Epidemics: Systematic Review Of MERS-CoV Seroprevalence and RNA Prevalence in Dromedary Camels

Graphical Abstract

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We are rapidly approaching the 7th anniversary of the discovery of the MERS-CoV virus - first isolated from a patient in Saudi Arabia - and it's been 6 years since camels were identified as a host species (see 2013's The Lancet Camels Found With Antibodies To MERS-CoV-Like Virus).

While bats are suspected to be the primary host reservoir for MERS, SARS, and an array of other novel pathogens (see Curr. Opinion Virology: Viruses In Bats & Potential Spillover To Animals And Humans), camels - due to their close contact with people in the Middle East - are the main conduit by which the virus appears to spillover to humans.

Despite some early optimism (see 2013's mBio: Engineered MERS Strain For Vaccine Research), six years have passed and an effective, commercially available vaccine remains elusive.

As we discussed last month in Manufacturing Pandemic Flu Vaccines: Easier Said Than Done, cobbling together a vaccine for a novel virus isn't nearly as easy as the media, and fiction writers, would have us believe.

Despite 16 years of research, no commercially available SARS vaccine has been developed, and twenty years after its discovery, a Nipah vaccine is still in the works.

As camels are the logical target for any vaccine, understanding how MERS spreads, and infects, dromedaries is key (see Epi.& Inf.: Global Status Of MERS-CoV In Camels - A Systemic Review). But many questions remain, including:

• Why 100% of the known and suspected camel-to-human transmissions have been recorded on the Arabian peninsula, while the MERS virus and antibodies have been detected in camels from both Africa and South-Central Asia. 
• Why roughly 90% of Middle Eastern human MERS infections have been reported by one country; Saudi Arabia
• Why spillover from camels appears to peak in the winter and spring
• And why human cases were never identified before 2012, despite evidence of MERS circulation in camels going back at least 30 years.

Complicating the quest for a MERS vaccine even further, in 2017's  MERS-CoV In Camels: The Gift That Keeps On Giving, we saw a study that showed  that camels can be reinfected by the MERS virus, despite having substantial antibody titers.

While this raises concerns over the ability of a vaccine to prevent infection, it may still be that a vaccine could lower viral shedding, and reduce the risks of zoonotic transmission. But for now, there are more questions than answers. 

All of which brings us to a detailed, data-heavy, open-access systematic review of Dromedary camel infection with the MERS virus in Africa, Asia, and the Middle East, and that discusses potential pitfalls in vaccine development.

By definition this review covers a good deal of previously trod ground, but it provides an excellent overview of our current understanding of how (and where) MERS circulates in camels, and some of the obstacles we may face in producing an effective MERS vaccine.

Follow the link to read it in its entirety, after which I'll have a brief postscript:

A systematic review of MERS-CoV seroprevalence and RNA prevalence in dromedary camels: Implications for animal vaccination

AmyDighe a ThibautJombart abc Maria D.Van Kerkhove d NeilFerguson a

https://doi.org/10.1016/j.epidem.2019.100350

Highlights

• Most adult dromedaries in Africa and the Middle East have been infected with MERS-CoV.
• Seroprevalence increases with age, while active infection is more common in calves.
• Prevalence is higher at sites where different dromedary populations mix
• Further study is needed to determine if prevalence of infection varies seasonally.

Abstract

Human infection with Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is driven by recurring dromedary-to-human spill-over events, leading decision-makers to consider dromedary vaccination.

Dromedary vaccine candidates in the development pipeline are showing hopeful results, but gaps in our understanding of the epidemiology of MERS-CoV in dromedaries must be addressed to design and evaluate potential vaccination strategies. We aim to bring together existing measures of MERS-CoV infection in dromedary camels to assess the distribution of infection, highlighting knowledge gaps and implications for animal vaccination.

We systematically reviewed the published literature on MEDLINE, EMBASE and Web of Science that reported seroprevalence and/or prevalence of active MERS-CoV infection in dromedary camels from both cross-sectional and longitudinal studies. 60 studies met our eligibility criteria.

Qualitative syntheses determined that MERS-CoV seroprevalence increased with age up to 80–100% in adult dromedaries supporting geographically widespread endemicity of MERS-CoV in dromedaries in both the Arabian Peninsula and countries exporting dromedaries from Africa. The high prevalence of active infection measured in juveniles and at sites where dromedary populations mix should guide further investigation – particularly of dromedary movement – and inform vaccination strategy design and evaluation through mathematical modelling.

       (SNIP)

Conclusions

Our findings provide strong evidence that MERS-CoV is endemic in dromedary populations across much of West, North, East Africa and the Middle East, in agreement with the similar systematic review conducted in parallel with our own (Sikkema et al., 2019).

In addition, our findings highlight several epidemiological characteristics of MERS-CoV that must be considered in the design of MERS-CoV animal vaccination strategies.

Calves are likely to play a central role in sustaining circulation of MERS-CoV and should be a target of potential dromedary vaccination.

However, the potential for mass vaccination of calves to change the age distribution of infected individuals should be investigated through mathematical modelling of transmission dynamics in dromedary populations and considered in the context of age-dependent human-camel contact frequency patterns.

Sites where dromedaries mix may also play a role in driving transmission. A better understanding of dromedary husbandry and trade patterns, as well as quarantine facilities, is needed to identify where dromedaries become infected with MERS-CoV – critical for focussing potential vaccination strategies both geographically and within the dromedary camel value chain.

Although in a few studies, prevalence of infection appears to peak in the first half of the year, which may be facilitated by the increase in susceptible animals after the calving season, further studies are needed to confirm this. More longitudinal studies are required to investigate the temporal dynamics of viral shedding and immunity in the animal host and should ideally be capable of distinguishing co-circulating MERS-CoV lineages.

The remaining gaps in our understanding of MERS-CoV transmission dynamics in dromedary populations are in agreement with the prioritized research outlined in the FAO-OIE-WHO Technical Working group report (FAO-OIE-WHO MERS Technical Working Group, 2018) and must be addressed to obtain a clearer picture of what an optimal epidemiological vaccination strategy would involve, as well as its likely impact, before wider challenges of implementation can be considered further.

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Some previous blogs on MERS-CoV in camels include:

Emerg. Microbes & Inf.: Bactrian Camels Shed Large Quantities of MERS-CoV After Experimental Infection

mBio: High Prevalence of MERS-CoV Infection in Camel Workers in Saudi Arabia

Eurosurveillance: Lack of Serological Evidence of MERS-CoV In Camel Abattoir Workers - Nigeria 2016

EID Journal: Geographic Distribution of MERS-CoV among Dromedary Camels, Africa

EID Journal: Serologic Evidence Of MERS-CoV Infection in Pakistani Camels

Taiwan: 11th ASF-Positive `Sea Drift' Pig Recovered

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The island of Taiwan sits between 60 and 90 miles off the Chinese mainland - more specifically Fujian Province - but the ROC exercises political control over several groups of islands (Kinmen, Wuqiu & Matsu) that lie much closer to the mainland.

Over the past 6 months, Taiwan's coast guard has intercepted dozens of `sea drift' pigs (see here, here, here, and here); carcasses found either floating in the water or washed up on beaches, presumably dumped into rivers in Fujian Province.

With today's report, 11 of these pig carcasses have tested positive for African Swine Fever (ASF), despite the fact that officially, Fujian Province hasn't reported an outbreak since since December 24th, 2018 and China's MOA officially lifted their blockade on the movement of pigs on February 6th.

As noted previously in this blog (see here, here, and here), China's farmers have a history of clandestine dumping of diseased livestock into rivers and lakes rather than reporting outbreaks to local officials.

This report from Taiwan's BAPHIQ (Bureau of Animal Plant Health Inspection & Quarantine):

China's mainland drifting Golden Gate pigs, detected African porcine virus DNA positive

The Central Disaster Response Center (Strain Center) of the African Hog ​​Chops said today (16th) that on the 14th, the bank of the two biliary islands in Liyu Township (Xiaojinmen), Jinmen County, found dead pigs drifting ashore, sampled by the Jinmen County Animal and Plant Epidemic Prevention Institute. 

It was sent to the Animal Husbandry Health Laboratory of the Council of Agriculture (the Animal Husbandry Institute) for testing. The nucleic acid of African swine fever virus was detected positively today, and the similarity between the gene fragment and the isolated strain of mainland China was 100%. 

There are no pigs on Erdan Island. Since the discovery location is located at the mouth of the Jiulong River, the pig body should be drifted from mainland China according to the geographical location. At present, there are 11 cases of positive detection of African swine fever virus nucleic acid in Haipeng pigs (9 cases in Jinmen County and 2 cases in Lianjiang County).

According to the Strain Center, the Jinmen County Animal and Plant Epidemic Prevention Institute received a notice from the ninth shore patrol team of the Golden Horse Department on the 14th, and found dead pigs on the bank of Erdan Island in Liyu Township. The institute will immediately join the ninth shore patrol team of the Golden Horse Department.

I rushed to the scene to understand, after collecting the relevant samples, the dead pigs were burned and buried on the spot, and the samples were sent to the animal husbandry for inspection. The related samples were detected by polymerase chain reaction (PCR), and the results of the detection of African swine fever virus nucleic acid were positive. The gene fragment sequence was 100% similar to the gene fragment of the Chinese swine fever virus strain in mainland China.

The strain center added that according to the return of the Jinmen County Animal and Plant Epidemic Prevention Institute, there was no abnormal death in the pigs in the county. The veterinarians of the public offices continued to pay close attention to the dynamics of the farms within the jurisdiction.

In response to this case, the Jinmen County Government has implemented disinfection measures for the personnel, vehicles and equipment that come into contact with the dead pigs. There are no pigs on the second biliary island, and no pig farms are found within a radius of 5 km around the site. Safety, the Jinmen County Government has conducted a comprehensive visit to 8 pig farms in the island of Liyu Township. No abnormalities have been found. The pig farm visits and biosafety counselling will continue to be strengthened to prevent the occurrence and spread of the epidemic.

While the number of pigs retrieved from the beaches of these Taiwanese held islands remains small, the number of infected pigs dumped into Mainland rivers and streams is likely much greater.

The ocean is vast, currents may carry many carcasses away from shore, some may land and decompose unnoticed on uninhabited beaches, while others may end up eaten by predators.

Additionally, many carcasses that have been recovered may have been too badly decomposed to allow for detection of the virus.

Despite the optimistic reporting by China's MOA - which admits just over 1.13 million pigs lost - many experts and organizations have come up with their own estimates of China's ASF losses.

• The FAO's Food Outlook Report - estimated China's losses closer to 20%; roughly 80 to 100 million pigs.

• A Rabobank Research report released in April estimated that between 150-200 million Chinese pigs have already been lost to ASF, and that China's pig production will drop 30% in 2019.

•  Other estimates (see ASF China: Global agribusiness suffers; estimates vary) propose even greater losses.

 And as discussed previously, China's agricultural woes don't stop with ASF, as drought continues in several regions, and half of the nation is battling a massive Fall Armyworm infestation (see below).

China: Update: Fall Armyworm Now in 15 of China’s Provinces

While the full size and scope of China's ASF epizootic remains frustratingly undefined - a serious shortfall in food production in China could have serious ramifications, both regionally, and internationally.

Stay tuned.

Belgium: ASFCA Update On LPAI H3N1

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Six weeks ago we began following reports of a low path H3N1 avian flu spreading among poultry farms in West Flanders (see Belgium: Non-Reportable LPAI H3N1 In Poultry). 

At the time Agriholland reported LPAI H3N1 On 16 Belgium Poultry Farms, a number that - according to recent media reports - now approaches 70 farms.

Since H5 and H7 are the only LPAI viruses considered reportable by the OIE (see Terrestrial Animal Code Article 10.4.1.), this outbreak would have likely gone unnoticed were it not for its unusually high mortality rate (said to be as high as 60%) in poultry.

Since H3N1 falls into a legal grey area, government agencies have been slow to step in with compensation and to recommend containment protocols. It was less than a week ago that an agreement in principle was finally reached on compensating farmers for their losses.

Thus far, we've yet to see a good explanation for the unusually high mortality rates being reported, and official statements on losses and on how the virus is being spread have been in short supply.

All of this has led to considerable debate in the industry over what the government should have done, and when (see pluimveeweb's Belgium should have acted as HPAI).

Given some of the evolutionary strides we're seeing in other LPAI viruses (i.e. H6N1, H9N2, H4N6, etc.), having enough flexibility to respond quickly to `atypical' outbreaks - even those not covered by the OIE's Terrestrial Animal Code - may become more important over time.  

J. Gen. Virology: Mutations in PB2 and HA Enhanced Pathogenicity of H4N6 Avian Influenza Virus in Mice 

Trans. Emerg, Dis: Continued Reassortment of Avian H6 viruses - Southern China, 2014-2016.

Virology: Receptor Binding Specificity Of H9N2 Avian Influenza Viruses

This week, Belgium's Federal Agency for the Safety of the Food Chain (ASFCA) has released revised protocols for the control of H3N1.  I've only included the opening summary, so follow the link to read it in its entirety.

   
Infections with influenza type H3

News update June 12, 2019

Since early April 2019, dozens of poultry farms were affected by the influenza virus H3. Most of the infected farms are located in West Flanders, some are located in East Flanders, two farms in the province of Antwerp and so far only infected farm was discovered in the provinces of Liege and Luxembourg. The most common symptoms are depression, pale eggs, a rapid decline in egg production (20% to 100%), a decrease in water consumption and food and a high mortality rate (sometimes up to 50% and more).

What influenza H3?

The influenza virus type H3 is a typical avian virus that is completely harmless to humans and the food chain. It has all the characteristics of a low pathogenic virus, which means that the virus itself can not be held responsible for the symptoms or the mortality of the poultry. Of course, it can, however, help to reinforce symptoms caused by other pathogens.

Although originally native to wild birds, it has since adapted to chickens, which explains its increased multiplication and transmission.

In addition, research has shown that this virus has some preference for the laying apparatus, which can contribute to the identified clinical problems and also explains why laying hens are mainly affected.

The virus is transmitted primarily through contact with contaminated materials and between animals, making the application of biosecurity more than strictly mandatory.

Measures

In the new Ministerial Decree of 6 June 2019 concerning emergency measures to prevent the spread of the virus H3-type influenza ( NUMAC number - 2019013193 - to view the consolidated version ), additional general preventive measures are imposed and that additional specific measures for farms where the H3 virus was detected.

In addition, this includes the AM measures of the previous MD of 16 May 2019 concerning emergency measures to prevent the spread of avian influenza H3.

The measures apply from Thursday, June 13, 2019.

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Candida Auris: CDC June Update & Other Resources

 

















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Three summers ago (June 24th, 2016) the CDC issued a Clinical Alert to U.S. Healthcare facilities about the Global Emergence of Invasive Infections Caused by the Multidrug-Resistant Yeast Candida auris.

C. auris is an emerging fungal pathogen that was first isolated in Japan in 2009. It was initially found in the discharge from a patient's external ear (hence the name `auris').  Retrospective analysis has traced this fungal infection back over 20 years.

A week later we saw a release from the UK's PHE On The Emergence Of Candida auris In The UK, where they detailed a large (and ongoing since April 2015) nosocomial outbreak at an adult critical care unit in England.

Since then we've been following the progress of this emerging pathogen - both in the United States and around the world - because:

1. C. auris infections have a high fatality rate
2. The strain appears to be resistant to multiple classes of anti-fungals  
3. This strain is unusually persistent on fomites in healthcare environments.
4. And it can be difficult for labs to differentiate it from other Candida strains

Late this week the CDC published their June update on their C. Auris surveillance page, where they show - as of April 30th  - 654 confirmed cases and 30 probable cases, across 12 states (primarily New York, New Jersey & Illinois).

Additionally, 1207 patients have been found to be asymptomatically  colonized with C. auris through targeted screening conducted in six states with clinical cases. 

To put this into perspective, this represents a roughly 25% increase in cases since the EOY 2018 numbers (520 confirmed), in just the first four months of 2019. First some excerpts from the latest CDC update, followed by a couple of recently published articles and/or studies.

Tracking Candida auris

June 14, 2019: Case Count Updated as of April 30, 2019

U.S. Map
World Map

Candida auris is an emerging fungus that presents a serious global health threat. C. auris causes severe illness in hospitalized patients in several countries, including the United States. Patients can remain colonized with C. auris for a long time and C. auris can persist on surfaces in healthcare environments. This can result in spread of C. auris between patients in healthcare facilities.

Most C. auris cases in the United States have been detected in the New York City area, New Jersey, and the Chicago area. Strains of C. auris in the United States have been linked to other parts of the world. U.S. C. auris cases are a result of inadvertent introduction into the United States from a patient who recently received healthcare in a country where C. auris has been reported or a result of local spread after such an introduction.

Candida auris was made nationally notifiable at the 2018 Council for State and Territorial Epidemiologists (CSTE) Annual Conference. For the updated case definition and information on the nationally notifiable condition status, please see the 2018 CSTE position statement pdf icon[PDF – 16 pages].

 

CDC encourages all U.S. laboratories that identify C. auris to notify their state or local public health authorities and CDC at candidaauris@cdc.gov. CDC is working closely with public health and healthcare partners to prevent and respond to C. auris infections. The CDC-sponsored Antibiotic Resistance Laboratory Network (ARLN) will help improve detection and response to C. auris nationwide.

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Our next stop is the AJIC (American Journal of Infection Control) whose June issue carries an analysis of early cases detected in New York State.

American Journal of Infection Control
Volume 47, Issue 6, Supplement, June 2019, Page S10

Presentation Number OIPH-21A

Description of the First Candida Auris-colonized Individuals in New York State, 2016-2017

https://doi.org/10.1016/j.ajic.2019.04.155

(EXCERPT)

RESULTS

Between 10/5/2016 and 11/7/2017, 114 facility-based surveillance cases were identified. The median age was 74 years (range 23-100 years). Facility-based surveillance cases had a median of three HCF admissions in 90 days before first positive culture (range 0-8). Ninety-three percent were from facilities in Brooklyn or Queens. Fifty-four percent had diabetes.

During the week before first positive culture, 81% received mechanical ventilation, 80% had tracheostomy, and 70% had a percutaneous feeding tube. Thirty-four percent had no prior indications for Contact Precautions at time of first positive culture. To date only 9% had serial negative C. auris surveillance cultures. Sixty-two percent were known to be deceased.

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We also get this overview overview from the Miami-Dade Florida Department of Health's March Epi Monthly report (excerpts below).

Candida auris: An Emerging Global Health Threat

By: Sebastian Arenas

Introduction
 
Candida auris is an emerging fungus that presents a serious global health threat. The concern is based on three main reasons: multidrug resistance, frequent misidentification, and potential to cause outbreaks in health care settings.

C. auris was first isolated in Japan and described as a new species in 2009. Subsequently, it was later isolated from patients in South Korea, Kuwait, South Africa, and Venezuela. Cases in the United States are a result of introduction by patients with international health care exposures where C. auris has been reported or as a result of local spread after such an introduction.

Most cases in the U.S. have been detected in recent years in New York, Illinois, and New Jersey with a total of 561 confirmed cases. As of March 29, 2019, Florida has 12 confirmed cases based on the latest tracking data from the Centers for Disease Control and Prevention (CDC). 1

How Serious is C. auris?

C. auris has been isolated most frequently from hospitalized patients and can be fatal; more than 1 in 3 patients with invasive C. auris infections die. 2 The patients with the highest risk for colonization and/or infection are those with prolonged hospitalizations, tracheostomy and ventilator dependence, intensive care unit admissions, indwelling devices (e.g., central lines, peg tubes), recent surgeries, and immunosuppression. 3

Furthermore, C. auris has demonstrated multidrug resistance properties worldwide, which has not been seen in other Candida species. 3 Most infections are treatable with a class of antifungal drugs called echinocandins.

However, some C. auris infections have been resistant to all three main classes of antifungal medications, making them more difficult to treat. 4 In addition, C. auris can be misidentified as a number of different organisms when using identification methods such as VITEK 2 YST, API 20C, BD Phoenix yeast identification system, and MicroScan. 5

An increase in unidentified Candida infections in a patient care unit should raise suspicion for C. auris because of its ability to cause nosocomial outbreaks.

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And finally, some on-topic studies we've looked at previously include:

Candida auris in Healthcare Facilities, New York, USA, 2013–2017

Candida auris in South Africa, 2012–2016

Emerging Fungal Pathogen Candida auris Evades Neutrophil Attack

And some past blogs include:

Notes from the Field: Surveillance for Candida auris — Colombia, September 2016–May 2017)

ECDC: C. Auris Rapid Risk Assessment For Healthcare Settings - Europe

mSphere: Comparative Pathogenicity of UK Isolates of the Emerging Candida auris

Preparedness: Some Emergency Power Solutions

My OLD Solar Power Setup

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The common denominator for most natural disasters (i.e. Hurricanes, Earthquakes, Tornadoes, Blizzards, etc.) is that the electrical grid is likely to take significant damage, and you and your family could be without power for hours, days, or even weeks.

But even without a disaster triggering an outage, our electrical grid often operates at near full capacity, and it is essentially a patchwork quilt of old and new technologies, with some of its vital components older than I am.

Every four years the ASCE (American Society of Civil Engineers) releases a report card on America’s infrastructure, and their latest (2017) grades our cumulative score for infrastructure sits at only a D+, and two of our most vulnerable infrastructures are drinking water and the electrical grid.

They warn:

Overview

Much of the U.S. energy system predates the turn of the 21st century. Most electric transmission and distribution lines were constructed in the 1950s and 1960s with a 50-year life expectancy, and the more than 640,000 miles of high-voltage transmission lines in the lower 48 states’ power grids are at full capacity. Energy infrastructure is undergoing increased investment to ensure long-term capacity and sustainability; in 2015, 40% of additional power generation came from natural gas and renewable systems.

Without greater attention to aging equipment, capacity bottlenecks, and increased demand, as well as increasing storm and climate impacts, Americans will likely experience longer and more frequent power interruptions.

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Living as I do in Hurricane Country, I may be at greater risk of prolonged outages than others, but no one is immune.  A point made quite clear last year by NIAC (National Infrastructure Advisory Council) in their 94-page report NIAC: Surviving A Catastrophic Power Outage.

https://www.hsdl.org/?view&did=819354

While a short-term outage can be little more than an inconvenience - assuming you don't rely on electrically powered medical devices - after a few hours sitting in the dark, having some sort of emergency power back up in your home may start to have some appeal. 

If you want to run A/Cs, refrigerators, big screen TV, and heating systems, you'll need to invest thousands for a professionally installed system.  But if you want a way to run some LED lights and a fan or two - and charge your phone, tablet, or laptop - then solutions can be had for less than $100. 

Some can be bought off the shelf, while others - if you are the least bit handy and familiar with batteries and basic electrical wiring - can be cobbled together as a home brew project.

But Fair Warning:

Batteries can off-gas Hydrogen gas, which can be explosive, and should be kept in a ventilated area. You will also need to check the electrolyte levels of the batteries and keep the plates covered with distilled water.

Solar panels, batteries, and inverters produce electrical currents and (even at low voltages) can be a dangerous shock hazard.  Always read and follow the instructions that come with your solar panels, batteries, chargers, and inverters.

If you are unsure of how to safely deal with these components, have someone who knows how give you instruction.

The first, easiest, and least expensive option is to buy one or more solar powered USB batteries (see below). While the most limited in terms of what they can power (and for how long), these are ideal for those who need a light weight bug-out friendly solution, or for anyone who isn't comfortable with the more complex systems that follow.

Battery, Solar Panel, Fan & Light - About $50.

A 10,000 milliamp battery with (3 fold) solar panel, a USB fan, and USB LED light. The beauty of this system is it will fit in a bug out bag, weighs about 2 lbs, and while the solar charging will be slow and you'll have to be judicious with their use, it should keep phones, lights, Tablets, MP3 players, and fans going for a few days.  Longer if you don't need the fan.

 

(Note: Newer products now have 20,000 and 25,000 milliamp batteries and larger (4 fold) solar panels)

  
While some assembly is required, a step up can be had for roughly $100, that - when combined with a small solar panel ($25 to $80) - can substantially increase what you can do.

Unlike the above solution, this package will provide 5v USB power, plus 12 volt DC and 120 volt AC. With this you can charge laptops, run larger fans, small DVD players, and other charging devices.

Although a full sized deep cycle battery can be used, to save my aching back I've elected to go with smaller, lighter, and less expensive lawn mower batteries. I built two, which allow me to charge one (using a solar panel), while I draw power from the other.

Note:  Solar power purists right now are probably foaming at the mouth, as the standard lead-acid batteries I'm using are not ideal for this type of system. And if I were designing a permanent off-grid system, I would agree. But this is for emergency standby power, not long-term use, and so I've elected to go with the most accessible, and least expensive options.

The beauty of this system is I keep both batteries fully charged using an $8 trickle charger. I switch the charging from one battery to the other every few days. That way, i don't have to hook it up to a solar panel until the power goes out. 

I keep these on a shelf on my (well ventilated) screened lanai and check the water levels every few weeks.  In two years, I've added distilled water once. 

Small (10 watt to 20 watt) solar panels can be had for under $40, which should be adequate for the smaller batteries. If you go with the bigger deep cycle batteries, consider getting a bigger panel with a charge controller.

If your solar panel is larger than 15 watts, you'll want to add a solar panel charge controller. These run $15 and up, and can prevent overcharging of your batteries. If you use a smaller  solar panel, they are generally not necessary.

And lastly, while far less portable and more expensive, you may want to consider a bigger more permanent solar setup, with multiple solar panels and/or batteries. Living aboard a sailboat, I depended upon this sort of a setup for years.

While still within the abilities of many do-it-yourself types, once you get to this stage, you might want to avail yourself of professional advice and go with better components (batteries, controllers, and panels).

If all you want is to be able to charge your phone, run some LED lights, and maybe a fan or two, then a self-contained Solar USB battery solution for about $50 may be adequate for you needs. 

If you want do more - like run a CPAP machine or laptop - you'll have to pay a bit more, but you should be able to cobble together a pretty good system for between $120 and $200.

Either way, it beats cursing the darkness.

WHO: IHR Committee Decides Ebola Outbreak In The DRC Is Not Currently A PHEIC

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In a press conference (which is still ongoing) the WHO's IHR Committee has announced their decision not to designate the Ebola outbreak in the DRC as a PHEIC (Public Health Emergency of International Concern).

This is the third time (see HERE and HERE) that the IHR Committee has met on Ebola in the DRC since the current outbreak began last August, and the third time the committee has declined to elevate the crisis to a PHEIC.

• 2014 Polio Declaration
• 2014 West Africa Ebola Outbreak
• 2016 Zika Declaration

The bar for declaring a PHEIC is purposefully set pretty high, as invoking one does have some down sides, particularly in regards to travel and trade for an affected region. 

That said, this decision is going to be highly controversial, since many observers fear the situation is worsening on the ground in the DRC.

The WHO has emailed the IHR Committee's statement to journalists (excerpts  below), and I'll add the link on the WHO website when it goes live.

Statement on the meeting of the International Health Regulations (2005) Emergency Committee for Ebola virus disease in the Democratic Republic of the Congo

on 14 June 2019

The meeting of the Emergency Committee convened by the WHO Director-General under the International Health Regulations (IHR) (2005) regarding Ebola virus disease in the Democratic Republic of the Congo (DRC) took place on Friday, 14 June 2019, from 12:00 to 17:00 Geneva time (CEST).

Context and Discussion

The Committee expressed its deep concern about the ongoing outbreak, which, despite some positive epidemiological trends, especially in the epicentres of Butembo and Katwa, shows that the extension and/or reinfection of disease in other areas like Mabalako, presents, once again, challenges around community acceptance and security. In addition, the response continues to be hampered by a lack of adequate funding and strained human resources.

The cluster of cases in Uganda is not unexpected; the rapid response and initial containment is a testament to the importance of preparedness in neighbouring countries. The Committee commends the communication and collaboration between DRC and Uganda.

At the same time, the exportation of cases into Uganda is a reminder that, as long as this outbreak continues in DRC, there is a risk of spread to neighbouring countries, although the risk of spread to countries outside the region remains low.

The Committee wishes to commend the heroic work of all responders, who continue to work under extremely challenging and stressful conditions. The Committee extensively debated the impact of a PHEIC declaration on the response, possible unintended consequences, and how these might be managed. Differing views were expressed, as the Committee acknowledged that recent cases in Uganda constitute international spread of disease.

1Conclusions and Advice

It was the view of the Committee that the outbreak is a health emergency in DRC and the region but does not meet all the three criteria for a PHEIC under the IHR. While the outbreak is an extraordinary event, with risk of international spread, the ongoing response would not be enhanced by formal Temporary Recommendations under the IHR (2005).

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