Study: Intra-Continental Spread of Invasive Non-Typhoidal Salmonella

 

 Salmonella typhimurium bacteria – Credit CDC PHIL

 

 

# 6599

 

You might not think there’d be much of a connection between an emergent serotype of Salmonella and the HIV epidemic in Sub-Saharan Africa - but if researchers from the Wellcome Trust Sanger Institute have it right - this highly pathogenic bacterial strain may have had a powerful viral ally.

 

There are more than 2500 serovars of Non-Typhoidal Salmonella (NTS) that can produce gastroenteritis or other infections in humans. Taken together, these Gram negative, anaerobic bacteria are believed to be the second most common source of food poisoning in the United States.

 

Those infected often develop diarrhea, fever, vomiting, and abdominal cramps that may persist for several days.

 

In the western world most recover without treatment, although the CDC estimates that nearly 400 people infected die each year in the United States (Cite  CDC Food borne Illness Estimates).

 

In developing countries, Non-typhoidal Salmonella can (and does) exact a much higher toll, particularly among those who may be malnourished or suffer from chronic ailments such as malaria and HIV.

 

In recent years researchers have also noted a much more virulent form of NTS, spreading across sub-Saharan Africa, that they’ve dubbed  Invasive Non-Typhoidal Salmonella (iNTS). 

 

Not only is it a multi-drug resistant strain, it is fatal in about 25% of those who contract it.

 

Today, we’ve a study that appears in Nature Genetics that links the Intracontinental spread and evolution of this invasive and severe form of Salmonella to the emergence and spread of HIV.

 

Intracontinental spread of human invasive Salmonella Typhimurium pathovariants in sub-Saharan Africa

Chinyere K Okoro,Robert A Kingsley,Thomas R Connor,Simon R Harris,Christopher M Parry,Manar N Al-Mashhadani,Samuel Kariuki,Chisomo L Msefula,Melita A Gordon,Elizabeth de Pinna,John Wain,Robert S Heyderman,Stephen Obaro,Pedro L Alonso,Inacio Mandomando,Calman A MacLennan, Milagritos D Tapia,Myron M Levine,Sharon M Tennant,Julian Parkhill & Gordon Dougan

Published online 30 September 2012

 

While the bulk of the study is behind a pay wall, the Abstract is available, as is this press release from the Wellcome Trust Sanger Institute.

 

New pathogen epidemic identified in sub-Saharan Africa

Researchers track the spread of human invasive non-Typhoidal Salmonella in sub-Saharan Africa

A new study out today (Sunday 30 September) reveals that the emergence and spread of a rapidly evolving invasive intestinal disease, that has a significant mortality rate (up to 45%) in infected people in sub-Saharan Africa, seems to have been potentiated by the HIV epidemic in Africa.

 

The team found that invasive non-Typhoidal Salmonella (iNTS) disease is caused by a new form of the bacteria Salmonella Typhimurium that has spread from two different focal hubs in Southern and Central Africa beginning 52 and 35 years ago, respectively. They also found that one of the major contributing factors for the successful spread of iNTS was the acquisition of genes that afford resistance to several front line drugs used to treat blood-borne infection such as iNTS.

 

iNTS is a blood-borne infection that kills approximately one of four people in sub-Saharan Africa who catch it. Yet, in the rest of the world, NTS is a leading cause of acute inflammatory diarrhoea that is self-limiting and tends to be fatal in less than 1 per cent of people infected. The disease is more severe in sub-Saharan Africa than the rest of the world because of factors such as malnutrition, co-infection with malaria or HIV and potentially the novel genotype of the Salmonella bacteria.

 

"The immune system susceptibility provided by HIV, malaria and malnutrition at a young age, may provide a population in sub-Saharan Africa that is large enough for this detrimental pathogen to enter, adapt, circulate and thrive," says Chinyere Okoro, joint first author from the Wellcome Trust Sanger Institute. "We used whole genome sequencing to define a novel lineage of Salmonella Typhimurium that is causing a previously unrecognised epidemic across the region. Its genetic makeup is evolving into a more typhoid like bacteria, able to efficiently spread around the human body"

 

<SNIP>

 

"There has been some evidence that this disease can be passed from human to human. Now the race is on to discover how NTS is actually transmitted in sub-Saharan Africa so that effective intervention strategies can be implemented."

 

(Continue . . . )

 

 

And for more on all of this, here’s Debra McKenzie’s article for New Scientist.

 

 

HIV could be turning salmonella nastier

 

18:00 30 September 2012 by Debora MacKenzie

 

A nastier kind of salmonella infection has emerged alongside the HIV epidemic in Africa. The finding is the first evidence that HIV might be allowing new human pathogens to evolve in immunosuppressed people.

 

(Continue . . . )

 

7.1 Magnitude Earthquake Strikes Columbia

 

USGS Real time earthquake monitor

 

NOTE:  USGS now shows the quake to be a 7.3 mag

# 6598

 

A 7.1 magnitude quake struck the southeastern region of Columbia around 12:31 pm EST (16:31 UTC) today - roughly 61km (38mi) SSE of Popayan, Colombia – the capital of of the Columbian department of Cauca, with a population of roughly 250,000 people.

 

The USGS shakemap indicates moderate shaking could have been expected in Popayan and surrounding communities.  This was a deep quake (162 km), and so that may have substantially lessened its impact.

 

 

 

We’ve no word on damage, or injuries as yet. 

The Pacific Tsunami Warning Center has issued a statement saying:

TSUNAMI INFORMATION STATEMENT NUMBER 1 NWS PACIFIC TSUNAMI WARNING CENTER EWA BEACH HI 639 AM HST SUN SEP 30 2012

EVALUATION BASED ON ALL AVAILABLE DATA A DESTRUCTIVE PACIFIC-WIDE TSUNAMI IS NOT EXPECTED AND THERE IS NO TSUNAMI THREAT TO HAWAII. REPEAT. A DESTRUCTIVE PACIFIC-WIDE TSUNAMI IS NOT EXPECTED AND THERE IS NO TSUNAMI THREAT TO HAWAII. THIS WILL BE THE ONLY STATEMENT ISSUED FOR THIS EVENT UNLESS ADDITIONAL DATA ARE RECEIVED

NPM12: Because We Don’t Know What Tomorrow Will Bring

 

Note: Today marks  the final day of National Preparedness Month, but that in no way signals the end of your need to prepare. Preparedness is a year-round job. 

 

 

Over the past 30 days I’ve posted more than a dozen preparedness blogs, so today I thought I’d explain how I became a `prepper’.

 

Follow this year’s campaign on Twitter by searching for the #NPM or #NPM12 hash tag.

 

 

# 6597

 

 

I confess that I didn’t really start to think seriously about preparedness until 1984, when I bought my first sailboat and began to outfit it for extended coastal cruising.

 

I knew there would be times when my wife and I would be absolutely on our own – often miles from shore or in some remote region of the Ten Thousands Islands - well beyond the puny range of our VHF radio.

 

Suddenly, I was faced with playing the `What if?’ game.

 

• What if one of us got hurt?
• What if we were dismasted or driven hard aground?
• What if the outboard motor or radio died?
• What if we sank!

 

What if . . . what if . . . what if . . .  the possibilities for disaster were endless and daunting, and then there were the less emergent considerations. 

 

How much food and water could we carry?  How much fuel?   How would we generate electricity for anchor, navigation, and interior lights . . . and for the radio?

 

As the only thing smaller than our 23-foot Grampian sailboat was the budget we had for outfitting her, it took nearly a year to get her ready for the cruise. Twelve months, and $7,500 dollars later (and that included the price of the 12 year old boat!), we headed south.

 

Cheryl at the Helm of Halcyon

 

I’m happy to report that while we did see our share of storms, gear failures, minor injuries, and accidental groundings we managed to enjoy the better part of a year cruising without any major mishaps.

 

But it wouldn’t have had a happy ending without proper planning.

 

During the mid-1990’s I moved from the water to the land, and tried my hand at taming 24 acres of Missouri backwoods. Once again, living miles from the nearest town and occasionally cut off for a week or more by snow and ice storms, made preparedness and self-sufficiency paramount.

 

The view from our 4000sf garden

 

I confess - I’m not really much of a backwoodsman - and while I learned many skills during that time, I finally was able to return to Florida in 2005 (the statute of limitations had expired).

 

So you see, I come by my preparedness streak honestly.

 

Even though I no longer live aboard a boat, or in the backwoods, I still believe in being prepared. 

 

Not for the end of the world - as seems to be the popular perception of preppers - but for the very real and all-to-common disasters and emergencies that happen all the time.

 

Thirty days ago, on the first day of National Preparedness Month, I highlighted a very effective graphic from  Ready.gov that shows the `day before disaster’ for all 50 states.

 

The date when it was still not too late to prepare.

Click through to the interactive map, to see each state’s date with destiny.

 

If you click on California, for example, you’ll get:

 

You get the idea. 

 

The takeaway point is, you never know whether today is the day before your disaster . . .

 

The thing that keeps emergency planners up at night is the knowledge that during a disaster, far too many people will be unprepared to fend for themselves until emergency help can arrive.

 

Which is why the Federal government wants all of us to be prepared for emergencies, as they know that during a `normal’ disaster (of which dozens occur every year) citizens may be on their own for up to 72 hours. 

 

In an extreme disaster (like we saw with Katrina in 2005), some people may end up having to fend for themselves for a week or longer.

 

 

Based on the  events in Japan (or after Hurricane Katrina in New Orleans, or the earthquake in Haiti) 3 days of supplies many not be enough for a truly worst case scenario.

 

The County of Los Angeles Emergency Survival Guide calls for having 3 to 10 days worth of food and water.

 

Personally, I believe that 2-weeks of supplies isn’t an unreasonable goal, particularly if you live in earthquake or hurricane country.

 

The L.A. guide may be downloaded here (6.5 Mbyte PDF).

 

 

The bottom line is everyone should have a disaster plan. Everyone should have a good first aid kit, a `bug-out bag’, and sufficient emergency supplies to last a bare minimum of 72 hours.

 

For more on  disaster preparedness, I would invite you to visit:

 

NPM12: Disaster Buddies

When 72 Hours Isn’t Enough

NPM12: The Gift Of Preparedness

An Appropriate Level Of Preparedness

WHO: Southern Hemisphere 2013 Flu Vaccine Composition

 

# 6596

 

Twice each year influenza experts gather to discuss recent developments in human and animal influenza viruses around the globe, and to decide on the composition of the next influenza season’s flu vaccine.

 

Due to the time it takes to manufacture a vaccine, decisions on which strains to include must be made six months in advance.

 

The composition of the northern hemisphere’s vaccine is decided upon in February of each year, and decisions on the southern hemisphere’ vaccine are made in September.

 

Recently (Sept 17-19) participants from divisions of the World Health Organization’s GISRS (Global Influenza Surveillance and Response System), along with members of OFFLU (the OIE/FAO Network on Animal Influenza), and other experts met in Beijing, China to discuss and decide on the formulation for next year’s vaccine in the Southern Hemisphere.

 

For those of us in the Northern Hemisphere the news is encouraging, as recommendations for next year south of the equator match our current vaccine formulation, that was decided upon last February.

 

Their discussions and recommendations may be found in the 16 page PDF document:

 

Recommended composition of influenza virus vaccines for use in the 2013 southern hemisphere influenza season

 

Here is the bottom line from the document:

It is recommended that trivalent vaccines for use in the 2013 influenza season (southern hemisphere winter) contain the following:

• an A/California/7/2009 (H1N1)pdm09-like virus;
• an A/Victoria/361/2011 (H3N2)-like virus;
• a B/Wisconsin/1/2010-like virus
  

It is recommended that quadrivalent vaccines containing two influenza B viruses contain the above three viruses and a B/Brisbane/60/2008-like virus.

 

Of particular note is the switch from a Victoria lineage Influenza B virus to a Yamagata- Lineage strain. While both lineages have been circulating over the past year, the Yamagata strain is perceived to be on the ascendant, and as it has not been included in the vaccine for several years, community immunity is likely low.

 

Regular readers of this blog are aware that over the past year we’ve seen An Increasingly Complex Flu Field, with the recent uptick in swine variant flu cases (H3N2v, H1N2v, & H1N1v) across North America.

 

Additionally, sporadic cases of avian influenza strains (H5N1, H5N2, H7’s, H9N2, and H3N8) continue to be reported around the globe. 

 

The report noted these zoonotic viruses by saying:

 

Zoonotic influenza infections caused by A(H5N1), A(H3N2) variant (v), A(H1N1)v, A(H1N2)v and A(H7N3) viruses

From 23 February to 18 September 2012, 17 confirmed human cases of A(H5N1), 10 of which were fatal, were reported by Bangladesh, Cambodia, China  Hong Kong Special Administrative Region, Egypt, Indonesia, and Viet Nam where highly pathogenic avian influenza A(H5N1) is present in poultry and/or wild birds. Since December 2003, a total of 608 cases with 359 deaths have been confirmed in 15 countries.

To date there has been no evidence of sustained human-to-human transmission. Human cases of influenza A(v) viruses have been detected since February 2012 in the United States of America where a total of 305 infections caused by A(H3N2)v viruses have been reported. One of these infections was fatal. A single case of A(H1N1)v and three cases of A(H1N2)v have also been detected.

 

Two human cases of conjunctivitis due to A(H7N3) have been reported by Mexico. Both cases had exposure to A(H7N3) infected poultry.

 

No human cases of influenza A(H9N2) were detected during the period 23 February to 18 September 2012.

 

We won’t know how well this decision will turn out in the southern hemisphere for another 6 to 12 months, but for those of us north of the equator, this is a pretty good indication that confidence in the makeup of this fall’s flu vaccine remains high.

 

A good enough reason to go ahead and get the shot this year, before flu season arrives.

Coronavirus `Closely Related’ To HK Bat Strains

Japanese pipistrelles – Credit Wikipedia

 

# 6595

 

Bats have been long associated with carrying rabies, but only in recent years have other bat-hosted viruses really gained our attention. Among the first, was the Nipah virus, which was first identified in Malaysia in 1998.

 

The Nipah virus first jumped from bats to local swine herds, probably via bat droppings into the swine’s environment or food. From there, it jumped to humans, resulting in 265 cases of acute encephalitis and more than 100 deaths (cite).

 

This first human outbreak was initially thought to be due to Japanese encephalitis, and so precautions around pigs were delayed for nearly two months, allowing the virus to spread.

 

Over the past decade, Nipah has caused a number of small outbreaks across Southern Asia, although the most intense activity has been centered around Bangladesh. In Australia, Hendra (a close relative to Nipah), is also carried by bats, and has infected horses and humans.

 

In 2003 and 2004, bats once again became a focal point after viruses similar to the SARS coronavirus were found in horseshoe bats in China (cite).  And in recent years, Fruit bats of the Pteropodidae family have been linked to the Ebola virus (cite).

 

Since the SARS outbreak, researchers have found a growing number of previously unknown coronaviruses carried by various species of bats.

 

This from the journal Virology, circa July 2006 (reparagraphed and reformatted for readability).

 

Molecular diversity of coronaviruses in bats.

Woo PC, Lau SK, Li KS, Poon RW, Wong BH, Tsoi HW, Yip BC, Huang Y, Chan KH, Yuen KY.

Source

Department of Microbiology, The University of Hong Kong, University Pathology Building, Queen Mary Hospital, Hong Kong.

Abstract

The existence of coronaviruses in bats is unknown until the recent discovery of bat-SARS-CoV in Chinese horseshoe bats and a novel group 1 coronavirus in other bat species.

 

Among 309 bats of 13 species captured from 20 different locations in rural areas of Hong Kong over a 16-month period, coronaviruses were amplified from anal swabs of 37 (12%) bats by RT-PCR.

 

Phylogenetic analysis of RNA-dependent-RNA-polymerase (pol) and helicase genes revealed six novel coronaviruses from six different bat species, in addition to the two previously described coronaviruses.

 

Among the six novel coronaviruses, four were group 1 coronaviruses (bat-CoV HKU2 from Chinese horseshoe bat, bat-CoV HKU6 from rickett's big-footed bat, bat-CoV HKU7 from greater bent-winged bat and bat-CoV HKU8 from lesser bent-winged bat) and two were group 2 coronaviruses (bat-CoV HKU4 from lesser bamboo bats and bat-CoV HKU5 from Japanese pipistrelles).

 

An astonishing diversity of coronaviruses was observed in bats.

 

All of which serves as prelude to a story today out of Hong Kong, where researchers from the University of Hong Kong have compared the gene structure of the newly discovered coronavirus in the Middle East, and find it to be a 90% match to the HKU4 and HKU5 viruses mentioned above.

This story from the South China Morning Post:

 

Sars-like virus in Middle East 'closely related to Hong Kong bat strains'

Expert says new coronavirus is 90pc similar to two other bugs that were discovered in city

(EXCERPT)

Yuen, an authority in coronaviruses, said the new virus' genetic sequence was 90 per cent similar to the two bat strains found locally, the closest match so far. "We can say the new virus has a common ancestor and come from the same family as the two bat viruses," he said.

 

No conclusion could be drawn that the Middle Eastern patients had contracted the new virus from bats, he said. It was also genetically distinct from the Sars coronavirus, he added.

(Continue . . . )

 

 

While the coronavirus detected in the Middle East is similar to other coronaviruses found in bats, this doesn’t necessarily mean that the two known victims contracted it directly from a bat.  

 

There may well have been an intermediate host involved (as were the pigs in Malaysia, and possibly civet cats with SARS).

 

This is another clue, however, in the epidemiological investigation into these two new cases. 

 

For now – with no sign of additional cases - the World Health Organization (along with many other experts) see the transmission of this virus to humans as being inefficient or `weak’.  

 

With luck, that status will remain unchanged as we learn more about this emerging virus.

 

For more on bats, and bat-hosted viruses, you may wish to revisit:

 

Disease Transmission At The Human-Animal Interface

A New Flu Comes Up To Bat

The Scientific Plausibility of `Contagion’

The Nipah Virus: An Emerging Infectious Threat

NPM12: The Rehydration Solution

 

 

Note: This is day 29 of National Preparedness Month.  Follow this year’s campaign on Twitter by searching for the #NPM or #NPM12 hash tag.

 

The following blog is a reprint (slightly edited) of a 2007 essay that has easily proven to be the most popular article in the nearly 7 year history of AFD (10,000+ downloads).

 

I rerun, and update it, it about once a year.

 

While it was written with a severe influenza pandemic in mind, emergency hydration can be lifesaving in a variety of situations including heat stroke and severe vomiting or diarrhea. 

 

# 6594

 

Dehydration, and severe diarrheal disease - particularly among children in the third world - is a massive killer. Recognizing this threat, more than 25 years ago the WHO (World Health Organization) came up with what is now called ORS, or an Oral Rehydration Solution.

 

Hundreds of millions of sachets, or packets of this powder, are shipped each year to various third world countries, and there is no doubt that their use has greatly decreased the loss of life due to cholera, dysentery, and other diseases.

 

In a Flu Pandemic, the need for ORS will be great throughout the world. In western societies, where modern medical care is common, IV’s are generally used instead of ORS. There are economic and psychological reasons for this, although many doctors argue that ORS would be just as effective for the majority of patients.

 

Dehydration, from a prolonged bout of flu; with it’s fever, vomiting, and diarrhea, can easily kill patients that might have otherwise survived the virus.

 

As IV’s may well be in short supply, or simply unavailable during a pandemic, the use of ORS may well be the most beneficial treatment that most patients can receive. Certainly, with home care being the most likely venue for most patients, ORS will play a large role in the treatment of pandemic flu.

 

There are, however, conflicting opinions as to what constitutes the proper formula for making your own ORS. All formulas use a base of sugar and salt, in an appropriate ratio. Some formulas, however, add potassium and Sodium Bicarbonate.

 

A little Biochemistry

 

When the human body becomes dehydrated, it loses both water and essential electrolytes, particularly sodium. This condition can quickly become life threatening.

 

In the human body, fluids tend to move from a less salty environment to the saltier one. As an example, if someone drowns in fresh water, the water in the lungs is less salty than the blood, and so this water is quickly absorbed from the lungs into the surrounding tissues.

 

If a person drowns in salt water, the water in the lungs is saltier than the blood, and so additional fluid is pulled into the lungs to `dilute’ the salt water. In other words, the body tries to balance both sides of the equation.

 

This is an important concept when dealing with rehydration therapy.

Ingesting plain water does not help restore the salt content of the body. But ingesting water with too much salt will draw fluids from the body, and make the dehydration worse.

 

While many believe the exact ratios of sugar and salt to be writ in stone, the truth is, if you have to err, err on the side of less salt.

 

Sugar is added to the ORS solution for two reasons. First, it was discovered in the early 1960’s that sugar helped with the transport of fluids across the cellular membranes in the bowel. In 1977, the British Medical Journal Lancet called this `possibly the most important medical discovery of the 20th century’.

 

Sugar also provides needed calories, and as a carbohydrate, can help prevent ketoacidosis from occurring.

 

But, as with salt, too much sugar can be detrimental, it can promote diarrhea, and make the loss of fluids worse.

 

This is one concern regarding the use of commercial sports drinks for rehydration therapy. Many of these commercially available mixtures simply have too much sugar.

 

Making your own ORS

 

The bottom line, of course, is how to make a cheap, safe, and effective ORS powder yourself.

Image Credit - http://rehydrate.org/

 

The simplest formula is 3 Tablespoons of sugar, and 1 teaspoon of salt, dissolved in 1 quart of potable water.

 

An alternative simple formula is 8 teaspoons of sugar, and 1 teaspoon of salt, dissolved in 1 quart of potable water.

 

This basic formula has been used effectively for more than 30 years by WHO, UNICEF, and other relief agencies and has saved millions of lives.

 

Over the past year, there has been some debate over the amount of salt and sugar in this formula. The old formula certainly works, and is safe. But some doctors have argued that a lower salt and sugar level might reduce fluid loss by curbing diarrhea.

 

I’ve elected to create single-serve packets of ORS powder, with each packet designed to be added to 1 liter of water. Two packets would be used for a 2-liter bottle.

 

I’ve located small plastic baggies, called bagettes sold at Michaels Art Supplies. You will find them in the bead section. Snack sized baggies, though lighter gauge plastic, would work as well. The small 2”x3” bagettes are just a little too small for the amount of powder required. You will need to go to the next size up, which are 3”x5”.

 

Along with these baggies, you will need table salt and sugar. I am electing to use non-iodized salt, although I am not aware of any reason why iodized salt would present a problem. The only other things you will need are measuring spoons and a felt tipped marker.

 

Into each baggie I am placing 3 TABLESPOONS of Sugar, and 1 TEASPOON of salt. These do not need to be mixed. I am writing on each Baggie “ORS POWDER- ADD TO 1 LITER OF WATER”.

 

This is the basic formula recommended by Dr. Grattan Woodson in his GOOD HOME TREATMENT OF INFLUENZA guide.

 

In his home medical guide, Dr. Woodson writes:

 

"Preventing or treating dehydration in people with flu will save more lives than any other intervention during the influenza pandemic."

Identification of dehydration

When patients have a fever, vomiting, and/or diarrhea, they lose much more water from the body than is commonly appreciated. Symptoms of dehydration include weakness, dizziness, headache, confusion, and fainting. Signs of dehydration include dryness of the mouth, decreased saliva, lack of or very small urine volume that is dark and highly concentrated, sunken eyes, loss of skin elasticity, low blood pressure, especially upon sitting up or rising from the sitting to the standing position, and fast pulse rate, especially when moving from the lying to sitting or standing positions

 

Since I make it a practice not to offer specific medical advice in this blog, I would refer you to to Dr. Woodson’s excellent guide for further guidance on the administration (when, how much, etc)  of rehydration fluids.

 

You may elect to add a flavoring to this mixture. Unsweetened Kool-Aid would add flavor and color, and make the drink more palatable to some. It might, however, prove to be an intestinal irritant to some people. I intend to leave mine unflavored, and will add Kool-Aid to individual liters of solution if desired.

 

At 15 cents a gallon, the price is right. And for someone who is dehydrated, having this solution on hand can be lifesaving.

 

CAVEATS

You should never attempt to force fluids by mouth on anyone who is unconscious. An eye dropper may be used to slowly infuse liquids in semi conscious patients but there is a risk of choking.

Better to dilute this powder too much, than too little. DO NOT SKIMP ON THE WATER.

 

For more complete information on oral rehydration fluids visit the Healthlink Worldwide webpage at

 

http://rehydrate.org/dd/su19.htm

Pathogens At the Gate

Thermal Scanner – Credit Wikipedia

 

# 6593

 

While there are no indications that the coronavirus detected recently in the Middle East has spread beyond the first two cases, some places around the world are taking this threat very seriously.

 

For example, local media is reporting that thermal scanners have been deployed at the Ninoy Aquino International Airport in the Philippines in an attempt to screen arrivals from the Middle East for possible infection.

 

Whenever a novel virus appears, people’s thoughts understandably turn to a pandemic scenario, even though experience has shown that most emerging viruses don’t have the `legs’ to spark a global epidemic (see Novel Viruses & Chekhov’s Gun).

 

Nevertheless, history tells us that pandemics come along several times each century, and another pandemic is all but inevitable.

 

And so the world’s attention this week has quite naturally focused on the novel coronavirus that killed one man in Saudi Arabia last July and has a Qatari man currently hospitalized in London.

 

Memories of the SARS outbreak in 2002 and 2003 remain vivid, particularly in Asia, where the virus hit hardest.

 

Fortunately, while there is still much we don’t know about this emerging pathogen, there are no immediate signs that this virus poses a pandemic threat.

 

While we may not know when - or which virus - will spark the next global health crisis, we have pretty good idea how it will arrive in most countries.

 

Scheduled airline traffic around the world, circa June 2009 – Credit Wikipedia

 

The world’s airlines carry 2.6 billion passengers each year, on more than 17 million flights.  And as the map above indicates, millions of them are international flights.

 

With most viral diseases having an incubation period of several days or longer, someone who is newly infected with a virus could change planes and continents several times before showing their first signs of illness.

 

Last July, in MIT: Contagion Dynamics Of International Air Travel we looked at a study appearing in PloS One, that simulated the early spread of a pandemic virus via air travel and ranked U.S. airports based on how much they contributed to the spread of the illness.

 

An excerpt from a report that appeared in MIT News.

 

New model of disease contagion ranks U.S. airports in terms of their spreading influence

Airports in New York, Los Angeles and Honolulu are judged likeliest to play a significant role in the growth of a pandemic.

Kennedy Airport is ranked first by the model, followed by airports in Los Angeles, Honolulu, San Francisco, Newark, Chicago (O'Hare) and Washington (Dulles). Atlanta's Hartsfield-Jackson International Airport, which is first in number of flights, ranks eighth in contagion influence. Boston's Logan International Airport ranks 15th.

 

 

All of which begs the question, can we really screen, identify, and isolate infectious airline passengers before they can spread a pandemic virus?

 

 

Sadly, the evidence to date has not been very encouraging.

 

Last April, in EID Journal: Airport Screening For Pandemic Flu In New Zealand, we examined a study that found the screening methods used at New Zealand’s airport were inadequate to slow the entry of the 2009 pandemic flu into their country, detecting less than 6% of those infected.

 

New Zealand did not employ thermal scanners, although countries that did, didn’t fare much better.

  

Proving that `there’s no place like home’ during a global crisis, in Vietnam Discovers Passengers Beating Thermal Scanners, we saw evidence of passengers taking fever-reducers to beat the airport scanners in a desperate attempt to get home.

 

In December of 2009, in Travel-Associated H1N1 Influenza in Singapore, I blogged on a NEJM Journal Watch article on of a new study that has been published, ahead of print, in the CDC’s  EID Journal  entitled:

 

Epidemiology of travel-associated pandemic (H1N1) 2009 infection in 116 patients, Singapore. Emerg Infect Dis 2010 Jan; [e-pub ahead of print]. Mukherjee P et al

Travel-Associated H1N1 Influenza in Singapore

Airport thermal scanners detected only 12% of travel-associated flu cases; many travelers boarded flights despite symptoms.

 

 

In June of 2010  CIDRAP carried this piece on a study of thermal scanners in New Zealand in 2008 (before the pandemic) presented at 2010’s ICEID.

 

Thermal scanners are poor flu predictors

Thermal scanners for screening travelers do moderately well at detecting fever, but do a poor job at flagging influenza, according to researchers from New Zealand who presented their findings today at the International Conference on Emerging Infectious Diseases (ICEID) in Atlanta.

 

And in early 2009, Helen Branswell penned an article for the Canadian Press, that stated:

 

Studies show little merit in airport temperature screening for disease

Monday, 16 February 2009 - 11:58am.

By Helen Branswell

TORONTO — Using temperature scanners in airports to try to identify and block entry of sick travellers during a disease outbreak is unlikely to achieve the desired goal, a report by French public health officials suggests.

(Continue. . .)

 

 

The evidence is pretty clear.

 

With the technology of today, coupled with likelihood of having many pre-symptomatic and asymptomatic carriers, there isn’t much hope to identify more than a fraction of infected travelers.

 

As far as the risk of catching a pandemic flu virus while a passenger on an airliner, in May of 2010 we saw a study that appeared in the BMJ that looked at that very topic (see BMJ: Flu Transmission Risks On Airplanes)

 

BMJ 2010;340:c2424

Research

Transmission of pandemic A/H1N1 2009 influenza on passenger aircraft: retrospective cohort study

Conclusions

A low but measurable risk of transmission of pandemic A/H1N1 exists during modern commercial air travel. This risk is concentrated close to infected passengers with symptoms. Follow-up and screening of exposed passengers is slow and difficult once they have left the airport.

 

Another study, conducted by researchers at UCLA and published in BMC Medicine in late 2009:

 

Calculating the potential for within-flight transmission of influenza A (H1N1)

Bradley G Wagner, Brian J Coburn and Sally Blower^*

Results

The risk of catching H1N1 will essentially be confined to passengers travelling in the same cabin as the source case. Not surprisingly, we find that the longer the flight the greater the number of infections that can be expected. We calculate that H1N1, even during long flights, poses a low to moderate within-flight transmission risk if the source case travels First Class.

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While there will likely be intense public clamor to try to block the entry of a pandemic virus into this, or any other country, the truth is – it is highly unlikely that it will work.

Areas that receive a very small number of arrivals might be able to institute a quarantine system (see Can Island Nations Effectively Quarantine Against Pandemic Flu? ), but even then the ability to identify and isolate infected travelers won’t be 100%.

 

Still, even if the success rate is likely to be low, there may be some value in trying to limit the number of infected persons arriving into a country, particularly during the opening days and weeks of an outbreak.

 

The more introductions of a virus into a population, the more points it will have from which to spread.

 

Since it takes months to produce and deploy a vaccine, and time to prepare a society to deal with a pandemic, any delaying action that can reduce the speed and spread of the virus has value.

 

The takeaway from all of this is that we ignore global healthcare and infectious disease outbreaks – even in the remotest areas of the world – at our own peril.

 

Vast oceans and extended travel times no longer offer us protection, and there is no technological shield that we can erect that would keep an emerging pandemic virus out.

 

The place to try to stop the next pandemic is not at the gate, but in the places around the world where they are likely to emerge.

 

Which makes the funding and support of international public health initiatives, animal health initiatives, and disease surveillance ever so important, no matter where on this globe you happen to live.

Coronavirus: WHO Update & Genome Sequence

Coronavirus – Credit CDC PHIL

 

# 6592

 

The World Health Organization has posted an update on the novel coronavirus situation, and indicate that no additional cases have been identified and the evidence to date suggests that this virus is not easily transmissible to humans.

 

Novel coronavirus infection - update

28 September 2012 - As of 28 September 2012, no additional confirmed cases due to infection with the novel coronavirus have been reported to WHO.

 

WHO is working closely with the national authorities of the involved countries (Qatar, Saudi Arabia, United Kingdom) and international partners in order to better understand the public health risk from the novel coronavirus.

 

From the information available thus far, it appears that the novel coronavirus cannot be easily transmitted from person-to-person.

 

Given the severity of the two laboratory confirmed cases, WHO is continuing to monitor the situation in order to provide the appropriate response, expertise and support to its Member States.

 

Rapid progress has been made in the characterization of the novel coronavirus, and in the development of sensitive and specific diagnostic assays. WHO is collaborating with partner laboratories to make these available as quickly as possible. It is anticipated that the first batch of reagents, together with information and testing algorithms, will be available for urgent testing within the coming days.

 

Tests for novel coronavirus infection of patients under investigation - based on the case definition issued by WHO – are currently available by some partner laboratories. National Health Authorities can contact these laboratories through WHO.

 

WHO continues to inform its Member States through the designated National Focal Points under the International Health Regulations (2005).

 

No travel or trade restrictions have been recommended by WHO for Saudi Arabia or Qatar with respect to the novel coronavirus infections.

 

 

Meanwhile, overnight the entire genome sequence for this betacoronavirus 2c was deposited at GenBank by a team from Erasmus University in the Netherlands headed by Ron Fouchier.

 

With only two known cases, roughly 2 months apart, the question now becomes what was the likely source of their infection?

 

The virus is similar to those previously detected in bats, but other animal hosts (intermediate or primary) are certainly possible.

 

For now, this novel coronavirus appears to pose more of a epidemiological enigma than a threat to public health.

 

While more is being learned about this new coronavirus everyday, our knowledge of this emerging pathogen is still very limited. And viruses can always change over time – so it is important that we not let down our guard. 

 

Stay tuned.

Miami Reports Locally Acquired Dengue Case

 

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# 6591

 

News this afternoon from the Miami-Dade Health Department on the detection of 2012’s first locally acquired case of Dengue fever in the state of Florida.

First some excerpts from the press release, and then I’ll return with more.

 

September 27, 2012

First Locally Acquired Case of Dengue Fever in Miami-Dade County

(Miami, FL – September 27, 2012) – Miami-Dade County Health Department officials received confirmation of the first locally acquired case of Dengue Fever in Miami-Dade County.

 

The individual was diagnosed with Dengue Fever based on symptoms and confirmed by laboratory tests. The individual fully recovered from this illness.

 

Dengue Fever is a viral disease transmitted by a type of mosquito common to the southeastern United States and the tropics. It is not spread from person to person. The symptoms of Dengue Fever include, fever (over 101 degrees Fahrenheit), severe headache, severe pain behind the eyes, muscle, joint and bone pain, rash, loss of appetite, nausea and vomiting. There is no specific medication or vaccine for Dengue Fever. If you are experiencing symptoms consistent with Dengue Fever, please call your healthcare provider to see if you need to be seen.

(Continue . . . )

 

When Dengue fever returned to the state of Florida in 2009 - after an absence of 70 years - (see Dengue Resurfaces In Key West), it wasn’t an entirely unexpected event.

 

The virus was likely reintroduced to the area by an infected traveler or visitor who was bitten by a local mosquito, and that mosquito went on to bite others.

 

Like many viral infections (influenza, West Nile, etc), not everyone who is infected experiences symptoms. And with Dengue, it is often the second or third infection (there are 4 sub-types) that proves the most serious.

 

The 2010 MMWR report  Locally Acquired Dengue --- Key West, Florida, 2009—2010 described South Florida’s vulnerability this way:

 

The environmental and social conditions for dengue transmission have long been present in south Florida: the potential for introduction of virus from returning travelers and visitors, the abundant presence of a competent mosquito vector, a largely nonimmune population, and sufficient opportunity for mosquitoes to bite humans.

 

There were 28 cases reported in 2009, and the state of Florida’s Weekly Data for Arbovirus Surveillance lists 63 locally-acquired cases in Key West, one in Broward County, and one in Miami-Dade County for 2010.

The following year, 2011, saw a significant reduction in cases with just three locally acquired in Miami-Dade County, two in Palm Beach County, and one each in Martin and Hillsborough counties.

 

While the most recent state surveillance report shows 67 cases of imported dengue in individuals with recent travel history to dengue endemic regions, today’s announcement is the first locally acquired case of the year.

 

In order to spread, Dengue requires the right mosquito vector.  And the two species best suited to transmit the virus are the Aedes aegypti and Aedes albopictus mosquitoes, which also can spread such diseases as West Nile, Malaria, Yellow Fever, and Chikungunya.

 

Map showing the distribution of dengue fever (red) and the distribution of the Aedes aegypti mosquito (cyan)  in the world, as of 2006. – Credit Agricultural Research Service of the US Department of Agriculture.

 

Map showing the native habitat (blue) and recent spread (green) of the Aedes albopictus mosquito. --Credit Wikipedia

 

According to a 2009 report, as many as 28 states in the US have at least one of the these mosquito vectors, a factoid that has some epidemiologists worried that Dengue, Chikungunya, and Malaria could one day become threats in the United States.

 

With only one locally-acquired dengue case in Florida this year, it’s pretty obvious the virus has not managed to get a solid foothold in the state. Each year, however - more travelers arrive carrying the virus - and that gives the virus another opportunity to take up residence.

 

Right now, Dengue is a minor threat in Florida, but when you add Dengue to the other mosquito-borne illnesses (EEE, WNV, SLEV) it just makes sense to do whatever you can to limit your exposure.

Which is why the State Health Department urges residents and visitors to follow the `5 D’s’:

 

 

For an extensive list of my blogs on Dengue and Mosquito Borne Diseases you can select the DENGUE Quick Search here,  or on my sidebar.

MMWR: H3N2v Related Hospitalizations In Ohio – Summer 2012

Credit Wikipedia

 

 

# 6590

 

During this summer’s outbreak of H3N2v swine-origin influenza that infected at least 305 people across 10 states, only Indiana (n=138) reported more cases than did Ohio (n=106).

 

While the number of new cases being reported has declined dramatically over recent weeks, the epidemiological investigation continues. For earlier reports on this outbreak, see HERE, HERE, and HERE.

 

Today the CDC’s MMWR presents an overview of 11 patients from Ohio that required hospitalization, which represents nearly 70% of all those hospitalized with the virus across the country, and the nation’s only H3N2v related fatality.

 

It’s a long report, providing extended case histories on two of the patients (including the fatality), and providing (via a chart) basic information on all 11 cases – including likely route of exposure.

 

Of the 11 cases reported on, only one did not report direct or indirect exposure to swine; a 6 year old that reportedly had:

 

No contact. No attendance at fairs. Saw grandmother on Aug 23, who works with horses on a farm where pigs are also kept. Grandmother had no recent illness. No known illness in pigs.

 

Follow the link to read it in its entirety, but I’ve posted a few excerpts.

 

Influenza A (H3N2) Variant Virus-Related Hospitalizations — Ohio, 2012

Weekly

September 28, 2012 / 61(38);764-767

Since July 2012, 305 cases of infection with influenza A (H3N2) variant (H3N2v) virus containing the influenza A (H1N1)pdm09 M gene have occurred in multiple U.S. states, primarily associated with swine exposure at agricultural fairs (1). In Ohio, from July 28 to September 25, 2012, a total of 106 confirmed H3N2v cases were identified through enhanced surveillance. Whereas most H3N2v patients experienced mild, self-limited influenza-like illness (ILI), 11 of the Ohio patients were hospitalized, representing 69% of all H3N2v hospitalizations in the United States. Of these hospitalized H3N2v patients, six were at increased risk for influenza complications because of age or underlying medical conditions, including the only H3N2v-associated fatality reported in the United States to date. This report summarizes the epidemiology and clinical features of the 11 hospitalized H3N2v patients in Ohio. These findings reinforce the recommendation for persons at high risk for influenza complications to avoid swine exposure at agricultural fairs this fall (2). In addition, persons not at high risk for influenza complications who wish to reduce their risk for infection with influenza viruses circulating among pigs also should avoid swine and swine barns at agricultural fairs this fall.

<SNIP>

Case Reports

Patient A. A woman aged 61 years with type 2 diabetes, congestive cardiomyopathy, hypertension, and a past history of B-cell lymphoma, experienced cough and sneezing on August 10 (Table, patient 11). Beginning 6 days earlier, she spent 4 days at a county fair where she visited a swine barn and had direct swine contact. Over the next 2 weeks, she experienced cough and fever and was treated with antibiotics for a sinus infection. On August 25, she sought care at an emergency department with worsening symptoms. The patient was transferred to a tertiary care center with hemodynamic instability and respiratory distress, and required mechanical ventilation. Her condition deteriorated, and she died on August 26. Blood cultures obtained on August 25 yielded Pseudomonas aeruginosa, and a nasopharyngeal swab was positive for H3N2v virus by rRT-PCR at ODH. Genetic sequencing of H3N2v virus from a clinical specimen from this patient at CDC was nearly identical to sequencing from several nonfatal H3N2v cases in Ohio, and from H3N2pM* viruses identified among pigs at fairs in Ohio.

(Continue . . .)

 

 

The MMWR report provides a summary of the findings, which reads:

 

What is already known on this topic?

Beginning in the summer of 2012, CDC reported increases in numbers of cases of human infections with influenza A (H3N2) variant (H3N2v) viruses associated with swine exposure at agricultural fairs. Nationwide, 305 cases, 16 hospitalizations, and one death across 10 states have been reported since July 2012.

 

What is added by this report?

 

Of 16 patients hospitalized with confirmed H3N2v virus infection, 11 were Ohio residents, including the only H3N2v-associated fatality to date. All but one of the Ohio patients were children, and six were considered high-risk for complications of influenza because they were aged <5 years or had underlying medical conditions; four high-risk persons became ill after indirect contact with pigs. These findings support current CDC recommendations that persons at high risk for complications of influenza should avoid exposure to swine at agricultural fairs this fall.

 

What are the implications for public health practice?

County and state fairs in the United States continue to occur through the month of October, highlighting the potential for continued cases of H3N2v virus infection. Persons at high risk for complications of influenza should avoid exposure to swine at agricultural fairs. Patients with suspected influenza, including H3N2v, who are hospitalized or at increased risk for influenza complications, should receive antiviral treatment with oral oseltamivir or inhaled zanamivir as soon as possible. Antiviral treatment also is encouraged for outpatients with suspected H3N2v who are not at increased risk for influenza complications.

NPM12: One For The Home, And One More For The Road

Note: This is day 27 of National Preparedness Month.  Follow this year’s campaign on Twitter by searching for the #NPM or #NPM12 hash tag.

 

This month, as part of NPM12, I’ll be rerunning some updated  preparedness essays (like this one) , along with some new ones.

 

Inside my primary first aid kit.  Notice the masks and goggles, along with two flashlights (one hands free). 

 

# 6589

As a former EMT/Paramedic, I confess to feeling a bit naked without a decent first aid kit within easy reach.  And this is why I maintain two, well equipped, medical kits; one for my home, and one for the trunk of my car.

 

I’ll admit that owning two ambu-bags borders on the excessive, but I certainly feel better knowing they are there.

 

Well equipped first aid kits are a necessity in every home, and should also be found in the trunk of every car. While you can purchase a ready-made kit (the quality of which varies depending on price), I’ve always preferred to create my own.

 

I undoubtedly have a more elaborate kit than most, but perhaps a look inside my auto first aid bag will inspire some of my readers to make one of their own.

 

The `bag’ is an old style Laptop computer case, with a handle and a shoulder strap.  I like these, because they have numerous compartments, are soft, and are reasonably waterproof.

 

 

On the `trauma’ side of the bag, I’ve got `Kling’ roll bandages, an ACE bandage, a couple of cravat `Triangle’ bandage (sling & swath), sterile 4x4 gauze pads, paper tape, Band-Aids, antibiotic cream and several absorbent feminine pads (they make excellent trauma dressings). 

 

 

On the opposite side, I’ve got an `ambu’ bag-mask resuscitator along with a selection of adult and child airways, a foam C-Collar, a B/P cuff, stethoscope, flashlight, and some ammonia caps – hidden away where you can’t see them are bandage shears, tweezers, and a magnifying glass, along with a spare pair of reading glasses.

 

 

There is also a penlight, a felt tipped pen, and a note pad.

 

Under the front `cover’ flap, I keep some basic OTC medicines, including aspirin, acetaminophen, some hand antiseptic, and a bulb syringe (can be used for minor suctioning).

 

 

Under the flap on the other side, I’ve got surgical & N95 masks, exam gloves, and a `space’ blanket.

 

 

Of course, having a kit isn’t enough.  You need to know how to use it.

 

And for that, you need first aid training.  If you haven’t already taken a course, contact your local Red Cross chapter, and find out what is available in your area.   And don’t forget the CPR training (or recertification!) as well.

 

Whether you buy a ready-made kit, or make your own, now is a good time to make sure you are fully equipped to deal with a medical emergency.

 

For more information I would invite you to visit:

 

FEMA http://www.fema.gov/index.shtm

READY.GOV http://www.ready.gov/

AMERICAN RED CROSS http://www.redcross.org/

Japan’s Earthquake: Learning from Megadisasters

 

 

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We are a little more than 18 months since the Great Japan Earthquake and Tsunami of 2011 - and while much progress has been made - much work still remains ahead to safely secure the damaged nuclear reactors, and to rebuild shattered lives and communities.

 

The events of March 11th, 2011 were far more complex and devastating than any emergency plan had previously considered;  A 9.0 earthquake spawning a massive tsunami, that would not only demolish coastal towns killing thousands, but would heavily damage nuclear power facilities as well.

 

While the term megadisaster is often bandied about, in this instance, it is an appropriate description. 

 

Via Reliefweb, we’ve the first phase of a joint project by the GFDRR, the Government of Japan, and the World Bank that should be of particular interest to emergency management officials and planners around the world:

 

The Great East Japan Earthquake: Learning from Megadisasters

Report

Download PDF (661.78 KB) Knowledge Notes Executive Summary

Download PDF (374.64 KB) Brochure

<EXCERPT>

Learning from Megadisasters, a knowledge-sharing project sponsored by the Government of Japan and the World Bank, is collecting and analyzing information, data, and evaluations performed by academic and research institutions, nongovernmental organizations, government agencies, and the private sector—all with the objective of sharing Japan’s knowledge on disaster risk management (DRM) and postdisaster reconstruction with countries vulnerable to disasters.  The World Bank and the Japanese government hope that these findings will encourage countries to mainstream DRM in their development policies and planning.

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McKenna: Remembering SARS & The New Coronavirus

Coronavirus – Credit CDC PHIL

 

# 6587

 

Maryn McKenna has penned a terrific look back at the SARS epidemic of 2002-2003, along with analysis of why this newly discovered coronavirus has so unnerved public health officials.

 

Maryn tells a medical detective story better than anyone I know, so I’ll simply invite you to click on the link below and read:

 

 

Why The New Coronavirus Unnerves Public Health: Remembering SARS

• By Maryn McKenna September 26, 2012 | 

 

DVBID Update On West Nile Virus

 

Source DVBID

 

# 6586

 

While the big infectious disease news this week has been the novel coronavirus that has killed one Saudi, and seriously sickened a Qatari man, there are other infectious disease threats we follow, including West Nile Disease.

 

The DVBID has updated their West Nile website, and while the number of new infections is beginning to decline, 13 additional deaths have been reported via ArboNet in the last week.

 

 

2012 West Nile virus update: September 25

As of September 25, 2012, 48 states have reported West Nile virus infections in people, birds, or mosquitoes. A total of 3,545 cases of West Nile virus disease in people, including 147 deaths, have been reported to CDC. Of these, 1,816 (51%) were classified as neuroinvasive disease (such as meningitis or encephalitis) and 1,729 (49%) were classified as non-neuroinvasive disease.

 

The 3,545 cases reported thus far in 2012 is the highest number of West Nile virus disease cases reported to CDC through the last week in September since 2003. Seventy percent of the cases have been reported from eight states (Texas, Mississippi, South Dakota, Michigan, California, Louisiana, Oklahoma, and Illinois) and 38 percent of all cases have been reported from Texas.

 

It should be noted that the latest numbers reported via ArboNet may lag behind the most recent totals being reported by each state.  

 

Case in point: Texas,  which is shown to have  1345 cases and 52 deaths in today’s report, is reporting somewhat higher numbers on their website:

 

The incidence level of the more serious neuroinvasive form of West Nile disease – which can produce encephalitis, meningitis, and/or acute flaccid paralysis – is illustrated by the following chart. 

 

 

 

Although the peak period of transmission for WNV may have passed, infected mosquitoes are still out there and are still biting and infecting people.

 

So we still need to heed the advice of our local health departments to  follow the `5 D’s’ of mosquito protection: