Saturday, August 30, 2014

PAHO/WHO: Epidemiological Alert On Chikungunya & Dengue In the Americas




# 9020


While Ebola garners the bulk of the headlines, other serious disease threats like Chikungunya and Dengue continue their inexorable spread across the globe, infecting hundreds of times more people than does Ebola, albeit with a far lower morality rate.   


For 2013, PAHO provides the following assessment for Dengue in the Americas:


In 2013, dengue behaved like a classic epidemic for the Americas region, with the largest historical cases reported. In total, countries in the Americas reported more than 2.3 million cases of dengue, with 37,692 cases of severe dengue and 1,280 deaths, for a mortality rate of about 0.05%.


This year, for the first time, the Americas are also dealing with Chikungunya – which arrived late last fall in the Caribbean, and has spread rapidly since then.  PAHO’s most recent report (Week 34) indicates just over 650,000 CHKV infections in the Americas, and 37 deaths.



The arrival of Chikungunya to the Americas has been anticipated for some time, and the CDC & PAHO produced a 161 page guide on preparing for its arrival 3 years ago (see Preparedness and Response for Chikungunya Virus Introduction in the Americas).


Last May, in Florida Prepares For Chikungunya we looked at local preparations for its arrival.  Given its climate, its position as the gateway to the Caribbean, and that it receives millions of tourists every year -  Florida was considered a likely first US battleground against any CHKV invasion.  


And indeed, the first first locally acquired case in Florida was reported in July.


For now, the major concern is in the Caribbean, Central & South America where both Dengue and CHKV co-circulate, and where the burden of these diseases is infinitely higher than it is in the United States. As the height of the Dengue season generally occurs in the second half the year, the next few months are considered a critical time for mosquito control programs.


Yesterday PAHO and the World Health Organization released an 8-page PDF Epidemiological Alert for the Americas on these co-circulating mosquito-borne diseases.  Follow the link to read the entire document:


Epidemiological Alert

Chikungunya & Dengue Fever In the Americas

29 August 2014

Situation summary

The first evidence of autochthonous chikungunya transmission in the Americas was recorded in December 2013, since then, autochthonous transmission has been detected in 33 countries and territories of the Americas (27 countries and territories in the Caribbean, 3 countries in Central America, 1 country and 1 territory in South America and 1 country in North America).1,2 As of epidemiological week (EW) 35 of 2014, the Pan American Health Organization / World Health Organization (PAHO/WHO) has been informed of a total of 659,367 cases, including 37 deaths, in the Americas.

Usually during the second semester of the year, Central America, Mexico and the Caribbean experience a seasonal increase in dengue fever transmission. Currently, the Dominican Republic, El Salvador, Guatemala, and Honduras, are recording increases in cases coinciding with this period of greater transmission.

The threats posed by the seasonal increase of dengue transmission and the introduction, or risks of introduction of the chikungunya virus in the Region require an integrated approach of prevention and vector control activities of both diseases. With the rapid spread of the chikungunya virus observed in some countries of the Americas, simultaneous dengue and chikungunya outbreaks may occur, which would result in increased health care demand. Accordingly, health care services must be prepared to meet expected increased demand without compromising quality of care; preparations should be guided by the PAHO/WHO recommendations for clinical management of patients with dengue or chikungunya.

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With the rapid expansion of both Dengue and Chikungunya around the globe, Europe and the United States are seeing signifcant increases in the number of imported cases every year – each with at least the potential to seed local mosquito populations with the virus. So far locally acquired infections in both regions remain relatively rare.


The lack of an abundant non-human animal reservoir for the virus is likely partly responsible. But in 2003, a CDC EID study also found that economics and lifestyle may have a lot to do to with our lack of locally transmitted Dengue (see Texas Lifestyle Limits Transmission of Dengue Virus).


But given the availability of two competent mosquito vectors (Aedes Aegypti & Aedes Albopictus), and repeated introductions of the virus from travelers coming from regions where the virus is endemic, our luck in this matter may not last forever.


The good news is that these mosquito-borne illnesses (and others, including WNV, SLEV, EEE, etc.) are largely preventable.


Florida’s Health department reminds people to always follow the `5 D’s’:


Referral: Mackay On The Expansion Of Ebola Into Senegal


Credit Dr. Ian Mackay VDU Blog


# 9019


In his blog overnight, Dr. Ian Mackay adds Senegal to his Ebola outbreak map, and makes an important point about the uniqueness of each disease outbreak, the human variables that drive them, and the danger of assuming that the public health responses of the past will always suffice in the future.


First a link to Ian’s blog, then I’ll be back with a comment.


The fifth I give you...


According to it's Minister of Health, Awa Marie Coll Seck [1,2], a case of Ebola virus disease (EVD) has been imported from Guinea and it is confirmed by testing at the World Health Organization's collaboration Centre, the Pasteur Institute in Dakar.

Interesting that this occurred one week after Senegal closed its borders (again) with Guinea.[3,4] The infected Guinean student travelled on 29-August to Dakar where he presented to a hospital but did not admit to being in contact with known EVD cases. Senegal had closed its borders around 22-August.[5,6].


(Continue . . . )



After forty years of outbreaks – all of which were geographically limited and comparatively small – Ebola had gained the reputation of being a horrific killer – but basically only of `local concern’


Conventional wisdom said that it killed too quickly to allow those infected to spread the disease far. The virus simply didn’t have the `legs’ to spark a major outbreak.


Fast forward to 2014, and those assumptions are taking it on the chin.  Not because the virus has changed, but because Africa has changed (a major point made in Michael Osterholm’s WaPo Article  Aug. 1st).  


Remote villages aren’t nearly as remote as they once were. Cars, busses, trains, even airplanes are far more common today in Africa than they were in 1976 when the virus was first detected.  Society is more mobile today than ever before, and that applies to just about everywhere on this planet.


The world was caught flat-footed in its initial response to this Ebola outbreak – no doubt lulled by earlier successes in containing the virus -  and that has allowed it to spread unchecked. Given its lack of `airborne’ transmission, I fully expect it will eventually be brought under control, albeit at a terrible cost. 


The takeaway lesson here goes beyond Ebola, and well beyond the continent of Africa.


As the world changes, so do the capabilities of its pathogens. A side effect of modern society is that it has become the great enabler of infectious disease.  A novel virus or resistant bacteria can hitch a ride in New Delhi or Shanghai this morning and can be in London, or New York by tonight.


Which means that we no longer have the luxury of ignoring `small disease outbreaks’  anywhere in the world, no matter how remote. 


Because the next pathogen to crawl out of the woodwork may be far more `pandemic-ready’  than Ebola could ever be. 

Friday, August 29, 2014

Nature: 100% Of Ebola Infected Macaques Recovered With ZMapp




# 9018



The wires are buzzing this afternoon with details on a freshly published study in the Journal Nature that looks at the outcome of 21 Ebola-infected Rhesus Macaques – 18 of which received the ZMapp monoclonal antibody cocktail. Incredibly, 100% of the treated monkeys – even those treated 5 days post exposure and already symptomatic – recovered.


First a link to the study, then I’ll be back with more.


Reversion of advanced Ebola virus disease in nonhuman primates with ZMapp

Xiangguo Qiu, Gary Wong, Jonathan Audet, Alexander Bello, Lisa Fernando, Judie B. Alimonti, Hugues  Fausther-Bovendo, Haiyan Wei, Jenna Aviles, Ernie Hiatt, Ashley Johnson, Josh Morton,  Kelsi Swope, Ognian Bohorov, Natasha Bohorova, Charles Goodman, Do Kim, Michael H. Pauly, Jesus Velasco, James Pettitt, Gene G. Olinger, Kevin Whaley, Bianli Xu, James E. Strong, Larry Zeitlin et al.

 (2014) doi:10.1038/nature13777

Published online 29 August 2014


Without an approved vaccine or treatment, Ebola outbreak management has been limited to palliative care and barrier methods to prevent transmission. These approaches, however, have yet to end the 2014 outbreak of Ebola after its prolonged presence in West Africa. Here we show that a combination of monoclonal antibodies (ZMapp), optimized from two previous antibody cocktails, is able to rescue 100% of rhesus macaques when treatment is initiated up to 5 days post-challenge. High fever, viraemia and abnormalities in blood count and blood chemistry were evident in many animals before ZMapp intervention. Advanced disease, as indicated by elevated liver enzymes, mucosal haemorrhages and generalized petechia could be reversed, leading to full recovery. ELISA and neutralizing antibody assays indicate that ZMapp is cross-reactive with the Guinean variant of Ebola. ZMapp exceeds the efficacy of any other therapeutics described so far, and results warrant further development of this cocktail for clinical use.

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Quite simply, a remarkable success rate by any measure. And while you can’t guarantee you’d see the same kind of results in human patients, it is highly encouraging.


That said, this news must also be tempered by fact that the existing limited supply of ZMapp has been exhausted, and it is expected that it will take weeks or even months to produce even a small quantity of the drug.


A pair of reports on this from two of the best science writers in the business. First this from Maggie Fox of NBC news.


ZMapp Saves Sick Monkeys From Ebola, Study Finds

By Maggie Fox

An experimental treatment used to treat two sick American missionaries saved a batch of monkeys infected with Ebola virus, even days after they got sick, researchers reported on Friday.

What works in monkeys doesn’t always work in humans, but it’s a piece of good news for the makers of ZMapp, a cocktail of engineered antibodies meant to boost the body’s defenses against the virus. ZMapp, made by California-based Mapp Biopharmaceutical, is grown in tobacco plants and is meant to improve on an old-fashioned approach that uses transfusions of blood from people who have survived an infection.

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And this from Helen Branswell of the Canadian Press.


Winnipeg lab created, tested Ebola drug ZMapp

By Helen Branswell The Canadian Press

 TORONTO – The experimental Ebola drug ZMapp was able to save infected monkeys even when treatment was only begun five days after the animals were infected, a new study shows.

This is the first research to demonstrate that an Ebola therapy could save primates if given so late in the course of their illness — a circumstance that more closely reflects how an Ebola drug would be used in people in an outbreak.

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For more on ZMapp you may wish to revisit  CDC FAQ On Experimental Ebola Treatments & Vaccine Development.

Senegal Reports 1st Imported Case Of Ebola


UPDATED: 10:00 Hrs EDT


The AP is now reporting this patient is a young man who appears to have been the subject of epidemiological surveillance team who were doing contact tracing of Ebola cases in Guinea, but he evaded them and crossed the border into Senegal. 

The patient sought medical care earlier this week in Dakar after falling ill, and told doctors he’d had contact with Ebola cases. His tests have come back positive for the virus and the WHO have been notified. 



# 9017



Senegal, which last week Closed its Border With Guinea Over Ebola Concerns, is reporting this morning an important case in a visitor from Guinea. Details at this time are scant,  and I’ve found nothing posted on the Senegalese Ministry Of Health website.

Gert van der Hoek on Flutrackers has translated article from PressAfrik


Urgent - the Senegal recorded his first Ebola case

This is confirmed Senegal recorded its first case of Ebola patient. This is a Guinean national who is on vacation on our soil. He is currently detained at the Department of Infectious Diseases Fann. The Minister of Health, Awa Marie Coll Seck will soon give the details of this unfortunate news.

(Continue . . .)

The following report from Reuters is fairly representative of what is currently in the English press.


First case of Ebola confirmed in Senegal - health minister

Fri Aug 29, 2014 12:31pm GMT


DAKAR Aug 29 (Reuters) - The first case of Ebola has been confirmed in Senegal, a major hub for the business and aid community in West Africa, Health Minister Awa Marie Coll Seck told a news conference on Friday.

The minister said the case was a Guinean national who had arrived from the neighbouring West African country, where the deadly virus was first detected in March. (Reporting by Diadie Ba; Writing by Daniel Flynn; Editing by Emma Farge)

I’ll update this story as more information comes in.

WHO: Ebola Response Roadmap Situation Report # 1


# 9017


This morning the World Health Organization has released as 7 page PDF SitRep (Situation Report) on the Ebola Outbreak in Western Africa.   This comes one day after releasing their Ebola Response Roadmap, which calls for a massive international effort and nearly 500 million dollars to respond to the crisis.


A few excerpts from the report, but follow the link to download and read it in its entirety.



WHO: Ebola Response Roadmap Situation Report 1

29 August 2014


The figures below show the distribution of confirmed and probable cases in each of these countries, accompanied by numbers of cases over time in capital cities.


These data indicate that the reporting of cases in Guinea appears to have been relatively stable, but with a marked increase in the recent week. Priorities continue to be to reduce incidence in the epicentre (Gueckedou), and to address threatening foci in Conakry.



By contrast, in Liberia, cases are increasing in the epicentre (Lofa) and in the capital, Monrovia.



The incidence of cases in Sierra Leone has been relatively flat, although with increases in the past week. Problems in scaling up response measures persist, notably in two districts, Kenema and Kailahun. Numbers of cases increased in the capital, Freetown.


Regarding Nigeria, the news yesterday that two new cases (1 confirmed, 1 suspected) had turned up in Port Harcourt means that containment of the virus has yet to be accomplished.



To date, the only country with cases linked to a case imported from a country with widespread and intense transmission is Nigeria. The table below shows the distribution of cases in that country.


The first 14 confirmed cases were all linked to persons, including health care workers, in close contact with an air traveller from Liberia, who entered Lagos on 20 July and died five days later. On 27 August, 1 additional case was confirmed in Port Harcourt by the Ministry of Health. A Ministry of Health and WHO team is in Port Harcourt supporting contact tracing and further investigation of the incident.


And lastly, a look at some of the response challenges on the ground.


There are serious problems with case management and infection prevention and control. The situation is worsening in Liberia and Sierra Leone.

  • In Guinea, the capacity to manage the current load of EVD cases is currently adequate in Gueckedou and in Conakry.
  • In Liberia, the capacity to cope with the increasing caseload remains dramatically low, especially in the capital, Monrovia, as well as in Bong and Nimba counties.
  • In Nigeria, a 40-bed isolation unit has been set up in the Mainland Hospital, and is sufficient to accommodate the patients currently isolated. The Ministry of Health has set up an isolation unit in Lagos town to care for cases.
  • In Sierra Leone, there is inadequate capacity to accommodate patients in Freetown. Patients must be transferred to Kenema, which is already overwhelmed by local demand.
  • Health care workers continue to be seriously affected in all countries, especially in Liberia and Nigeria.

Laboratory capacity

In Guinea, laboratory capacity currently appears to be sufficient. Support is being provided by the Pasteur Institute Dakar in Conakry, the European Union Mobile Laboratory in Gueckedou, and WHO.

  • In Liberia, specimens from Lofa county are tested in Guinea. Additional laboratory support is needed in Lofa to alleviate this burden. Specimens from other counties far from Lofa are sent to Monrovia, where laboratory capacity, supported by the United States Army Medical Research Institute of Infectious Diseases, US National Institutes of Health, and US Centers for Disease Control and Prevention, is stretched. The need for more laboratory support is being assessed in Bong (Pheebe hospital), Nimba and Bomi counties.
  • In Sierra Leone, additional laboratory support is needed in addition to the Kenema laboratory (supported by Metabiota and the US Department of Defense Critical Reagent Team) to cope with the increasing disease burden. A mobile laboratory from South Africa has been deployed to Freetown, where Ebola treatment centres are being constructed to care for patients locally and in better conditions, rather than referring them to Kenema.
  • In Nigeria, the Lagos University Teaching Hospital virology lab and the Lagos University Laboratory are being supported by WHO and an EU mobile team from the WHO Collaborating Centre in Hamburg, Germany.


Kansas City Outbreak Identified As HEV 68


Credit CDC – Non Polio-Enteroviruses



# 9016


Local media reports (see Unusual respiratory virus strikes metro kids) from Kansas City, Mo. indicate that a rarely seen – and not yet well understood – respiratory virus called HEV 68 (Human Enterovirus 68) has sickened hundreds of kids in the region this week, and that the local Children’s Hospital is unusually at full census in late August.

Without specifying the pathogen, Children’s Mercy Hospital posted the following notice yesterday on their website: Viruses in the Community Prompt Inpatient Visiting Restrictions.


I’ve checked the local and state Health departments but can find no official statement regarding this respiratory outbreak.  Hopefully we’ll get some official confirmation soon, but assuming local media reports are correct . . .


Enteroviruses encompass a large family of small RNA viruses that include the three Polioviruses, along with myriad non-polio serotypes of Human Rhinovirus, Coxsackievirus, echovirus, and human, porcine, and simian enteroviruses.  We’ve looked at EV-71 and the Coxsackieviruses on numerous occasions in regards to AFP (Acute Flaccid Paralysis) and HFMD (see herehere & here).


According to the CDC  Non-Polio Enteroviruses (NPEVs) cause 10 to 15 million – mostly mild and often asymptomatic – infections in the United States each year, primarily among infants, children, and teenagers. Fever, runny nose, sneezing, coughing, a skin rash or mouth blisters, and body and muscle aches are the most commonly reported symptoms.


First isolated in 1962, EV 68 (genus Enterovirus - family Picornaviridae – species HEV-D) has only rarely been identified over the years.  In 2011 – in MMWR: Clusters Of HEV68 Respiratory Infections 2008-2010 – we looked at a half dozen  HV 68 associated clusters which occurred in Asia, Europe, and the United States during 2008--2010.

A few excerpts from that report:


HEV68 infection was associated with respiratory illness ranging from relatively mild illness that did not require hospitalization to severe illness requiring intensive care and mechanical ventilation. Three cases, two in the Philippines and one in Japan, were fatal. In these six clusters, HEV68 disproportionately occurred among children.


This report highlights HEV68 as an increasingly recognized cause of respiratory illness. Clinicians should be aware of HEV68 as one of many causes of viral respiratory disease and should report clusters of unexplained respiratory illness to the appropriate public health agency.


The spectrum of illness caused by HEV68 remains unclear. HEV68, like other enteroviruses, has been associated with central nervous system disease (9). Further investigation could help clarify the epidemiology and spectrum of disease caused by HEV68. Some diagnostic tests might not detect HEV68 or might misidentify it as an HRV


Unlike influenza, classic enteroviruses tend to break out in summer-to-fall, although EV 68 has been observed to occur well into the winter season. The largest outbreak characterized by this MMWR report involved 28 children and adolescents from Pennsylvania in the fall of 2009. 

Since the vast majority of  mild-to-moderate respiratory infections are never tested, the actual incidence of this viral infection isn’t well understood, but it tends to be among the least commonly identified enteroviruses.


In recent years, with advances in microbiology and sequence-independent amplification of viral genomes, the ability of laboratories to identify new or rarely seen viruses has steadily improved, and so it is hard to know whether these recent clusters indicate that the incidence of EV 68 is increasing, or they are a result of better surveillance and testing.


Unlike other enteroviruses which can produce a wide spectrum of respiratory, gastrointestinal, and neurological symptoms – EV 68 is mainly associated with respiratory symptoms – although it was tentatively linked to two of five children (see Acute Flaccid Paralysis Cases In California) who developed a rare polio-like syndrome last winter.


Whether EV-68 was actually the cause of these paralysis cases, or simply an incidental finding, is something that will require more research to establish.


Although there is no vaccine and no specific treatment for this virus, there are things that can be done to protect yourself.  In addition to the standard `flu’ etiquette urged every year (hand washing, covering coughs, sneezes, staying home when sick), the CDC’s recommendations to prevent NPEV transmission include:


You can help protect yourself and others from non-polio enterovirus infections by—

  • Washing your hands often with soap and water, especially after using the toilet and changing diapers,
  • Avoiding close contact, such as touching and shaking hands, with people who are sick, and
  • Cleaning and disinfecting frequently touched surfaces.

According to Dr. Mary Anne Jackson, an infectious disease specialist interviewed yesterday by local media, roughly 10%-15% of the children currently affected in Kansas City are experiencing serious illness, and that it is hitting kids with asthma particularly hard.


With schools just letting in for the fall, we’ll want to keep a close eye on this outbreak to see how it progresses, and if it spreads to other areas of the country.