those who received praise and recognition were less likey to suffere burnout, according to the study in Archives of Environmental & Occupational Health.

Pancreatic cancer in Shanghai
The diagnosis and treatment of pancreatic cancer in Shanghai has room for improvement, according to researchers from Fudan University. In a review of management of pancreatic cancer published in Cancer Letters, they report that most patients miss out on the recommended histologically verified diagnosis and the 1-year and 2-year survival rates were 35% and 14.4%, respectively.

H7N9 flu death doctor hailed as hero for continuing to work while sick

translated by Michael Woodhead
The Shanghai doctor who died of H7N9 avian influenza is being hailed in the Chinese media as a hero for continuing to go into work despite being sick.
The 32-year old Zhang Xiaodong who worked as a surgeon in the emergency department of the Pudong New Area Renmin Hospital, died on the 18 of January from pneumonia complications of H7N9 infection.
In an article published today, his colleagues said he was a hardworking doctor who worked in a very busy and understaffed department and did not want to let his colleagues down. They said it was extremely exhausting working in the surgical department and it was not unknown for a surgeon to perform five appendix removal operations in one shift.
On the 16th of January Dr Zhang came into work feeling feverish and insisted on staying at work despite feeling sick. The next day he felt worse and had an 'IV infusion' before resuming his work on his shift. However, his condition quickly deteriorated and he became critically ill and was taken to intensive care. He was put on a ventilator when he developed chest pain and breathing problems. A CT scan showed that infection had invaded many lobes of his lung. The top experts of the hospital were called in to oversee treatment and Dr Zhang received the best drugs available, according to a local newspaper, The Morning Times. However, despite the efforts to save him, Dr Zhang died without making a recovery.
His colleagues said Dr Zhang would not have wanted to miss a shift because the lack of staff meant one of the other doctors would have had to have done a 24 hour shift to cover for him.
Dr Zhang left a wife who was seven months pregnant. The hospital has filed a report of industrial injury and his family will receive compensation.

Beijing female doctor jailed for 6 months for bomb scare attempt to stop boyfriend flying with other women

Dr Yang Liu, the head of the health protection department for Beijing's Haidian district has been jailed for 6 months for staging a fake bomb alert at Beijing Capital airport in September. A Beijing court heard that Dr Yang acted out of jealousy against her boyfriend, who was a tour guide who often went away on trips with tour groups.
When her boyfriend told Dr Yang  he was taking a group to Australia, Dr Yang became suspicious and believed he would be travelling with a mistress. Her suspicions grew when she was unable to contact her boyfriend by phone after he left. She then hatched a scheme to make him miss his connecting flight to Australia by delaying his flight from Beijing to Shanghai, where he would board the plane for Australia.
According to Xinhua, She phoned in a recorded message that announced there was a bomb on the Beijing to Shanghai flight. The message caused a major security alert at Beijing airport including mobilisation of 16 police cars, 4 police trucks and a 64-strong SWAT team.
The security alert caused major disruption at the airport and large economic losses.
Dr Yang was arrested a short time afterwards and when she was brought to court she hid her face and cried, looking very depressed. She confessed her guilt and asked for leniency, saying she had not realised how much trouble her scheme would cause. She said she was very remorseful and asked to be given a second chance. the court sentenced her to the standard six month jail sentence for staging a fake terrorist activity.

Hospital clinicians face infection risk from procedures

Hospital clinicians face a high risk of respiratory infection when performing high-risk procedures such as airway suctioning, a Chinese study has found.
In a prospective study of 481 hospital healthcare workers in China, those who performed a high risk procedure had a threefold increase in the risk of respiratory infections.
The findings should inform occupational health and safety policies, say the researchers from the Beijing Centre for Disease Prevention and Control.
Source: Epidemiology and Infection

Curbing antibiotic overuse in China will need major reforms - researchers

by Michael Woodhead

China’s new get-tough approach to overuse of antibiotics is having some impact, but there are still huge obstacles  to reversing the tide of antibiotic resistance, researchers from Zhejiang say.

Rates of antibiotic prescribing in hospitals have declined slightly since mandatory curbs and punishments were introduced in 2009, according to a new analysis by Dr Xiao Yonghong and colleagues at the Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou.

In a review published in PLOS Medicine, Dr Xiao says antibiotic overuse will continue to be a major problem for China unless further restrictions are introduced on hospitals profiting from antibiotic sales, OTC sales of antibiotics and the use of antibiotics in animal feeds.

The analysis notes that misuse of antibiotics in China has led to high rates of antibiotic resistance. The prevalence of superbugs such as MRSA ranges from 50% to over 71%, the researchers note. This is not surprising given that hospitals derive much of their profits for the sales of medications, of which antibiotics are the most commonly prescribed.

Initial reforms to promote better antibiotic stewardship introduced in 2006 have not been successful because they were voluntary and not complied with, the review found. However, stricter mandatory measures introduced since 2009 have begun to show effect on antibiotic use, figures show.

Hospitals were compelled to draw up antibiotic management strategies and set targets with audits. In some cases, hospital managers were dismissed and clinicians had their prescribing rights withdrawn for failing to address the problem of antibiotic overuse.

After these reforms were implemented,  the percentage of prescriptions for antimicrobials decreased from 68% to 58% for inpatients and from 25% to 15% for outpatients.

This is a significant downturn, says Dr Xiao, but a number of issues still need to be addressed to ensure further improvements in antibiotic use.

Overuse of antibiotics continues through OTC sales and in animal feed, but regulation of these areas is hampered because authority is divided between the State Food and Drug Administration, the Ministry of Agriculture and the ministry of Health.  There is also a need for education of clinicians and the public on the need for antibiotic stewardship, says Dr Xiao.

“Finally, and critically, the government should widen the healthcare reforms and provide financial guarantees to medical institutions to ensure that economic incentives from drug sales are eliminated. This will return healthcare institutions to a not-for-profit status and aid professional standards,” the researchers conclude.

Read the full article at: PLOS Medicine

Contaminated instruments kill five patients at Beijing hospital

 Acinetobacter baumannii infection was transmitted from an inadequately-cleaned bronchoscope

by Michael Woodhead
At least five patients have died at a Beijing hospital with a 'superbug' infection from a dirty bronchoscope that doctors were sterilising themselves.
An outbreak caused by multidrug-resistant Acinetobacter baumannii  affected 12 patients being treated at the intensive care unit of a 1200-bed hospital in Beijing.
An investigating team led by Dr Xia Yukun of the Department for Hospital Infection Control & Research at the Institute of Disease Control & Prevention of PLA, Academy of Military Medical Sciences  traced the outbreak  to inadequate sterilisation techniques used to clean the ICU's bronchofiberscope.
The researchers found that there was only one bronchofiberscope in the ICU and bronchofiberscopy was performed once or twice each day for secretion clearance, tracheal intubations, and bronchoalveolar lavage. Usually, the bronchofiberscope  was sterilised thoroughly by professional staff in the hospitals' disinfection unit according to according to the appropriate guidelines for endoscopy cleaning and disinfection However, when the bronchofiberscope was used in an emergency situation it was cleaned  manually by a doctor in the ICU after use. During the outbreak period, 12 patients were infected with the multidrug-resistant Acinetobacter baumannii, which is hard to eliminate because it survives on many surfaces and has extensive resistance to many of the currently available antibiotics, including cephalosporins, aminoglycosides, quinolones, and carbapenems.
Five patients died of the infection during the outbreak.
The researchers say the bacteria might have been transmitted through direct contact with the bronchofiberscope or transmitted through healthcare workers’ hands during other medical procedures.
"In our investigation, most of the [bacteria] were isolated from the healthcare-associated environmental surfaces including the bed sheets, bedrails, dispensing table and nurses’ desk," they note.
"Our findings emphasize that bronchofiberscopy must be performed with appropriate infection control measures ... strict bronchofiberscope reprocessing should be performed after each procedure and at the end of the day according to the published guidelines. It might be wise to increase the number of bronchofiberscopes available in each ICU to guarantee professional bronchofiberscope
reprocessing," they conclude.
Source: BMC Infectious Diseases