By Carol A. Kemper, MD, FACP

Dr. Kemper reports no financial relationships relevant to this field of study.

Dental Care May Reduce Risk of Pneumonia

SOURCE: Doll M, Kelly K, Ratliff S, et al. Access to dental care and the risk of pneumonia: The importance of healthy teeth. IDWeek Thursday afternoon poster session, Oct. 27, 2016; New Orleans.

Dentists have seized on this data presented at IDWeek in New Orleans in October, and for good reason. It is generally believed that dental care is important to overall good health, nutritional status, and a reduction in certain kinds of infection. Indeed, data derived from the 2013 Medical Expenditure Panel Survey (MEPS) found that a lack of routine dental care may be associated with an increased risk of pneumonia.

MEPS is administered by the Agency for Healthcare Research and Quality, and evaluates national data on healthcare utilization and cost, with data garnered from individual households. Data from the 2013 survey included questions regarding the number of annual dental visits, the frequency of dental check-ups, and the presence of dental insurance during the previous two years. In addition, the survey identified 441 individuals diagnosed with at least one episode of pneumonia in 2013 (1.68% of the sample).

In simple and bivariate logistical analyses, Caucasian race, older age, a perception of general poor health, a lack of dental insurance, and a lower frequency of dental visits were each significantly associated with an increased risk of pneumonia. Individuals with no routine dental check-ups in the previous two years had an 86% increased risk of pneumonia compared to those with two or more routine annual dental check-ups (confidence interval [CI] 1.30-1.65, P = 0.0008). In a complex multivariate model, an increased frequency of routine dental check-ups remained significantly associated with a lower risk of pneumonia. Interestingly, while the presence of dental insurance was strongly associated with the frequency of dental check-ups, dental insurance did not appear to affect the risk of pneumonia in the final statistical model.


Stop Kissing Your Chickens

SOURCE: MMWR. Eight multistate outbreaks of human Salmonella infections linked to live poultry in backyard flocks (final update). Oct. 6, 2016. Centers for Disease Control and Prevention. Available at: www.cdc.gov/salmonella/live-poultry-05-16/index.html. Accessed Dec. 12, 2016.

The year 2016 has shaped up to be a banner year for Salmonella infections in the United States. Beginning Jan. 4 through Sept. 10, 2016, eight large multistate outbreaks of Salmonella were investigated by the CDC, multiple states, and the U.S. Department of Agriculture’s Animal and Plant Health Inspection Service (USDA-APHIS), each of which has been linked to backyard chicken flocks and purchases of chicks and ducklings. This is the largest number of outbreaks in a single year (from 2005 to 2014 there were only about four outbreaks per year).

In 2016, a total of 895 individuals were affected by these eight multistate outbreaks, which were caused by eight different strains of Salmonella (two strains of S. infantis, and one strain each of S. enteritidis, S. muenster, S. hadar, S. mbandaka, and S. braenderup). The ill people ranged in age from 1 to 106 years, with a median age of 27 years. A total of 209 individuals were hospitalized, and three died. Children aged 5 years or younger represented 28% of the total number affected.

Epidemiologic tracking and laboratory analysis linked the eight outbreaks to contact with live backyard poultry, including chicks and ducks purchased from multiple hatcheries.

Of 745 individuals who provided information, 552 (74%) reported contact with live poultry (including chickens, chicks, ducks, and ducklings). Exposures occurred at home, at other people’s homes, at schools, and at work. Nearly 60% of exposures were to baby poultry and most of these occurred in the home. Cultures obtained from individual homes, hatcheries, and work locations confirmed the presence of five of the strains.

Nearly half of the individuals said they allowed poultry in the house, including the living room (22%), the kitchen (12%), the bathroom (10%), and the bedroom (10%). (As a poultry owner, I can personally add the dining room and the garage, where we have kept a sick bird on occasion, and even raised hatchlings.) Of those who owned baby poultry, 49% snuggled the birds, and 13% kissed chicks.

Keeping backyard poultry is increasingly popular (and the eggs are fantastic). In addition to ourselves, at least three immediate neighbors keep chickens and one neighbor kept a small flock of ducks until they were killed one afternoon (we live six miles from Stanford University, in a semi-rural area bordering open space, so deer, coyote, and an occasional mountain lion are not unfamiliar). It is not unusual to see kids holding their chickens or petting them — and for many of us, they have become pets, with special places in our families. But many people may not know that chickens and ducks can harbor Salmonella and Campylobacter, even if they look perfectly healthy. While the authors of this report were adamant that “poultry should never be allowed in the house,” it seems doubtful this practice will stop.

Recommendations for backyard poultry owners include the following basics:

  • Always wash your hands thoroughly with soap and water after handling live poultry or chicks, and after cleaning cages or water dispensers.
  • Do not eat or drink while handling the birds or while cleaning cages.
  • Do not bring live poultry in the house.
  • Do not let children younger than the age of 5 years handle birds or chicks without supervision, and make sure they wash their hands well afterward.

Blood Safety and Global Infections

SOURCE: Bloch EM, Simon MS, Shaz BH. Emerging infections and blood safety in the 21st century. Ann Intern Med 2016;165:57-58.

With globalization, increased international travel, and emerging infections around the globe, never has the potential infectious threat to the safety of blood products been greater and directly colliding with cost-containment efforts and healthcare utilization reforms. This interesting editorial focuses the problem. Mergers of blood centers and increased transport of blood products (to save cost) increases the risk of unexpected pathogens in non-endemic areas. I realized that although I have been focusing my histories on recent travel and potential international exposures, I seldom focus on receipt of blood products as a potential risk for non-locally active infections.

At present, United States blood screening tests for HIV, hepatitis B virus, hepatitis C virus, human T-lymphotropic virus, syphilis, Chagas disease, and West Nile virus and the potential for transmission of these organisms has been virtually eliminated in our blood supply. Testing varies for each organism. For example, since 2003, screening for West Nile virus employs a complex algorithm based on local West Nile virus activity and NAT testing, using both testing of batched blood samples and specific testing of suspect specimens. As a result, transfusion-associated West Nile virus has virtually been eliminated from the U.S. blood supply.

But what about other infections, such as Babesia microti, dengue, hepatitis E, Anaplasma, and Zika? A major problem is that there is little incentive for industry development of screening tests for certain organisms, e.g., Babesia, given its limited regional occurrence. Although molecular screening for Babesia has been developed, FDA approval for such assays requires years of testing, which is quite expensive. And yet, 13% of the 162 reported transfusion-associated Babesia cases within the United States occurred outside of endemic areas due to donor travel or traveling blood products.

Other parts of the world may have a greater issue with blood product safety. For example, 2.8% of blood donations during a recent outbreak in French Polynesia tested PCR positive for Zika virus. And 4 of 2,149 (0.2%) donated blood samples in Martinique were NAT+ for dengue virus.

It is hoped that newer multiplex screening techniques can be developed that can save on cost and efficiency of screening. In the meantime, consider that blood products may pose a risk for unusual pathogens not necessarily endemic to your area.