Fullest clinical report of Saudi MERS cases to date points to important differences with SARS

Main Category: Infectious Diseases / Bacteria / Viruses
Also Included In: Flu / Cold / SARS
Article Date: 26 Jul 2013 - 2:00 PDT Current ratings for:
Fullest clinical report of Saudi MERS cases to date points to important differences with SARS

Saudi and UK scientists provide the most detailed picture yet of the clinical and laboratory characteristics of Middle East Respiratory Syndrome (MERS) coronavirus, revealing a wide range of clinical symptoms and an extremely high death rate among patients with co-existing medical conditions.

The new research, published in The Lancet Infectious Diseases, also reveals some important differences with severe acute respiratory syndrome (SARS).

MERS emerged a year ago in Saudi Arabia and almost all those infected have been reported there, or have been linked to people who contracted the virus there.

The new analysis, the largest case series to date, includes 47 cases (46 adults, 1 child) of confirmed MERS infections from Saudi Arabia between Sept 1, 2012, and June 15, 2013.

By combining clinical records, laboratory results, and imaging findings with demographic data, the authors noted a trend of older patients, more men, and patients with underlying medical conditions who succumb to the disease.

As with SARS, MERS infections presented with a wide spectrum of symptoms. Most patients admitted to hospital exhibited fever (98%), chills/rigors (87%), cough (83%), shortness of breath (72%), and muscle pain (32%). A quarter of patients also experienced gastrointestinal symptoms, including diarrhoea and vomiting.

However, in contrast to SARS, the majority of cases (96%) occurred in people with underlying chronic medical conditions including diabetes (68%), high blood pressure (34%), chronic heart disease (28%), and chronic renal disease (49%).

"Despite sharing some clinical similarities with SARS (eg, fever, cough, incubation period), there are also some important differences such as the rapid progression to respiratory failure, up to 5 days earlier than SARS"*, explains Professor Ziad Memish, the Deputy Minister for Public Health from the Kingdom of Saudi Arabia, who led the research.

"In contrast to SARS, which was much more infectious especially in healthcare settings and affected the healthier and the younger age group, MERS appears to be more deadly with 60% of patients with co-existing chronic illnesses dying, compared with the 1-2% toll of SARS. Although this high mortality rate with MERS is probably spurious due to the fact that we are only picking up severe cases and missing a significant number of milder or asymptomatic cases, so far there is little to indicate that MERS will follow a similar path to SARS."*

According to co-author Professor Ali Zumla from University College London, "The recent identification of milder or asymptomatic cases of MERS in health care workers, children, and family members of contacts of MERS cases indicates that we are only reporting the tip of the iceberg of severe cases and there is a spectrum of milder clinical disease which requires urgent definition. Ultimately the key will be to identify the source of MERS infection, predisposing factors for susceptibility to infection, and the predictive factors for poor outcome. Meanwhile infection control measures within hospitals seem to work."*

Writing in a linked Comment, Professor Christian Drosten from the University of Bonn Medical Centre in Germany points to the urgent need for accurate diagnostic tests to help focus control efforts and minimise the risk of spread to others, "To ascertain relevant data for MERS epidemiology, we need to develop serological assays using samples from well defined groups of patients, such as described here. Population-based antibody testing could establish the extent of MERS-CoV infection, instead of only seeing the tip of the iceberg represented by cases admitted, such as those summarised in this important paper."

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our infectious diseases / bacteria / viruses section for the latest news on this subject.

*Quotes direct from authors and cannot be found in text of Article.

The Lancet

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In China over 90 percent of dementia cases go undetected

Main Category: Alzheimer's / Dementia
Also Included In: Psychology / Psychiatry;  Mental Health
Article Date: 28 Jul 2013 - 0:00 PDT Current ratings for:
In China over 90 percent of dementia cases go undetected

An international team of researchers has found that over 90 percent of dementia cases in China go undetected, with a high level of undiagnosed dementia in rural areas. The team of public health experts led by Dr Ruoling Chen at King's College London argues that more mental health education targeting high-risk populations is now needed to improve diagnosis rates, and increase support for sufferers and their families.

Dementia affects 10 million in China and up to 50 million worldwide, of which around 35 million sufferers are undiagnosed. Dementia causes deterioration in memory, thinking, behaviour and the ability to perform everyday activities. Although the condition mainly affects older people, it is not a normal part of ageing. Dementia is one of the major causes of disability and dependency among older people worldwide. Early diagnosis is crucial to alleviating the significant physical, psychological, social and economical impact the condition has on caregivers, families and society.

The new study, led by Dr Chen, a research leader in global health in the School of Medicine at King's, found that in China 93 percent of dementia cases in people aged 60 and over went undetected. The level of undetected dementia is much higher than has been seen in studies undertaken in high income countries, where about 60 percent of older adults with dementia are not diagnosed.

Published in the British Journal of Psychiatry and funded by Alzheimer's Research UK and the BUPA Foundation, the large population based study is a collaboration between scientists at King's College London and other universities in the UK, and Anhui Medical University and five other medical universities in China. The study is the first to examine factors influencing the poor diagnosis of dementia in older people in low-income countries, where there are more dementia sufferers than in high-income countries.

Dr Chen and his team interviewed a random sample of 7,072 older adults in six provinces across China, with one rural and one urban community in each province. They identified 359 older adults with dementia and 328 with depression. There were only 26 participants who had doctor-diagnosed dementia reported and 26 who had doctor-diagnosed depression. Overall, 93 percent of dementia cases and 93 percent of depression was not detected.

The team found that, in China, undetected dementia among older adults is strongly associated with low socioeconomic status such as a low educational and occupational class, and living in a rural area.

In rural China, the average annual income is two to five times lower than in urban areas and about 90 percent of older people are illiterate. Medical coverage and health services are often insufficient in rural areas, with primary care clinics mainly staffed by health-workers with limited training. In high-income countries most studies have not shown a strong association between low socioeconomic status and undetected dementia, which could be due to better access to healthcare.

The research team also identified that Chinese cultural factors may play a role in poor detection rates of dementia. Unlike in high-income countries, most of older Chinese people live with their families. A surprising, important finding was that undetected dementia is related to strong social support. Such 'help available when needed' may mask the disease and hinder detection. In addition, Chinese may interpret dementia symptoms in older people as being an acceptable part of the ageing process rather than as an illness.

Dr Ruoling Chen said: 'Dementia is increasingly a major global health challenge given that the world's population is ageing. China has the most dementia sufferers of any country in the world, but at the same time it is a poorly recognised condition.

Mental health services need to be prioritised as economic development extends throughout China. Mental health campaigns will ensure that health workers and the general population are able to recognise the condition, so that sufferers receive the support they need.

Our hope is that by looking at the rate of undetected dementia in China we can offer globally applicable insights into the common risk factors, aid earlier diagnosis, ultimately improve prognosis for sufferers and maintain caregivers' health and wellbeing .'

Professor Martin Prince, global mental health expert from the Institute of Psychiatry at King's College London, who was not involved in the research, commented: 'This is an important study, highlighting the very low detection rate by Chinese health services of dementia among older people.

Large treatment gaps for mental and neurological disorders have been observed in low income countries, but this is the first study to focus on older adults, among whom dementia is a major concern.

Detection is the first step in accessing evidence-based treatment and care. Limited knowledge, skills and confidence among health care workers, and a lack of understanding of the benefits that may stem from diagnosis and intervention are all likely to contribute.'

In a related recent commentary in the Lancet, Professor Prince argued: '... the Chinese Government faces a daunting task in addressing future needs for long-term care. Previously, these needs have been met by families, consistent with traditional values and enforced through the Elderly Rights and Protection Law of 1996. However, central government policy is shifting towards new social care initiatives and increased investment in social protection, as outlined in a radically amended version of the 1996 law which will take force from July, 2013.'

Dr Simon Ridley, Head of Research at Alzheimer's Research UK, said: 'We know that dementia is a global problem and it is important to understand more about the risk factors and barriers to diagnosis across different countries. Investigating the social, economic and cultural factors influencing attitudes and access to dementia diagnosis can help shape strategies that could benefit multiple countries across the world.

We must ensure long-term investment for dementia research if we are to improve the lives of millions living with this condition worldwide.'

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our alzheimer's / dementia section for the latest news on this subject.

'Determinants for undetected dementia and late-life depression' is published in the British Journal of Psychiatry doi: 10.1192/bjp/bp.112.119354

'Dementia in China: east-west collaboration bears fruit' is published in the Lancet doi:10.1016/S0140-6736(13)60770-9

King's College London

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Now proof of minor added benefit from Fidaxomicin in severe cases or recurrences of C. difficile infections

Main Category: Infectious Diseases / Bacteria / Viruses
Article Date: 27 Jul 2013 - 0:00 PDT Current ratings for:
Now proof of minor added benefit from Fidaxomicin in severe cases or recurrences of C. difficile infections

In the commenting procedure on early benefit assessment pursuant to the German Act on the Reform of the Market for Medicinal Products (AMNOG), under certain circumstances drug manufacturers may submit to the Federal Joint Committee (G-BA) additional documents for dossiers. The Institute for Quality and Efficiency in Health Care (IQWiG) has now assessed such additional information for two studies comparing the antibiotic fidaxomicin, which is used for diarrhoea caused by Clostridium difficile infections, with vancomycin.

In contrast to the first dossier assessment, the Institute now sees proof of a minor added benefit of fidaxomicin versus the appropriate comparator therapy in patients with severe or recurrent disease. An added benefit is still not proven in patients with mild disease; the manufacturer provided no new data for this indication.

Manufacturer dossier did not allow an overall conclusion

The antibiotic fidaxomicin (trade name: Dificlir) has been approved in Germany since December 2011 for the treatment of adults with diarrhoea caused by Clostridium difficile. IQWiG already presented an assessment pursuant to AMNOG in April 2013.

On the basis of the dossier submitted by the manufacturer, an advantage of fidaxomicin for the outcome "global cure" could be inferred for severe cases and recurrences. However, the magnitude of this advantage could not be inferred from the data presented. In addition, it could not be excluded that more severe side effects occurred precisely in these cases, thus outweighing advantages with regard to global cure. An overall conclusion on added benefit was therefore not possible.

Greater harm not proven in patients with severe disease

In the commenting procedure the manufacturer subsequently provided study results in a form that allows the weighing of positive and negative effects. Whereas no statistically significant difference between fidaxomicin and vancomycin was shown for all-cause mortality, the data provide proof of an added benefit for the outcome "global cure" in patients with severe or recurrent disease. In addition, in these subpopulations there is no suggestion of greater harm from fidaxomicin than from vancomycin.

An overall conclusion is thus possible: an added benefit of fidaxomicin versus the appropriate comparator therapy (vancomycin) is now proven for the treatment of patients with severe or recurrent Clostridium difficile infections. IQWiG classifies the extent of added benefit as minor.

An added benefit in patients with mild disease was not claimed by the manufacturer.

G-BA decides on the extent of added benefit

The dossier assessment is part of the overall procedure for early benefit assessments supervised by the G-BA. After publication of the manufacturer's dossier and the IQWiG dossier assessment, the G-BA conducted a commenting procedure in which the manufacturer submitted additional information. The G-BA subsequently commissioned IQWiG on 28 May 2013 to undertake a new assessment including the additional data.

If, in the course of the discussions on a commission of the G-BA, a need for further revision arises, IQWiG presents its report in the form of an addendum. The Institute sent this addendum to the contracting agency (the G-BA) on 12 June 2013. The G-BA then decides on the extent of the added benefit in each case, thus completing the early benefit assessment.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our infectious diseases / bacteria / viruses section for the latest news on this subject.

The website gesundheitsinformation.de, published by IQWiG, provides easily understandable and brief German-language information on fidaxomicin (English-language information [addendum and health information] will also be available in the near future; if you would like to be informed when this is published, please send an email to info@iqwig.de).

The G-BA website contains both general English-language information on benefit assessments pursuant to §35a Social Code Book V and specific German-language information on the assessment of fidaxomicin.

Addendum

Benefit assessment (dossier assessment)

Institute for Quality and Efficiency in Health Care

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Institute for Quality and Efficiency in Health Car. (2013, July 27). "Now proof of minor added benefit from Fidaxomicin in severe cases or recurrences of C. difficile infections." Medical News Today. Retrieved from
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