Tuesday, September 30, 2014

CDC Statement On Dallas Ebola Case



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The CDC has posted the following statement on today’s announced Ebola case in Dallas, Tx.


First Imported Case of Ebola Diagnosed in the United States


CDC confirmed on September 30, 2014, through laboratory tests, the first case of Ebola to be diagnosed in the United States in a person who had traveled to Dallas, Texas from West Africa. The patient did not have symptoms when leaving West Africa, but developed symptoms approximately five days after arriving in the United States.

The person sought medical care at Texas Health Presbyterian Hospital of Dallas after developing symptoms consistent with Ebola. Based on the person’s travel history and symptoms, CDC recommended testing for Ebola. The medical facility isolated the patient and sent specimens for testing at CDC and at a Texas lab participating in CDC’s Laboratory Response Network. CDC and the Texas Health Department reported the laboratory test results to the medical center to inform the patient. Local public health officials have begun identifying close contacts of the person for further daily monitoring for 21 days after exposure.

The ill person did not exhibit symptoms of Ebola during the flights from West Africa and CDC does not recommend that people on the same commercial airline flights undergo monitoring, as Ebola is only contagious if the person is experiencing active symptoms. The person reported developing symptoms several days after the return flight.

CDC recognizes that even a single case of Ebola diagnosed in the United States raises concerns. Knowing the possibility exists, medical and public health professionals across the country have been preparing to respond. CDC and public health officials in Texas are taking precautions to identify people who have had close personal contact with the ill person and health care professionals have been reminded to use meticulous infection control at all times.

We know how to stop Ebola’s further spread: thorough case finding, isolation of ill people, contacting people exposed to the ill person, and further isolation of contacts if they develop symptoms. The U.S. public health and medical systems have had prior experience with sporadic cases of diseases such as Ebola. In the past decade, the United States had 5 imported cases of Viral Hemorrhagic Fever (VHF) diseases similar to Ebola (1 Marburg, 4 Lassa). None resulted in any transmission in the United States.


Dallas,Tx Patient Tests Positive For Ebola



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In what is shaping up to be the worst-kept news embargo of all time, this afternoon the CDC has announced that the first undiagnosed Ebola case has arrived in the United States, and has tested positive after being isolated in a Dallas, Texas hospital since yesterday.


Now, before anyone is tempted to head down to the bunker, this was an expected development and one for which hospitals and public health departments across the country have been preparing for some time. 


While it is conceivable that an Ebola infected visitor could pass on the virus to close contacts here in the United States, the risks of seeing a significant outbreak here are considered low.  We have a public health infrastructure in place that can do contact tracing and health monitoring for the incubation period of up to 21 days.

At this time there are no other suspected cases in Texas.

The CDC’s timeline has the patient leaving Liberia on September 19th, and arriving on the 20th. At that time, the patient was not symptomatic.  Several days later the patient became unwell (24th), and apparently went to a hospital or clinic on the 26th, but was not diagnosed with the disease (early symptoms are often non-specific), and sent home.  


Two days later the patient returned to the hospital with more severe symptoms and was placed into isolation.  Very few details regarding the patient, his possible exposures in Liberia, and his condition have been released.


The news conference – which should be archived on the CDC Media site in the next couple of days - included statements and answers from:


Thomas Frieden, M.D., M.P.H,

Director, Centers for Disease Control and Prevention

David Lakey, M.D.,

Commissioner, Texas Department of State Health Services

Edward Goodman, M.D., FACP, FIDSA, FSHEA

Hospital Epidemiologist, Texas Health Presbyterian Hospital Dallas

Zachary Thompson, M.A.

Director, Dallas County Health and Human Services


As Dr. Thomas Frieden stated in this news conference, as long as the Ebola epidemic continues to rage in West Africa, we have to be prepared for the possibility of  additional cases like this showing up in the United States.

The Texas Department of Health has released the following statement:


Texas Confirms Ebola Case

News Release

September 30, 2014

A Texas hospital patient has tested positive for Ebola, making the patient the first case diagnosed in the United States. The test was conducted at the state public health laboratory in Austin. The Centers for Disease Control and Prevention confirmed the positive result.

The patient is an adult with a recent history of travel to West Africa. The patient developed symptoms days after returning to Texas from West Africa and was admitted into isolation on Sunday at Texas Health Presbyterian Hospital in Dallas.

The Texas Department of State Health Services is working with the CDC, the local health department and the hospital to investigate the case and work to prevent transmission of the disease. The hospital has implemented infection control measures to help ensure the safety of patients and staff.

Ebola is a severe, often fatal disease. Early symptoms of Ebola include sudden fever, fatigue and headache. Symptoms may appear anywhere from 2 to 21 days after exposure.

Ebola is spread through direct contact with blood, secretions or other bodily fluids or exposure to contaminated objects, such as needles. Ebola is not contagious until symptoms appear.

The CDC recommends that individuals protect themselves by avoiding contact with the blood and body fluids of people who are ill with Ebola. DSHS also encourages health care providers to ask patients about recent travel and consider Ebola in patients with fever and a history of travel to Sierra Leone, Guinea, Liberia, and some parts of Nigeria within 21 days of the onset of symptoms.

Saudi MOH 1 New MERS Case – Sept 30th



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The Saudi MOH has announced their 11th MERS Case of September, this time from Al Madinah, involving a 70 year-old male with camel exposure.  

Earlier today, we learned that Austria has Reported their 1st Imported MERS Case (ex- KSA).

This  uptick in cases has come just as the annual Hajj – which will attract more than 2 million religious pilgrims to Saudi Arabia for the month of October – begins.




Three Early Release MMWRs On The Ebola Outbreak



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The CDC has released a series of three early release MMWRs today on the Ebola outbreak in Africa.  One on the ongoing outbreak in Liberia, Guinea and Sierra Leone, while the other two concentrate on the rapid responses to Nigeria’s and Senegal’s imported cases. 

Below you’ll find links, and the CDC’s capsule descriptions for each document.


MMWR Early Release


Ebola Virus Disease Outbreak — West Africa, September 2014
Incident Management System Ebola Epidemiology Team, CDC; Ministries of Health of Guinea, Sierra Leone, Liberia, Nigeria, and Senegal; Viral Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, CDC.
MMWR 2014;63(Early Release):1-2

Updated data on the Ebola virus disease outbreak in West Africa indicate that, as of September 23, a total of 6,574 cases had been reported from five West Africa countries (Guinea, Liberia, Nigeria, Senegal, and Sierra Leone). The highest reported case counts were from Liberia (3,458 cases), Sierra Leone (2,021), and Guinea (1,074).


Ebola Virus Disease Outbreak — Nigeria, July–September 2014
Faisal Shuaib, DrPH, Rajni Gunnala, MD, Emmanuel O. Musa, MBBS, et al.
MMWR 2014;63(Early Release):1-6
On July 20, an acutely ill traveler from Liberia arrived at the international airport in Lagos, Nigeria, and was confirmed to have Ebola virus disease after being admitted to a private hospital. The Federal Ministry of Health, with the Lagos State government and international partners, activated an Ebola Incident Management Center as a precursor to the current Emergency Operations Center to rapidly respond to this outbreak. The index patient died on July 25; as of September 24, there were 19 laboratory-confirmed Ebola cases and one probable case in two states, with 894 contacts identified and followed during the response.


Importation and Containment of Ebola Virus Disease — Senegal, August–September 2014
Kelsey Mirkovic, PhD, Julie Thwing, MD, Papa Amadou Diack, MD.
MMWR 2014;63(Early Release):1-2
On August 29, 2014, Senegal confirmed its first case of Ebola virus disease in a Guinean man, aged 21 years, who had traveled from Guinea to Dakar, Senegal, in mid-August to visit family. Senegalese medical and public health personnel were alerted about this patient after public health staff in Guinea contacted his family in Senegal on August 27. This report describes the investigation and containment measures that followed.


The CDC has also published a the following statement, summarizing what (for now, at least) appears to have been a successful containment campaign in Senegal and Nigeria. 



Ebola outbreak is nearing possible end in Nigeria

Strong emergency operations center, polio eradication experience keys to success

The Ebola outbreak in Nigeria appears to be nearing a possible end thanks to a rapid response coordinated by Nigeria’s Emergency Operations Center with assistance from international partners, including the U.S. Centers for Disease Control and Prevention (CDC). The official end to an Ebola outbreak comes when two of the 21-day incubation periods for Ebola virus have elapsed without any new cases.

During the outbreak there were 19 laboratory-confirmed and one probable Ebola cases in two Nigerian states. Nearly 900 patient contacts were identified and followed; all but three have completed 21 days of follow-up without Ebola symptoms.  There have been no new cases since August 31 and the last three patient contacts will exit their 21-day follow-up on October 2 – strongly suggesting the outbreak in Nigeria has been contained.  A report on Nigeria’s response to the outbreak appears in a Sept. 30 early release issue of CDC’s Morbidity and Mortality Weekly Report (MMWR).

"Although Nigeria isn’t completely out of the woods, their extensive response to a single case of Ebola shows that control is possible with rapid, focused interventions,” said CDC Director Tom Frieden, M.D, M.P.H. “Countries throughout the region as well as Nigeria need to take rapid steps to prepare for possible cases of Ebola in order to prevent outbreaks in their country.”

(Continue . . . )


Given the gravity of the situation in the three hardest hit nations of Guinea, Liberia, and Sierra Leone the apparent successful containment of Ebola in Nigeria and Senegal provides some welcome good news.

Egyptian MOH: 4th H5N1 Case Of 2014


Note: While the MOH has only announced 4 cases this year, FluTrackers has a fifth case reported by Ministry of Health of Beheira governorate, which would bring the total to 5.

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While we haven’ heard much about H5N1 in Egypt in recent months, we’ve continued to see FAO reports of outbreaks in Egyptian poultry, and so it isn’t terribly surprising that overnight the Egyptian MOH has issued the following (machine translated) statement on their 4th reported human H5N1 infection of the year.


Minister of Health: Injured bird flu .. and in stable condition

Dr. Adel Adawi, Minister of Health and Population injury a new case of bird flu to a baby girl at the age of 3 months from the Giza governorate, pointing out that it is the fourth case of injury this year.

The Minister of Health that the date of onset of the disease is due to on Monday 22/09/2014 where she was suffering from a case (fever - sore throat - cough - vomiting), where the girl's parents went to the outpatient clinic at the Hospital of the Abbasid released on 25/9 / in 2014, and he asked the people of the situation indicate exposure to dead birds, have been isolated little girl at the hospital on suspicion of bird flu, then was taken from the throat swab on the same day were sent the sample to the central laboratory of the Ministry of Health and Population and the girl began to take Tamiflu, as well as the work of the rays normal Sadr hailed the show a pneumonia Ayman, was the result of the sample positive for the disease were confirmed case experimentally in the central laboratory to be positive for the avian influenza virus (A / H5N1), and was the work of Ohotai issued to follow the situation where it was found that the situation is improving and the overall situation is stable.

Source: Center for Media


Although H5N1 has taken a bit of a back seat to MERS-CoV, Ebola, and H7N9 it remains endemic in wild birds and poultry in both Asia and the Middle East, continues to evolve into new clades, and continues to pose a threat both to agricultural interests and (on occasion) to human health.

The most recent WHO Update: Influenza at the human-animal interface (H5N1), advises:

Overall public health risk assessment for avian influenza A(H5N1) viruses: Whenever influenza viruses are circulating in poultry, sporadic infections or small clusters of human cases are possible, especially in people exposed to infected poultry or contaminated environments. These influenza A(H5N1) viruses do not currently appear to transmit easily among people. As such, the risk of community-level spread of these viruses remains low.


That said, reserachers continue to watch H5N1, along with a growing cadre of recently emerged avian flu viruses (H7N9, H5N6, H10N8) for any signs that they are becoming better adapted to human physiology.

Report: Hansen’s Disease (Leprosy) In Mississippi



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With the advent of modern antibiotics - Hansen’s Disease, aka Leprosy – has been vastly reduced around the globe over the past couple of decades, although more than 200,000 new cases are still reported each year (see WHO Prevalence of leprosy).  


While limited cases of drug resistant Leprosy have been reported (see Primary Multidrug-Resistant Leprosy, United States), this infection remains largely treatable. The World Health Organization has this to say about MDT (Multi-Drug Therapy) and resistance.


MDT and drug resistance

Is the threat of rifampicin-resistant leprosy a serious problem?

There are a few isolated reports of rifampicin-resistant leprosy; these are mainly from areas where rifampicin was given as monotherapy, either alone or in combination with dapsone, to dapsone-resistant patients. At the moment, the problem of rifampicin-resistant leprosy is not a serious one; however, selective non-compliance with dapsone and/or clofazimine by patients may facilitate the selection of rifampicin-resistant strains.


Although  rare, the United States still sees about 150-220 cases each year. Indigenous cases are primarily associated with contact with armadillos – for some, a southern delicacy – and known reservoir for the bacteria: Mycobacterium leprae (see my 2011 blog  Hint: Don’t Order The `Possum On the Half Shell’)

Nine-banded Armadillo -wikipedia

Here in the United States, Hansen’s disease is studied and tracked  by the HHS’s National Hansen's Disease (Leprosy) Program.  Some excerpts from their homepage:


A genetic study at the National Hansen’s Disease Program reports that armadillos may be a source of infection in the southern United States. The Program advises:

  • The risk of transmission from animals to humans is low, but armadillos are wild animals and should be treated as such, with all proper precautions.
  • Individuals should decide for themselves whether or not to interact with these animals and, if so, what precautions to take.

Hansen's Disease (Leprosy) Facts

  • Most (95 percent) of the human population is not susceptible to infection with M. leprae, the bacteria that causes Hansen's disease (leprosy).
  • Treatment with standard antibiotic drugs is very effective.
  • Patients become noninfectious after taking only a few doses of medication and need not be isolated from family and friends.
  • Diagnosis in the U.S. is often delayed because health care providers are unaware of Hansen's disease (leprosy) and its symptoms.
  • Early diagnosis and treatment prevents nerve involvement, the hallmark of Hansen's disease (leprosy), and the disability it causes.
  • Without nerve involvement, Hansen's disease (leprosy) is a minor skin disease.
  • 213 new cases were reported in the U.S. in 2009 (the most recent year for which data are available).
  • Most (97 or 65%) of these new cases were reported in
    • California
    • Florida
    • Hawaii
    • Louisiana
    • Massachusetts
    • New York
    • Texas

All of which brings us to a fascinating new  Mississippi State Department of Health report, released yesterday, on the prevalence of Hansen’s disease in that state. Some excerpts follow:

Mississippi Morbidity Report

Volume 30, Number 5 September 2014

Hansen’s Disease (Leprosy) in Mississippi

Background: Leprosy, also known as Hansen's disease, is a chronic infectious disease of the skin and peripheral nerves caused by the bacteria Mycobacterium leprae (M. leprae). The infection, with an average incubation period between 8 and 12 years, is seen mainly in poor countries and rarely seen in developed nations. In the United States, 213 new cases of leprosy were reported in 2009 [1]. Approximately 75 percent of these reported cases occurred among immigrants. However, endemic acquisition foci exist in parts of the south-central U.S., primarily in Louisiana, Mississippi, Florida, and Texas [1].


Transmission: Although the mode of transmission of M. leprae has not been proven, person-to-person aerosol spread from infected nasal secretions is posited in most cases worldwide. However, there is increasing evidence that a very small number of cases may be classified as zoonotic infections in countries where nine-banded armadillos (Dasypus novemcinctus) are found in the wild. As the wild nine-banded armadillos are the only identified species in the U.S. that can serve as a reservoir for M. leprae in nature and has a range that includes the Southeastern U.S., it has been postulated that they may be spreading the bacteria into the environment and transmitting infection to humans in the U.S. south [2]. Human indigenous leprosy cases have been described in the same geographic regions where infected armadillos have been reported, mainly Texas and Louisiana and Mississippi [3]


Epidemiology of Hansen’s disease in Mississippi: A total of 53 cases of Hansen’s disease have been reported in Mississippi from 1922 to 2013. The majority of the cases (43) have been classified as indigenous cases, defined as occurring in individuals living for more than 12 years in Mississippi prior the diagnosis(see Figure 1). Ten cases were classified as non-indigenous due to foreign birth (in a country with endemic Hansen’s disease) or residency in MS of less than 12 years. Of the indigenous cases, the median age among the reported cases is 69 years, with ages of cases ranging from 23 to 87 years at time of diagnosis. A majority of the reported cases are male (77%); 86% of the cases are Caucasian and 14% are African-American.


Cases of indigenous leprosy have been identified in many parts of the state, with the majority occurring in south Mississippi and the Delta. Armadillos positive for M. leprae have been identified in two areas in Mississippi, the Delta and in Northeastern Mississippi. (Figure 2). Of sixteen indigenous cases with information on prior armadillo exposure, eight (50%) reported prior contact with armadillos. Information pertaining to the nature of the exposures was not available

Conclusions: Hansen’s disease is a rare but increasing diagnosis among Mississippi residents. Increased reports of Hansen’s disease in Mississippi may reflect an increasing incidence, improved reporting or improved diagnostics. The majority of cases were identified in patients older than 62 years of age and 50% with available data reported previous contact with armadillos. Medical providers should consider a diagnosis of Hansen’s disease in patients with persistent skin lesions, particularly if associated with localized loss of sensation or a history of exposure to armadillos.

Submitted by: Luis Marcos, MD, MPH; Paul Byers, MD; Jannifer Anderson, RN; and Thomas Dobbs MD, MPH


While not a huge public health problem today, this report is a good reminder for doctors that while you should always first `think horses’ when you hear hoof beats, every once in awhile there’s a zebra hidden in the herd.