A new report on three of the first patients in China to contract a novel strain of bird flu has U.S. officials worried about a grim scenario that includes severe illness with pneumonia, septic shock, brain damage and multi-organ failure.

All three of the patients died, according to a Thursday report by a group of Chinese scientists in the New England Journal of Medicine.

“It is possible that these severely ill patients represent the tip of the iceberg,” wrote Dr. Timothy Uyeki and Dr. Nancy Cox, both of the influenza division at the Centers for Disease Control and Prevention, in a perspective piece accompanying the article.

The reports chronicle the early days of an outbreak of a new influenza A virus, H7N9, which has never before been seen in humans. As of Friday, Chinese officials said it had infected at least 43 people in four Chinese provinces and killed 11 in the past two months.

On Saturday, China's center for disease control confirmed the first case of the new bird flu strain in Beijing: A seven-year-old girl whose parents work in the live poultry trade has been infected.

The patients described in the report included two men, ages 87 and 27, both from Shanghai, and a 35-year-old woman from Anhui. All had preexisting health conditions and two had been exposed to chickens at live poultry markets in the previous week. They became ill between Feb. 18 and March 13 and died between March 4 and April 9 of severe complications, the report said. 

The virus, which has been traced to a reassortment of genes from wild birds in east Asia and chickens in east China, “raises many urgent questions and global public health concerns,” the U.S. researchers wrote.

It’s particularly concerning because the virus clearly has the potential to cause severe disease, it has genetic characteristics that suggest that it might be better adapted than other bird flu strains to infect mammals -- including humans -- and people have no resistance to it, the U.S. scientists reported.

The virus doesn’t make birds sick, so it may spread widely and remain undetected until people become ill.

In addition, previous vaccines developed to fight other H7 strains did not invoke strong immune responses in humans, the U.S. scientists wrote. Even so, researchers at the Centers for Disease Control and Prevention said they received an isolate of the virus from China on Thursday and were continuing to rush efforts to create a vaccine, a process that could take several months.

Scientists are expected to start growing more of the virus to share for use in several ways, including not only developing a vaccine, but also creating a blood test that can detect previous human immune system protection against the virus, and testing to see whether the virus remains susceptible to antiviral drugs.

CDC officials also will use it to create a diagnostic test that could be used to detect infection in travelers who return to the U.S. from China with symptoms of flu, or those who’ve been in contact with someone who’s been sick.

Officials with CDC and the Food and Drug Administration are working to quickly expedite approval and manufacture of the kits, said Mike Shaw, associate director of laboratory science for the CDC's flu division. About 400 diagnostic kits, which each can perform 1,000 tests, may be complete by Monday, he said. They could be shipped as early as next week to public health labs across the country. 

The CDC has urged local public health officials to watch for signs of sick travelers from China. So far, about 10 people who recently traveled from China to the U.S. have been tested for the H7N9 virus because of suspicious symptoms, officials said.

"So far, everyone that has been tested in the U.S. has been negative," Shaw said. 

The virus remains contained to China and there is no evidence of sustained person-to-person transmission, both good signs, scientists said.

But as the U.S. researchers concluded, vigilance remains high.

“We cannot rest our guard,” they wrote.

Related: 

US rushes to make vaccine against new bird flu -- just in case

Don't panic over new bird flu outbreak, CDC cautions

New H7N9 bird flu has officials worried about skimpy resources

This story was originally published on Fri Apr 12, 2013 7:40 AM EDT

BSIP / UIG via Getty Images

An electron micrograph image of rabies viruses. A Maryland kidney transplant patient died of rabies transmitted by the organ, federal officials say.

Rabies killed a patient who got a kidney transplant more than a year ago, federal officials said Friday. Now they are treating three other people who got a second kidney, a heart and a liver from the same donor – an Air Force recruit who apparently died of undiagonosed rabies.

The donor died in Florida, and the heart, kidneys and liver from the patient were transplanted into three other people, the Centers for Disease Control and Prevention said. The Defense Department said the donor was a 20-year-old recruit who had been in the Air Force for just under four months when he died in 2011.

Doctors did not suspect rabies killed the donor and did not test for the virus, the CDC said. "Rabies was only recently confirmed as the cause of death after the current investigation began in Maryland," the CDC said.

"Shortly before becoming ill, the donor had moved to Florida, but was a previous resident of North Carolina where it is believed the exposure may have occurred. How the donor may have gotten rabies is currently under investigation," the CDC said in a statement.

The agency is not naming any of the patients involved.

"In 2011, the donor became ill and was admitted to a healthcare facility in Florida and then died.  At that time, the donor’s organs, including the kidneys, heart, and liver, were recovered and sent to recipients in Florida, Georgia, Illinois, and Maryland," the CDC said.

Potential organ donors in the United States are screened and tested  for viruses, bacteria and other infections. But rabies isn't one of the usual microbes that is tested for, in part because the test takes too long and in part because rabies is so rare in people.

People can become infected with rabies without knowing it. It  is transmitted in saliva -- which is why animal bites are dangerous -- and blood. But vaccination after a bite can prevent symptoms. Once a patient develops symptoms from rabies, it is almost always fatal.

Bats are the most common cause of rabies infection, while raccoons, skunks, and foxes are the most commonly reported rabid animals.

"CDC’s preliminary laboratory analysis indicates that the recipient and the donor both had the same type of rabies virus—a raccoon type.  This type of rabies virus can infect not only raccoons, but also other wild and domestic animals. In the United States, only one other person is reported to have died from a raccoon-type rabies virus,' the CDC said. Genetic testing can reveal what strain of virus has infected someone and advanced testing that looks for genetic mutationscan show whether someone was directly infected by someone else.

"The three other people who received organs from the donor have been identified and are currently being evaluated by their healthcare teams and receiving rabies anti-rabies shots (immune globulin and anti-rabies vaccination)," the CDC said.

"CDC is working with public health officials and healthcare facilities in five states (Fla., Ga., Ill., Md., and N.C.) to identify people who were in close contact with the initial donor or the four organ recipients and might need rabies post-exposure treatment," the agency says.

Doctors perform 40,000 organ transplants  annually worldwide.  In 2011, a team at Northwestern University’s school of medicine estimated that fewer than 1 percent of all organ transplants also transmitted an infection.

More than 28,000 organ transplants are performed in the U.S. each year,  while more than 114,000 people are waiting for organ transplants, according to the United Organ Sharing Network. In 2011, 6,669 people died waiting for organ transplants.

Organ donors are routinely tested for hepatitis viruses, HIV, a virus called HTLV that can cause leukemia, the syphilis bacteria, West Nile virus and the parasite that causes Chagas disease. But other infections have been transmitted by organ, tissue and other transplants – including  the deadly brain disease called Creutzfeldt Jakob disease or CJD; herpes, cytomegalovirus and a variety of bacterial and fungal infections.

Rabies is also known to have been transmitted both by cornea transplants and organ transplants – most recently a batch of three organ recipients treated at Baylor University in Texas in 2004. Officials ended up treating hundreds of people who had been in contact with the organ donor and the recipients.

But last August, Melissa Greenwald,  chief of the Tissue and Reproduction Branch at the Food and Drug Administration raised concerns about the lack of a systematic protocol for testing organs and tissue used for transplant.

“Disease transmission through organ and tissue transplantation has been documented. Recognizing emerging infectious diseases in organ and tissue transplantation is challenging because of nonstandardization of donor evaluations and data collection, pathogen characteristics, and recipient surveillance,” Greenwald and colleagues wrote in Emerging Infectious Diseases.

“Because organs, cells, and some tissue grafts cannot be subjected to sterilization steps, the risk of infectious disease transmission remains and thorough donor screening and testing is especially important.”

Organ recipients are especially vulnerable because they’ve usually been ill for along time, and then must take drugs to suppress their immune systems so their bodies will tolerate the donated organ.

Related:

• Infected organs post deadly transplant risks
• Disclose organ transplant risks: Now or later?
• Rabies on the rise but vaccine supply tight

By Genevra Pittman
Reuters

When there was a shortage of a drug used to prevent IV-related infections in kids, the frequency of those infections increased almost ten-fold at one Michigan hospital, a new study shows.

Known as ethanol lock therapy, the preventive drug is given to kids with bowel problems who require an IV feeding line because their intestines don't absorb enough nutrients.

Those children are at higher risk of infection to begin with because their gut bacteria don't have as much practice killing off germs, researchers said.

Luitpold Pharmaceuticals, then the sole supplier of ethanol, or dehydrated alcohol, voluntarily stopped manufacturing the drug between April and September, 2011 after scrutiny of pharmaceutical facilities by the U.S. Food and Drug Administration.

The details of the production halt were not made public.

Up until early 2011, kids being treated at C.S. Mott Children's Hospital in Ann Arbor were given daily ethanol lock therapy in their catheters to prevent infection. But with the shortage, that was cut back to weekly prophylaxis for most young patients.

The new study, published this week in Pediatrics, covers eight children ranging in age from 22 months to 18 years who'd been diagnosed with necrotizing enterocolitis or other intestinal conditions requiring an IV line.

When ethanol was readily available, there was an average of one catheter-related infection per child every four years.

But when the dosing frequency dropped, seven of the eight children developed catheter-related infections in just a few months. Six of them needed to be hospitalized as a result and spent more than two weeks in the hospital, on average. Treating them cost over $100,000 per patient, and two of the youths ended up in the intensive care unit.

"We definitely had concerns that rationing (ethanol) or decreasing the amount of time we used it could lead to an increase in infection," said lead author Dr. Matthew Ralls, from Mott and the University of Michigan Medical School.

But the researchers said the spike in infections was far greater than what they'd expected.

"We had basically a complete failure in prophylaxis," Ralls told Reuters Health. "We reverted back to the numbers from before we even used ethanol."

He said he and his colleagues hope that in the future, the FDA can come to an agreement with companies that are the sole producers of important drugs to only shut down some of their production facilities at any given time, for example.

"This had a profound effect on these kids," Ralls said. "Some of the complications were pretty devastating for some of these children."

A press officer at the FDA said the agency hadn't reviewed the new study.

But, Sarah Clark-Lynn told Reuters Health in an email, "the FDA is working hard with pharmaceutical companies to prevent and resolve drug shortages. Drug shortages (are) a top priority issue for the FDA and we are working hard to help assure that patients in the United States have access to the high quality medications they need."

She added that another company, Akorn Pharmaceuticals, is now manufacturing ethanol lock therapy. "We do not anticipate any further shortage issues at this time for this drug," she said.

Luitpold did not respond to a request for comment.

A Medicare payment policy designed to push hospitals to cut their infection rates has had no effect in reducing two types of preventable infections among patients in intensive care units, researchers say in the latest issue of the New England Journal of Medicine.

In 2008, the Centers for Medicare and Medicaid Services began denying additional payments to hospitals whose patients became sicker as a result of bloodstream infections and urinary tract infections associated with the use of central lines or catheters.

Researchers looked to see whether denying additional payments would spur hospitals to cut their infection rates, comparing those infections with a type of pneumonia not targeted by the payment policy.

“The financial penalty did not further reduce infection rates, which were already going down because of multitude of (infection control) campaigns and interventions that were already ongoing,” said the study’s lead author Grace Lee, associate professor, Harvard Pilgrim Health Care Institute and Harvard Medical School.

Infections picked up by hospitalized patients are an area of growing concern. It is estimated that about one in 20 hospitalized patients get an infection, resulting in up to $33 billion in additional costs each year. Efforts to reduce the rate of infections include public reporting requirements and the payment policy in Medicare, which is now being expanded into state Medicaid programs.

Other studies have found the payment policy resulted in increased attention by hospital leaders, sometimes at the expense of other infections not targeted by the policy.

As policy efforts expand, the researchers say “careful evaluation is needed to determine when these programs work … and when they have unintended consequences.” They did give did give some caveats about their findings: The study looked only at patients in the ICU, for example, so it can’t say if infection rates in other parts of hospitals changed. Researchers tracked data reported to the National Healthcare Safety Network by 398 hospitals from January 2006 to March 2011.

Many of those 398 hospitals were voluntarily reporting that data even before the payment policy was implemented, which means they may have been further ahead in their infection control efforts than others, thus resulting in no additional slowdown after the penalties, says Lisa McGiffert of Consumers Union, publisher of Consumer Reports.

She and others say efforts to affect hospital payments and to publish infection rates do work.

“When you start affecting payments and publishing results, it does get the attention of leadership in a hospital,” said McGiffert. “This study shows it’s enormously difficult to connect a singular policy with progress.”

The study is consistent with data from other studies, including one recently completed by the American Hospital Association, said Nancy Foster, vice president for quality and patient safety policy at the association. Those studies have shown an ongoing decline in infections that pre-dated the payment policy.

Still, Foster said a key piece of any effort to reduce hospital infections is not just to count the number of patients who have problems, but to have a specific, detailed prevention strategy. Preliminary results from the association study found a 40 percent reduction in central line-associated bloodstream infections in intensive care units when they used a team-based approach.

“With infections, you need a series of things you’re doing right each and every time. Not just washing hands, although that is important. Not just the right antiseptic, not just the right antibiotic. But all of those things together,” said Foster. “That’s the shift in perspective hospitals have gained.”

CMS spokesman Brian Cook did not address the study results directly, but said the 2010 federal health care law strengthens policies to reduce infections in hospitals.  ”We’re confident that these polices will improve health care quality and reduce costs,” Cook said.

Related stories: 

• Burned-out nurses linked to more infections in patients
• Surviving sepsis: New device speeds ID of dangerous bacteria
• Calif. lab worker who died from meningitis identified

© 2012 This information was reprinted with permission from KHN. Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

The New England Journal of Medicine

The owner of this dragonfly tattoo was among dozens who developed hard-to-treat rashes associated with an infection spread by contaminated distilled water.

Who would have thought that distilled water could carry an infection? Disease sleuths said on Wednesday they traced infected tattoos in four states to ink diluted using distilled water.

More than 40 men and women got hard-to-treat rashes from the ink -- even though they went to licensed tattoo artists who followed every sterile procedure, public health officials said. They issued warnings so that people who get new tattoos and their doctors can be on the alert. With 21 percent of the U.S. public now sporting tattoos, a lot of people could be affected.

The investigation started when a 20-year-old man in upstate New York got a rash that wouldn’t go away after he got a new tattoo. Tests showed the rash was caused by a rare bacteria called Mycobacterium chelonae. It’s a distant relative of the tuberculosis bug, and lives in soil and water. While the rashes are not life-threatening, it can take weeks of antibiotic therapy to get rid of them.

County and state health officials tracked down a total of 19 people who got tattoos from the same artists, and it turned out they all got the same fashionable artistic treatment -- a gray wash that makes a tattoo resemble a photograph. But the artist who did the work had done it by the book, following sterile procedures all the way, according to the report in this week’s issue of the New England Journal of Medicine.

"We went there several times," said Dr. Byron Kennedy of the Monroe County, N.Y., department of public health. "And we interviewed all 19 patients. they all confirmed they observed the artist using disposable gloves ... using clean needles, and the like."

The artist bought the ink from one manufacturer at a large trade show in Arizona, so health officials called in the Food and Drug Administration, which got ink samples and sent them to the Centers for Disease Control and Prevention for testing. The ink, it turned out, was contaminated with M. chelonae.

Tara MacCannell, a CDC epidemiologist, said the agency sent out a wider alert. “As a result of putting out a more general health alert, we found several brands of inks that were linked to this particular type of infection,” she said in a telephone interview.

In all, 32 more people in Washington, Iowa and Colorado had possible or confirmed infections from inks made by three other companies, CDC reported.

The New England Journal of Medicine

The infections were not the fault of tattoo artists, who followed proper procedures, but were caused by the tainted ink.

The needles used to give tattoos can pass along serious infections, from hepatitis to HIV.  People have also caught nasty methicillin-resistant Staphylococcus aureus -- MRSA -- infections from dirty needles. Tattoo artists must follow strict hygiene procedures, including using sterile materials and wearing protective gloves. They must attend regular educational classes and they must be inspected.

“They can do all those things right and get this contaminated tattoo ink and still result in infection,” MacCannell said.  “There are lots of people who are very conscientious about their practices … yet they are not given the tools to ensure the sterility of the product.”

The most likely source of the contamination is distilled water, CDC says. “Tattoo ink manufacturers think distilled water is sterile,” MacCannell said. Sometimes they use alcohol or witch hazel as a preservative, but that doesn’t work on these particular germs.

“Non-tubercular mycoplasmae have no problem living in alcohol. They have no problem living in witch hazel,” MacCannell said. “They are related to tuberculosis and that is a very hard bug to kill, too. They are generally known to be resistant to disinfectants.”

The researchers point out that it can take four months or longer of treatment, often with a cocktail of antibiotics, to get rid of these infections. Some patients may need to have the whole area surgically removed, leaving an ugly scar. So if you get a tattoo and develp a rash, Kennedy advises, it's best to go straight to a doctor. And doctors need to be aware that the rash may be caused by this tricky and hard-to-treat bacteria.

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