Thursday, September 03, 2015

WHO Statement On The 10th Meeting Of the IHR Emergency Committee On MERS


Credit ECDC



Yesterday the World Health Organization convened the 10th meeting of the IHR Emergency Committee on MERS to discuss the most recent developments, and to determine whether the virus constitutes a PHEIC (Public Health Emergency Of International Concern).


Not unexpectedly, the committee decided the conditions to declare MERS a PHEIC have not yet been met, but they `emphasized that they have a heightened sense of concern about the overall MERS situation.’


The committee – without specifically naming the Saudis – chastised the response to MERS in unusually blunt terms, stating:


The Committee further noted that its advice has not been completely followed. Asymptomatic cases that have tested positive for the virus are not always being reported as required.

Timely sharing of detailed information of public health importance, including from research studies conducted in the affected countries, and virological surveillance, remains limited and has fallen short of expectations. 

Inadequate progress has been made, for example, in understanding how the virus is transmitted from animals to people, and between people, in a variety of settings. The Committee was disappointed at the lack of information from the animal sector.


Shortcomings we’ve looked at often in the past, including WHO EMRO: Scientific Meeting Reviews MERS Progress & Knowledge Gaps, and that have frequently been addressed by Crof , Ian Mackay’s VDU Blog , and FluTrackers

The full statement, which contains recommendations to better contain the threat,  follow:



WHO statement on the tenth meeting of the IHR Emergency Committee regarding MERS

WHO statement
3 September 2015

The tenth meeting of the Emergency Committee (EC) convened by the Director-General under the International Health Regulations (2005) (IHR 2005) regarding the Middle East respiratory syndrome was held by teleconference on 2 September 2015, from 1300 to 1620 Central European Summer Time (UTC +2). During the meeting the WHO Secretariat provided an update to the Committee on epidemiological and scientific developments, including recent cases and transmission patterns in the Kingdom of Saudi Arabia (KSA), Jordan and the United Arab Emirates. The Secretariat also provided current risk assessments with regard to these events, and information on control and prevention measures.

The following States Parties provided information on the status of events and assessments of the MERS-CoV situation in their countries: Jordan, KSA, Republic of Korea, Philippines, Thailand and the United Arab Emirates.

The Secretariat reported on a recent WHO mission to KSA that was conducted on 23 August 2015 because of a hospital-based outbreak of MERS cases. One of the preliminary conclusions was that virus transmission in the emergency room of the most heavily affected hospital resulted in a significant nosocomial outbreak. Despite an established triage system, virus transmission was able to occur because of overcrowded conditions, movement of patients who were infected but did not yet have a diagnosis, and some breakdowns in the application of infection prevention and control (IPC) measures. These key factors facilitated the outbreak.

Members of the EC agreed that the situation still does not constitute a Public Health Emergency of International Concern (PHEIC). At the same time, they emphasized that they have a heightened sense of concern about the overall MERS situation. Although it has been three years since the emergence of MERS in humans was recognized, the global community remains within the grip of this emerging infectious disease. There is continued virus transmission from camels to humans in some countries and continued instances of human-to-human transmission in health care settings. Nosocomial outbreaks have most often been associated with exposure to persons with unrecognized MERS infection. The major factors contributing to the ongoing situation are insufficient awareness about the urgent dangers posed by this virus, insufficient engagement by all relevant sectors, and insufficient implementation of scalable infection control measures, especially in health care settings such as emergency departments. The Committee recognizes that tremendous efforts have been made and some progress has been achieved in these areas. However, the Committee also notes that the progress is not yet sufficient to control this threat and until this is achieved, individual countries and the global community will remain at significant risk for further outbreaks.

Moreover, the current outbreak is occurring close to the start of the Hajj and many pilgrims will return to countries with weak surveillance and health systems. The recent outbreak in the Republic of Korea demonstrated that when the MERS virus appears in a new setting, there is great potential for widespread transmission and severe disruption to the health system and to society.

The Committee further noted that its advice has not been completely followed. Asymptomatic cases that have tested positive for the virus are not always being reported as required. Timely sharing of detailed information of public health importance, including from research studies conducted in the affected countries, and virological surveillance, remains limited and has fallen short of expectations. Inadequate progress has been made, for example, in understanding how the virus is transmitted from animals to people, and between people, in a variety of settings. The Committee was disappointed at the lack of information from the animal sector.

The Committee felt it important to alert all relevant authorities, especially national public health, animal and agricultural agencies, to the continued and significant public health risks posed by MERS. These sectors must collaborate, among themselves and internationally, and follow the advice that has been issued by WHO.

The Committee advised as follows:

  • Its previous advice remains applicable.
  • National authorities should ensure that all health care facilities have the capacity, knowledge and training to implement and maintain good practices, especially infection prevention and control measures and early identification of cases.
  • Appropriate authorities should collaboratively address deeper systemic issues that are impeding control of MERS, both in animals and humans.
  • National authorities should ensure the rapid and timely sharing of information of public health importance, including epidemiological investigations, viral genetic sequence information and findings from research studies.
  • International collaboration to develop human and animal vaccines and therapeutics should be accelerated.
  • In view of the evidence that camels are the main source of community-acquired infections, public health, animal health and agricultural sectors must improve their collaboration to address the public health risk of MERS.
  • National leadership is essential to ensure a flexible, efficient and well-coordinated whole-of-government response to the challenges posed by MERS.

Based on the Committee’s advice and information currently available, the Director-General accepted the Committee’s assessment. She thanked the Committee for its work.

There is no public health justification for implementing any measures to prevent the spread of MERS through the restriction of travel or trade. Screening at points of entry is considered unnecessary at this time. However, raising awareness about MERS and its symptoms among those travelling to and from affected areas, particularly in light of the Hajj, is strongly advised.

WHO will continue to provide updates to the Committee Members and Advisors. The Emergency Committee will be reconvened should circumstances require.

CID Journal: Outcomes Of Prompt Influenza Antiviral Treatment Of Older Adults


Photo Credit – Wikipedia


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Although it runs contrary to to what some in the `popular press’- and some activists - would like to project, there is a substantial body of evidence showing that antiviral medications – like oseltamivir (aka Tamiflu ®) - can make a real difference in the outcome of severe influenza infection.


Unfortunately, what most people know or remember about these drugs comes from hyperbolic media reports like the Guardian’s Tamiflu’s limitations in preventing pandemics exposed by trial results  and the Daily Mail’s  Ministers blew £650MILLION on useless anti-flu drugs.


Much of the ire surrounding this drug has been garnered through Roche’s long-standing resistance to releasing all of their testing data, and that has led to critical editorials in the BMJ, and frequent excoriation in the British press.


Fueling this fire have been repeated Cochrane group analyses that have found insufficient evidence that the drug reduces seasonal influenza complications in healthy adults, although they limit their analyses to RCTs (Randomized Controlled Trials) of which few exist for this drug.  


We’ve seen numerous observational studies that show antivirals are useful in the treatment of severe flu (see Study: Antivirals Saved Lives Of Pregnant Women  and  Study: The Benefits Of Antiviral Therapy During the 2009 Pandemic), particularly in those with heightened risk factors. 


Sadly,  many people (and probably even some doctors) have come away with the erroneous impression that these drugs are worthless – or worse.  We saw evidence of this last summer, in  CID Journal: Under Utilization Of Antivirals For At Risk Flu Patients, showing that antiviral drugs are underused for at-risk patients, while antibiotics (which don’t work against viral infections) are overused.

Working to address these beliefs, have been the CDC (see The CDC Responds To The Cochrane Tamiflu Study) and the UK PHE (see Revisiting Influenza Antiviral Recommendations), while  last January we saw a meta-analysis in The Lancet that supported its use as well (see CIDRAP News On The Lancet Oseltamivir (Tamiflu ®) Meta-Analysis).

Today we’ve new CDC research that looked at the extended care needs of elderly post-hospital-discharge flu patients who either received, or did not receive, early antiviral treatments.  As you will see, early administration of antivirals was associated with reductions in length of hospital stays, and reduced odds of needing extended care after discharge.


Impact of prompt influenza antiviral treatment on extended care needs after influenza hospitalization among community-dwelling older adults

Sandra S. Chaves1, Alejandro PĂ©rez1, Lisa Miller2, Nancy M. Bennett3, Ananda Bandyopadhyay4, Monica M. Farley5,6,  Brian Fowler7,  Emily B. Hancock8, Pam Daily Kirley9,  Ruth Lynfield10, Patricia Ryan11, Craig Morin10, William Schaffner12, Ruta Sharangpani13, Mary Lou Lindegren12, Leslie Tengelsen14, Ann Thomas15, Mary B. Hill16, Kristy K. Bradley17, Oluwakemi Oni18, James Meek19, Shelley Zansky20, Marc-Alain Widdowson1, and Lyn Finelli1



Background.  Patients hospitalized with influenza may require extended care upon discharge. We aimed to explore predictors for extended care needs and the potential mitigating effect of antiviral treatment among community-dwelling adults aged ≥65 years hospitalized with influenza.

Methods. We used laboratory-confirmed influenza hospitalizations from 3 influenza seasons. Extended care was defined as new placement in a skilled nursing home/long-term/rehabilitation facility upon hospital discharge. We focused on those treated with antiviral agents to explore the effect of early treatment on extended care and hospital length of stay (LOS) using logistic regression and competing risk survival analysis, accounting for time from illness onset to hospitalization. Treatment was categorized as early (≤4 days) and late (>4 days) in reference to date of illness onset.

Results. Among 6,593 community-dwelling adults aged ≥65 years hospitalized for influenza, 18% required extended care at discharge. Need for care increased with age and neurologic disorders, ICU admission, and pneumonia were predictors of care needs. Early treatment reduced the odds of extended care after hospital discharge for those hospitalized ≤2 or >2 days from illness onset (adjusted odds ratio [aOR] 0.38; 95% confidence interval [CI] 0.17, 0.85, and aOR 0.75; 95% CI 0.56, 0.97 respectively). Early treatment was also independently associated with reduction in LOS for those hospitalized ≤2 days from illness onset (adjusted hazard ratio [aHR] 1.81; 95% CI 1.43, 2.30) or >2 days (aHR 1.30; 95% CI 1.20, 1.40).

Conclusions. Prompt antiviral treatment decreases the impact of influenza on older adults through shorten hospitalization and reduced extended care needs.


The CDC has released a statement regarding this study, excerpts of which follow:


Early flu treatment reduces hospitalization time, disability risk in older people

Press Release

For Immediate Release: Wednesday, September 2, 2015

Early treatment of flu-hospitalized people 65 and older with flu antiviral medications cuts the duration of their hospital stay and reduces their risk of needing extended care after discharge, a new CDC study finds. The study is the first to look at the benefits of early antiviral treatment on preventing the need for extended care in community-dwelling flu-hospitalized people 65 and older.

Because people 65 and older are at high risk of serious flu complications, CDC recommends that they be treated for flu with influenza antiviral medications as early as possible because these drugs work best when started early. The study, published today in the journal Clinical Infectious Diseases, supports this recommendation.

“Flu can be extremely serious in older people, leading to hospitalization and in some cases long-term disability. This important study shows that people 65 and older should seek medical care early when they develop flu symptoms,” says Dr. Dan Jernigan, director of CDC's Influenza Division.

The study found that community-dwelling patients 65 years and older who sought medical care or who were hospitalized within two days of illness onset and who were treated with antiviral medications early (in the first four days of illness) had hospital stays that were substantially shorter than those who received treatment later (after 4 days of illness onset). This benefit was observed even among those who sought care later (more than two days after they got sick), but the reduction in hospital stay was not as great.

Similarly, early treatment was associated with patients being 25 percent to 60 percent less likely to need extended care after leaving the hospital. The study authors suggest that the shorter hospital stays associated with early treatment could account for the reduced risk of needing extended care after discharge since lengthy bed restriction can lead to disability. Other factors like older age, the presence of neurologic disorders, intensive care unit (ICU) admission, and pneumonia at admission were also independent risk factors for extended care needs.

(Continue . . .)


While far from perfect, and certainly not a `cure’ for flu, antivirals remain our best pharmaceutical option for the treatment of severe influenza.

Saudi MOH: Four New MERS Cases



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The latest update from the Saudi MOH indicates 4 new MERS cases (2 HCWs in Riyadh, 1 in Najran, and 1 in Al Kharj), along with two recent deaths.  This makes 135 cases reported out of Saudi Arabia over the past 30 days, an unusually high number of cases for this time of year.

While most of the activity has been centered around the capital Riyadh, the past few days we’ve seen a growing number of cases from Najran, near the Yemen border.  


Today, we also see the first case in several weeks from Al Kharj, the source of which isn’t stated.  



The source of these  sporadic `primary cases’ – community cases without a known risk exposure –  are the topic of a blog overnight by Dr. Ian Mackay (see Where do these 'primary' MERS cases come from?), which includes a fascinating chart showing their incidence.


This is also an issue we’ve looked at previously, in  WHO EMRO: Scientific Meeting Reviews MERS Progress & Knowledge Gaps  and The Community Transmission Mystery).


Based on the limited scientific studies that have been released, for now, we still have more questions than answers.

#NatlPrep : Disaster Preparedness For Kids




Note: This is day 3 of National Preparedness Month.  Follow this year’s campaign on Twitter by searching for the #NatlPrep hash tag.  This month, as part of NPM15, I’ll be rerunning some updated  preparedness essays, along with some new ones.



Growing up in Hurricane Alley, during the very active 1950s and 1960s, I was primed at an early age to respect the power of nature and to be prepared for the unexpected. If that wasn’t enough, our daily barrage of lightning storms during the summer months only added emphasis to the need to always keep a weather eye out. 


During my `formative years’, a lot of named storms crossed my path (I spent most of that time living in the green circle around Tampa Bay), and like most kids in Florida, I kept a hurricane tracking map my  bedroom wall to monitor their progress.  


I knew their strength, forward speed, and direction of movement, and dutifully updated the map every 6 hours.



Call it therapeutic. But I took comfort in knowing where these storms were, where they were likely headed, and knowing when they posed a potential threat - and more importantly – when they didn’t.   


I was involved, and so I felt in control.

Throw in the cold war, the 1962 Cuban Missile Crisis, and constant school duck & cover drills and evacuations, CONELRAD alerts on TV, films like Survival Under Atomic Attack and `Bert the turtle’ PSAs in elementary school, and you’d think you’d have a recipe for night terrors and phobias.



But amazingly, most of us just took it in stride.  In large part, I believe, because we were encouraged at a very young age to participate in disaster preparedness. 


While the atomic attack scenarios were certainly scary, we were empowered by being `prepared for the worst’, even if some of those preparations were a bit dubious (the protective properties of student desks against high yield atomic blasts likely being less than advertised).


Fortunately, disaster preparedness – particularly for kids - has come a long way from the `bad old days’ of the cold war.


Today, our concerns are focused on natural disasters, like floods, hurricanes, and earthquakes.  Scenarios that are far more survivable than an all-out nuclear attack, and that can be approached in a more `kid-friendly’ fashion.


Still, the core message – that disasters happen, and we should all be prepared – hasn’t changed.’s kid friendly preparedness page contains games and activities for kids along with information for parents and educators on how to teach simple, but effective preparedness lessons.  


Many states have their own preparedness site for kids, such as Florida Division of Emergency Management’s Kids Get A Plan page, which provides an excellent interactive introduction to preparedness for children. 


Florida’s  Disaster Preparedness For Kids


Most of these programs are designed for younger kids, so I was pleased earlier this year to find an online disaster preparedness game more suitable for older kids; the ISDR: The `Stop Disasters’ Simulation Game.  The game has five scenarios, with three levels of difficulty in each, to choose from.  Earthquake, tsunami, hurricane, wildfire or flood.



For more ideas on teaching kids to be disaster resilient (albeit, earthquake centric) SHAKEOUT.ORG has a long list of educational resources divided up by suitable school grade brackets (K-6, 7-12). 


Although most parents want to protect their kids from undo worry - when a disaster threatens, it threatens all of us – regardless of our age. 


Helping kids to understand more about emergency preparedness and community resilience will help them cope (and perhaps, even help) in the event they, or their community, are caught up in a disaster.

Wednesday, September 02, 2015

ECDC: Epidemiological Update On MERS-CoV - Sept 2nd


MERS by month of Onset – Credit ECDC

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The ECDC has published an updated Epidemiological Update on MERS cases, which includes the 1st four Jordanian cases of 2015, along with Saudi cases reported through September 2nd.  As always, they pack a lot of information, and some excellent graphics, into their updates.

As the chart above illustrates, while our history of tracking  MERS is pretty short, we do seem to be seeing more MERS activity the past few months than we have during previous summers. These numbers, however, are largely being propelled by three major nosocomial outbreaks (Hofuf, South Korea, Riyadh). 


I’ve only included the outbreak summaries, so follow the link for the entire update:


Epidemiological update: Middle East respiratory syndrome coronavirus (MERS-CoV)

02 Sep 2015



According to WHO the four cases reported from Jordan between 26 and 28 August 2015 seem to be part of a MERS-CoV outbreak at a hospital in Amman.

The first case reported was a 60-year-old man who lived in Jeddah, Saudi Arabia, but had travelled to Amman on 28 July 2015. The onset of symptoms began on 31 July and he was hospitalised for the first time from 10 to 18 August. However, he was readmitted to another hospital on 20 August. It is not known how this case  became infected.

The second case is a 38-year-old man from Kuwait City who travelled to Amman on 7 August 2015. He developed symptoms on 12 August. He was hospitalised on 17 August in the same hospital where the first case was treated. One possible exposure is that he frequently visited a family member who was being treated at the same hospital as the first case.

The third case is a 76-year-old man from Amman who was hospitalised for treatment of a chronic health condition on three different occasions at the same hospital as the two previous cases. According to WHO he was hospitalised twice for an underlying condition and then admitted on 20 August 2015 after he was diagnosed with MERS-CoV.

The fourth case is a 47-year-old woman from Kuwait City who travelled to Amman on 15 July 2015. She is a contact of the second case and tested positive for MERS-CoV on screening tests. She is asymptomatic and is in home isolation. Her only known exposure is that she visited family members at the hospital where the first patient was being treated.

In addition to the four cases mentioned, Jordan has announced two extra cases, a 56-year-old Jordanian man who was diagnosed with MERS-CoV after undergoing surgery and a 74-year-old woman who has pre-existing medical conditions.


Saudi Arabia

Since the beginning of 2015, Saudi Arabia has reported 367 cases, of which 30 were reported after ECDC’s risk assessment of 27 August 2015. Twenty-eight of the cases occurred in Riyadh (Figure 4) and two in Najran.

Figure 3. Number of cases (n=131) reported by Saudi Arabia in Riyadh, 3 August 2015 – 2 September 2015, by date of reporting

For four of the 30 cases it was clearly indicated that they did not have any contact with a previously identified or suspected case. The remaining 26 cases had either had contact, or were under review for having had contact, with suspected or confirmed cases in the community or hospital. This may indicate that there might be a low-level community transmission but the majority of the cases are clearly related to nosocomial transmission of MERS-CoV in Saudi Arabia. Six of the 30 cases are healthcare workers.

(Continue . . .)



WHO MERS Update – Saudi Arabia Sept 2nd


Credit WHO



We’ve another lengthy WHO GAR update on the ongoing MERS outbreak in Saudi Arabia.  Today’s update lists 15 cases reported by the MOH between August 24th and 25th. Due to the length of this update, I’ve elected to briefly chart the cases (see spreadsheet below), rather than print the entire update.


Only one is listed as having direct contact with a known case, while 10 appear to be the unlucky recipients of  `collateral infection’  while admitted to - or visiting - a healthcare facility. In four cases, the mode of infection isn’t stated.


Two are healthcare workers, but none are described as having provided care to a known MERS case.  As we’ve seen previously, the actual chain of transmission within hospitals is often murky. .  



The average patient age for this batch is 63.57 years, 6 are female while 9 are male. Four are listed in critical condition, 2 have died, while the rest are listed in stable condition.  The average delay between testing positive and being reported by the MOH is near to 3 days, with a maximum of 7.



Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Saudi Arabia

Disease outbreak news
2 September 2015

Between 24 and 25 August 2015, the National IHR Focal Point for the Kingdom of Saudi Arabia notified WHO of 15 additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, including 2 deaths. Eleven (11) of these reported cases are associated with a MERS-CoV outbreak currently occurring in a hospital in Riyadh city.


Contact tracing of household and healthcare contacts is ongoing for these cases.

The National IHR Focal Point for the Kingdom of Saudi Arabia also notified WHO of the death of 9 MERS-CoV case that were reported in previous DONs on 26 August (case no. 4, 5, 8, 13, 14, 17), on 21 August (case no. 4, 9) and on 18 August (case no. 7).

Globally, since September 2012, WHO has been notified of 1,493 laboratory-confirmed cases of infection with MERS-CoV, including at least 527 related deaths.