Sunday, May 01, 2016

Saudi MOH Announces Primary MERS Case In Hofuf


In May and June of 2015, most of the MERS activity in Saudi Arabia centered around the town of Hofuf (aka `Hafoof’, `Hafuf’, etc.) in the Northeastern part of the country.

What started with a single `primary case - with camel contact' in mid-April grew into a family cluster, and then into a full blown nosocomial outbreak which ran for more than 2 months (see WHO: A Saudi MERS Infographic) infecting dozens.

While sporadic cases were reported well into the fall (see WHO MERS Update: Saudi Arabia – Nov 13th), reports dried up over the winter.  In April, however, we saw two new cases (one symptomatic, one asymptomatic) linked to camel exposure from Hofuf.

Today the Saudi MOH reports another case from Hofuf - linked to camel exposure - in a 55 year old male listed in critical condition.   Additionally, 1 death (in Najran) of previous case is announced.


J. Virology: H5N6 Receptor Cell Binding & Transmission In Ferrets

Flu Virus binding to Receptor Cells – Credit CDC


Until early 2013 the only serious avian flu threat on our radar was HPAI H5N1, which first emerged in 1996, sparked a mini-epidemic in Hong Kong a year later - and then after disappearing for 5 years - resurfaced again in 2003.

By the end of 2006, it had killed millions of birds, infected hundreds of people, and had been detected in more than 60 countries. 

While there were some `also rans' - HPAI and LPAI avian flu subtypes that sparked outbreaks in poultry (H7N7, H7N3, H9N2, H5N2, etc.) -  none were regarded as posing the kind of threat to humans and the poultry industry that H5N1 did.

At least, not until the spring of 2013, when a new  LPAI H7N9 virus emerged in Eastern China.   Asymptomatic in birds, it nonetheless produced serious illness in humans, and in its first three years has nearly caught up with H5N1 in terms of human cases and deaths. 

Over the 12 months, China would see three other important avian flu viruses emerge; H10N8, H5N8, and H5N6

Since 2013 we've seen the number of avian flu threats explode around the globe, and new incarnations, clades, and subtypes continue to emerge.

Admittedly H5N6 has nowhere near the track record of H5N1 or H7N9, but virus continues to spread in China, has infected at least a dozen people (causing serious illness or death), and may eventually move beyond China's borders.

All of which makes it important we watch for any signs of human or mammalian adaptation of the virus. Avian adapted flu viruses bind preferentially to the alpha 2,3 receptor cells found in the gastrointestinal tract of birds.

While there are some alpha 2,3 cells deep in the lungs of humans, for an influenza to be successful in a human host, most researchers believe it needs to a able to bind to the α2-6 receptor cell found in the upper airway (trachea).  

This week we have a new study (alas, behind a pay wall) that looks at four H5N6 isolates collected from Chinese waterfowl in 2013-2014, and finds them not only
`fully infective and highly transmissible by direct contact in ferrets', but that they also have a `high affinity' to binding to human α2-6 receptor cells.

J Virol. 2016 Apr 27. pii: JVI.00127-16. [Epub ahead of print]
Highly pathogenic avian influenza H5N6 viruses exhibit enhanced affinity for human type sialic acid receptor and in-contact transmission in model ferrets.


Since May 2014, highly pathogenic avian influenza (HPAI) H5N6 virus has been reported to cause six severe human infections three of which were fatal. The biological properties of this subtype, in particular its relative pathogenicity and transmissibility in mammals are not known. We characterized the virus receptor binding affinity, pathogenicity and transmissibility in mice and ferrets of four H5N6 isolates derived from waterfowl in China from 2013-2014. 

All four H5N6 viruses have acquired binding affinity for human-like SAα2,6Gal linked receptor to be able to attach to human tracheal epithelial and alveolar cells. The emergent H5N6 viruses, which share high sequence similarity with the human isolate A/Guangzhou/39715/2014 (H5N6), were fully infective and highly transmissible by direct contact in ferrets but showed less severe pathogenicity in comparison with their parental H5N1 virus. The present results highlight the threat of emergent H5N6 viruses to poultry and human health and the need to closely track their continual adaptation in humans.
Extended epizootics and panzootics of H5N1 viruses have led to the emergence of the novel clade of H5 virus subtypes including H5N2, H5N6 and H5N8 reassortants. Avian H5N6 viruses from this clade have caused three fatalities out of six severe human infections in China since the first case in 2014. However, the biological properties of this subtype, especially the pathogenicity and transmission in mammals are not known. 

 Here, we found that natural avian H5N6 viruses have acquired high affinity for human-type virus receptor. In comparison with parental clade 2.3.4 H5N1 virus, emergent H5N6 isolates showed less severe pathogenicity in mice and ferrets, but acquired efficient in-contact transmission in ferrets. These findings suggest that the threat of avian H5N6 viruses to humans should not be ignored.

Copyright © 2016, American Society for Microbiology. All Rights Reserved.

Although a binding to human α2-6 receptor cells is considered the biggest single obstacle for an avian virus to overcome in order to successfully jump to humans – it isn’t the only one.
Avian viruses also typically replicate best at the higher temperatures found in birds, and would need to adapt to the lower (roughly 33C) normally found in the upper human respiratory tract.

There are other factors – some we know about, others we don’t – that must come in sync to allow an avian virus to become a `humanized' virus.

While H5N6 may not be the virus that pulls all of this together, the growing constellation of HPAI avian viruses in the wild increases the odds that someday one of them will.

Saturday, April 30, 2016

Saudi MOH Reports 1 MERS Case In Hail


After going 6 days without a reported MERS infection, the Saudi MOH wraps up the month of April with their 15th notification - that of a 70 year-old male from Hail listed in critical condition.  

The source of his exposure is still under investigation.

MMWR: Ongoing Zika Virus Transmission - Puerto Rico

Credit MMWR


The news late yesterday afternoon of the first Zika death in a United States territory - while garnering a lot of press coverage - is far from unexpected.

Zika, like West Nile Virus and Chikungunya, has often been described as `rarely fatal', but last year West Nile Virus killed 119 Americans, and in 2015 PAHO reported 73 CHKV deaths in the Americas.
Both are likely under counts. And while rare in comparison to the hundreds of thousands of those mildly affected, fatal outcomes do occur.

This same (rare) pattern is expected with the Zika virus, particularly among the elderly, or in those with comordbidities or compromised immune systems.

While the greatest threat from the Zika virus remains to the developing fetus - for an unlucky few serious, and sometimes fatal complications such as Guillain-Barré syndrome (GBS) , Encephalitis, or Myelitis are possible.

This first death - which occurred back in February and was listed as due to severe thrombocytopenia - was announced in an Early Release MMWR published yesterday afternoon  that updates the epidemiology and public health response to the ongoing Zika epidemic in Puerto Rico, from November 1, 2015–April 14, 2016.  

During the first five and a half months, public health authorities screened  6,157 specimens, and validated 683 (11%) as laboratory confirmed Zika infections. The most frequently reported signs and symptoms were rash (74%) and myalgia (68%), with headache, fever, and arthralgia all reported in 63% of cases.

First, the MMWR summary, followed by the link to and some excerpts from the full report.  Follow the link to read the report in its entirety.


What is already known about this topic?
 Zika virus transmission in Puerto Rico has been ongoing, with the first patient reporting symptom onset in November 2015. Zika virus infection is a cause of microcephaly and other severe birth defects. Zika virus infection has also been associated with Guillain-Barré syndrome.

What is added by this report?
 During November 1, 2015–April 14, 2016, a total of 6,157 specimens from suspected Zika virus–infected patients from Puerto Rico were evaluated and 683 (11%) had laboratory evidence of current or recent Zika virus infection. The public health response includes increased capacity to test for Zika virus, preventing infection in pregnant women, monitoring infected pregnant women and their fetus for adverse outcomes, controlling mosquitos, and assuring the safety of blood products.

What are the implications for public health practice?
 Residents of and travelers to Puerto Rico should continue to employ mosquito bite avoidance behaviors, take precautions to reduce the risk for sexual transmission, and seek medical care for any acute illness with rash or fever. Clinicians who suspect Zika virus disease in patients who reside in or have recently returned from areas with ongoing Zika virus transmission should report cases to public health officials.

 Emilio Dirlikov, PhD1,2; Kyle R. Ryff, MPH1; Jomil Torres-Aponte, MS1; Dana L. Thomas, MD1,3; Janice Perez-Padilla, MPH4; Jorge Munoz-Jordan, PhD4; Elba V. Caraballo, PhD4; Myriam Garcia5,6; Marangely Olivero Segarra, MS5,6; Graciela Malave5,6; Regina M. Simeone, MPH7; Carrie K. Shapiro-Mendoza, PhD8; Lourdes Romero Reyes9; Francisco Alvarado-Ramy, MD10; Angela F. Harris, PhD11; Aidsa Rivera, MSN4; Chelsea G. Major, MPH4,12; Marrielle Mayshack1,12; Luisa I. Alvarado, MD13; Audrey Lenhart, PhD14; Miguel Valencia-Prado, MD15; Steve Waterman, MD4; Tyler M. Sharp, PhD4; Brenda Rivera-Garcia, DVM1 (View author affiliations)
View suggested citation

Zika virus is a flavivirus transmitted primarily by Aedes species mosquitoes, and symptoms of infection can include rash, fever, arthralgia, and conjunctivitis (1).* Zika virus infection during pregnancy is a cause of microcephaly and other severe brain defects (2). Infection has also been associated with Guillain-Barré syndrome (3). In December 2015, Puerto Rico became the first U.S. jurisdiction to report local transmission of Zika virus, with the index patient reporting symptom onset on November 23, 2015 (4). 



Zika virus remains a public health challenge in Puerto Rico, and cases are expected to continue to occur throughout 2016. Building upon existing dengue and chikungunya virus surveillance systems, PRDH collaborated with CDC to establish a comprehensive surveillance system to characterize the incidence and epidemiology of Zika virus disease on the island. Expanded laboratory capacity and surveillance provided timely availability of data, allowing for continuous analysis and adapted public health response. Following CDC guidelines, both symptomatic and asymptomatic pregnant women are tested for evidence of Zika virus infection. 

Information from the Zika Active Pregnancy Surveillance System will be used to raise awareness about the complications associated with Zika virus during pregnancy, encourage prevention through use of mosquito repellent and other methods, and inform health care providers of the additional care needed by women infected with Zika virus during pregnancy, as well as congenitally exposed fetuses and children. In addition, the prevalence of adverse fetal outcomes documented through this system can be compared with baseline rates as further evidence of associations between Zika virus infections and adverse outcomes, such as microcephaly (2).

The finding that women constitute the majority of cases might be attributable to targeted outreach and testing. The most common symptoms among Zika virus disease cases were rash, myalgia, headache, fever, and arthralgia, which are similar to the most common signs and symptoms reported elsewhere in the Americas (9). Although Zika virus–associated deaths are rare (10), the first identified death in Puerto Rico highlights the possibility of severe cases, as well as the need for continued outreach to raise health care providers’ awareness of complications that might lead to severe disease or death. To ensure continued blood safety, blood collection resumed with a donor screening program for Zika virus infection, and all units screened positive are removed.

Residents of and travelers to Puerto Rico should continue to employ mosquito bite avoidance behaviors, including using mosquito repellents, wearing long-sleeved shirts and pants, and ensuring homes are properly enclosed (e.g., screening windows and doors, closing windows, and using air conditioning) to avoid bites while indoors.††† To reduce the risk for sexual transmission, especially to pregnant women, precautions should include consistent and proper use of condoms or abstinence (5). Such measures can also help avoid unintended pregnancies and minimize risk for fetal Zika virus infection (6). Clinicians who suspect Zika virus disease in patients who reside in or have recently returned from areas with ongoing Zika virus transmission should report cases to public health officials.

Friday, April 29, 2016

A Repellent Argument


While the CDC, the media, and most of the residents of the lower 48 states wait to see how much of an impact the Zika virus will have this summer in the U.S., it is worth noting that last summer - during just a moderately active year  - we saw more than 1,300 hospitalizations and 119 deaths from the West Nile Virus.

While only about 20% of the people who are infected with WNV develop symptoms – and most only experience a mild flu-like illness (and are therefore rarely counted)  – a very small percentage go on to develop a more severe, and sometimes deadly, `neuroinvasive’ form of WNV.

The CDC summarized last year's WNV activity:

As of January 12, 2016, a total of 48 states and the District of Columbia have reported West Nile virus infections in people, birds, or mosquitoes in 2015.
Overall, 2,060 cases of West Nile virus disease in people have been reported to CDC. Of these, 1,360 (66%) were classified as neuroinvasive disease (such as meningitis or encephalitis) and 700 (34%) were classified as non-neuroinvasive disease.

Bad, but not as bad as 2012. where we saw :  

A total of 5,674 cases of West Nile virus disease in people, including 286 deaths, were reported to CDC. Of these, 2,873 (51%) were classified as neuroinvasive disease (such as meningitis or encephalitis) and 2,801 (49%) were classified as non-neuroinvasive disease. 

On top of that, each year we usually see a smattering of EEE (Eastern Equine Encephalitis) cases, along with some La Crosse virus (LACV), Jamestown Canyon virus (JCV) and St. Louis Encephalitis (STLV) infections. Small outbreaks of Dengue and Chikungunya are even possible.

And we haven't even touched on the tick borne infections, like Lyme Disease, which the CDC estimates may affect as many as 300,000 Americans every year

The CDC maintains a long (and growing) list of of tick spread pathogens found in North America, including:
Anaplasmosis, Babesiosis, Borrelia miyamotoi, Colorado tick fever, Ehrlichiosis, Heartland virus, Lyme disease, Powassan disease, Rickettsia parkeri rickettsiosis ,Rocky Mountain spotted fever (RMSF), STARI (Southern tick-associated rash illness)Tickborne relapsing fever (TBRF), Tularemia,364D rickettsiosis 

To this growing rogues gallery, we recently added Borrelia mayonii, which has recently been discovered to be causing a Lyme-like illness in Minnesota and Wisconsin (see CDC: New Lyme-Disease-Causing Bacteria Species Discovered).

To this Florida boy who spent a lot of time in the woods camping and hiking (often without repellents) - and who saw nary a tick or chigger bite in all those years (mosquitoes, yes) - all of this seems a bit surreal.  

Although it seems counter-intuitive, in our increasingly urbanized and modernized society the threat of vector-borne diseases has grown greater over the past couple of decades, as has our need to take steps to prevent them.

With summer-like weather either here or on the way, now is the time to consider how you will protect yourself and your family members from these vector borne threats.

For mosquitoes, health departments advise you follow the 5 D's. 


While the CDC recommends for ticks:

Avoid Direct Contact with Ticks

  • Avoid wooded and brushy areas with high grass and leaf litter.
  • Walk in the center of trails.

Repel Ticks with DEET or Permethrin

  • Use repellents that contain 20 to 30% DEET (N, N-diethyl-m-toluamide) on exposed skin and clothing for protection that lasts up to several hours. Always follow product instructions. Parents should apply this product to their children, avoiding hands, eyes, and mouth.
  • Use products that contain permethrin on clothing. Treat clothing and gear, such as boots, pants, socks and tents with products containing 0.5% permethrin. It remains protective through several washings. Pre-treated clothing is available and may be protective longer.
  • Other repellents registered by the Environmental Protection Agency (EPA).

Find and Remove Ticks from Your Body

  • Bathe or shower as soon as possible after coming indoors (preferably within two hours) to wash off and more easily find ticks that are crawling on you.
  • Conduct a full-body tick check using a hand-held or full-length mirror to view all parts of your body upon return from tick-infested areas. Parents should check their children for ticks under the arms, in and around the ears, inside the belly button, behind the knees, between the legs, around the waist, and especially in their hair.
  • Examine gear and pets. Ticks can ride into the home on clothing and pets, then attach to a person later, so carefully examine pets, coats, and day packs.
  • Tumble clothes in a dryer on high heat for an hour to kill remaining ticks. (Some research suggests that shorter drying times may also be effective, particularly if the clothing is not wet.)
To help you decide on a repellent, the EPA has created an interactive insect repellent search engine that will allow you to input your needs and it will spit out the best ones for you to use.

While the old school vector borne illnesses like Lyme Disease, Ehrlichiosis, or WNV may not inspire the same kind of fear and media coverage as Zika, they are nothing to take lightly, and in many cases can be avoided by taking a few simple precautions.

While Zika will likely get star billing, we'll be following all of these vector borne diseases all summer long in AFD.


Wisconsin: Infant At Children's Hospital Tests Positive For Elizabethkingia


For the past two months we've been following a multi-state community outbreak of Elizabethkingia bacterial infection among mostly elderly residents in Wisconsin, Illinois and Michigan. 

Although it isn't immediately clear whether this is connected to the larger outbreak we've been following - or is even the same strain - overnight local media are reporting an Elizabethkingia infection in an infant at the neonatal unit of Children's Hospital. 

The genus Elizabethkingia includes not only E. Anophelis , but also  E. meningoseptica,  E. miricola, and E. endophytica. Most cases in the literature have involved HAI's (Hospital Acquired Infections), and community outbreaks are rare. 

This from the Milwaukee News. 

Updated: Yesterday 10:15 p.m.
A strain of the Elizabethkingia bacteria has been found in an infant being treated in the neonatal intensive care unit at Children's Hospital of Wisconsin, the hospital confirmed Thursday.

It appears to be the first case involving a child in what has become the largest known outbreak of its kind in the country.

To date, 18 people have died, most of them over the age of 65. All had severe chronic conditions, such as cancer, renal disease, cirrhosis and diabetes.

Children's Hospital said there was no indication that the child's infection is serious, and that no additional precautions are necessary because the bacteria is not easily transmitted from person to person.

(Continue . . . )

Hopefully we'll get a clarification on this case in the next few days.  In the meantime, the latest Wisconsin DOH update adds two additional cases.

Wisconsin 2016 Elizabethkingia anophelis outbreak

The Wisconsin Department of Health Services (DHS), Division of Public Health (DPH) is currently investigating an outbreak of bacterial infections caused by Elizabethkingia anophelis.

The majority of patients acquiring these infections are over 65 years old, and all patients have a history of at least one underlying serious illness.

The Department quickly identified effective antibiotic treatment for Elizabethkingia, and has alerted health care providers, infection preventionists and laboratories statewide. Since the initial guidance was sent on January 15, there has been a rapid identification of cases and healthcare providers have been able to treat and improve outcomes for patients. DHS continues to provide updates of outbreak-related information that includes laboratory testing, infection control and treatment guidance.

At this time, the source of these infections is still unknown, and the Department continues to work diligently to control this outbreak.  Disease detectives from the Department and the Centers for Disease Control and Prevention (CDC) are conducting a comprehensive investigation which includes:

  • Interviewing patients with Elizabethkingia anophelis infection and/or their families to gather information about activities and exposures related to healthcare products, food, water, restaurants, and other community settings.
  • Obtaining environmental and product samples from facilities that have treated patients with Elizabethkingia anophelis infections. To date, these samples have tested negative and there is no indication the bacteria was spread by a single healthcare facility.
  • Conducting a review of medical records.
  • Obtaining nose and throat swabs from individuals receiving care on the same units in health care facilities as a patient with a confirmed Elizabethkingia anophelis to determine if they are carrying the bacteria.  To date, all of these specimens tested negative, which suggests the bacteria is not spreading from person to person in healthcare settings.
  • Obtaining nose and throat swabs from household contacts of patients with confirmed cases to identify if there may have been exposure in their household environment.
  • Performing a “social network” analysis to examine any commonalities shared between patients including healthcare facilities or shared locations or activities in the community.


Affected counties include Columbia, Dane, Dodge, Fond du Lac, Jefferson, Milwaukee, Ozaukee, Racine, Sheboygan, Washington, Waukesha and Winnebago.

There have been 18 deaths among individuals with confirmed Elizabethkingia anophelis infections and an additional 1 death among possible cases for a total of 19 deaths. It has not been determined if these deaths were caused by the infection or other serious pre-existing health problems. Counties where these deaths occurred are: Columbia, Dodge, Fond du lac, Milwaukee, Ozaukee, Racine, Sheboygan, Washington and Waukesha.

*This investigation is ongoing. Case counts may change as additional illnesses are identified and more cases are laboratory confirmed.
**These are cases that tested positive for Elizabethkingia, but will never be confirmed as the same strain of Elizabethkingia anophelis because the outbreak specimens are no longer available to test.