SFTS Fatality Reported In Japan

Photo Credit Wikipedia

# 6899

 

 

Having recently read David Quammen’s terrific book on emerging infectious diseases called `Spillover’ (see EID Book Review – Spillover), I may be hyper-sensitized to any odd reports of newly emerging pathogens.

 

Nevertheless, this next story – which involves a recently discovered virus showing up in a new country  –  is unusual enough to merit mention.

 

Today the Mainichi is reporting that a Japanese adult – without recent travel history outside of the country – died last fall from a recently discovered viral infection called SFTS (Severe Fever with thrombocytopenia syndrome) that until now, has only been seen in China.

 

SFTS – linked to a recently discovered Bunyavirus - is believed to be transmitted primarily by ticks. Outbreaks were first identified in central China's Hubei and Henan provinces during the spring and summer of 2009.

 

We got our first real look at this syndrome from the NEJM in 2011 (see Fever with Thrombocytopenia Associated with a Novel Bunyavirus in China).  At that time, they stated `There was no epidemiologic evidence of human-to-human transmission of the virus.’

For more details on that NEJM report, I would invite you to read Lisa Schnirring’s excellent summary for CIDRAP NEWS  (Chinese researchers link febrile disease to new virus).

 

Since then, in February of 2012, the journal Vector Borne Zoonotic Diseases carried this game-changing report:

 

Person-to-person transmission of severe fever with thrombocytopenia syndrome virus.

 

Liu Y, Li Q, Hu W, Wu J, Wang Y, Mei L, Walker DH, Ren J, Wang Y, Yu XJ.

Abstract

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease caused by a newly discovered bunyavirus, SFTS virus (SFTSV), and causes high fatality (12% on average and as high as 30%). The objective of this study was to determine whether SFTSV could be transmitted from person to person.

 

We analyzed sera of 13 patients from two clusters of unknown infectious diseases that occurred between September and November of 2006 in Anhui Province of China for SFTSV antibody by indirect immunofluorescence assay and for SFTSV RNA by RT-PCR. We found that all patients (n=14) had typical clinical symptoms of SFTS including fever, thrombocytopenia, and leukopenia and all secondary patients in both clusters got sick at 6-13 days after contacting or exposing to blood of index patients.

 

We demonstrated that all patients in cluster 1 including the index patient and nine secondary patients and all three secondary patients in cluster 2 had seroconversion or fourfold increases in antibody titer to SFTSV and/or by RT-PCR amplification of SFTSV RNA from the acute serum. The index patient in cluster 2 was not analyzed because of lack of serum. No person who contacted the index patient during the same period, but were not exposed to the index patient blood, had got illness.

 

We concluded that SFTSV can be transmitted from person to person through contacting patient's blood.

 

The question now is how did an adult male in Japan contract this never-reported-before-in-Japan virus? 

 

One might surmise that he came in contact with the blood of an infected individual who had recently visited China . . .  but today’s report states that:

 

Genetic studies show the virus that killed the Japanese occurred in Japan and did not come from China, the ministry said.

 

Which if correct, creates a bit of an epidemiological puzzle for public health experts to investigate.

 

Note: A h/t to Makoto on Twitter for the link.

Influenza Transmission, PPEs & `Super Emitters’

 

Photo Credit PHIL (Public Health Image Library)

 

# 6898

 

Ideally, the well-protected HCW (Health Care Worker) working in an infectious environment would be wearing an N95 mask, gloves, gown and eye protection – what are collectively known as  PPEs or Personal Protective Equipment.

 

 

But during the opening months of the 2009 pandemic, it became apparent that our world faced a serious shortage of PPEs, and so strategies were adopted to maximize their use.

 

In some cases nurses were issued only one N95 mask to be used for an entire 8 hour shift, while in other venues, HCWs were issued surgical masks in lieu of N95s, despite the recommendation at the time from the CDC that N95 masks were the preferred level of protection when caring for influenza patients.

 

These policies led to a number of complaints (see Nurses Protest Lack Of PPE’s , Report: Nurses File Complaint Over Lack Of PPE), as the debate over appropriate PPEs for pandemic influenza dragged on (see NEJM Perspective: Respiratory Protection For HCWs).

 

In June of 2010, the CDC proposed new guidance that relaxed those recommendations to using surgical masks for routine care, and reserving N95 masks for aerosol producing procedures (intubation, suctioning, etc).

 

Today, from the IDSA Journal of Infectious Diseases, we get a new study that casts doubts over the effectiveness of those revised PPE protocols. 

 

The paper is called:

 

Exposure to Influenza Virus Aerosols During Routine Patient Care

Werner E. Bischoff1, Katrina Swett3, Iris Leng3 and Timothy R. Peters2

Background. Defining dispersal of influenza virus via aerosol is essential for the development of prevention measures.

 

Methods. During the 2010–2011 influenza season, subjects with influenza-like illness were enrolled in an emergency department and throughout a tertiary care hospital, nasopharyngeal swab specimens were obtained, and symptom severity, treatment, and medical history were recorded. Quantitative impaction air samples were taken not ≤0.305 m (1 foot), 0.914 m (3 feet), and 1.829 m (6 feet) from the patient's head during routine care. Influenza virus was detected by rapid test and polymerase chain reaction.

 

<SNIP  Results>

 

Conclusions. HCPs within 1.829 m of patients with influenza could be exposed to infectious doses of influenza virus, primarily in small-particle aerosols. This finding questions the current paradigm of localized droplet transmission during non–aerosol-generating procedures.

 

(Continue . . . )

 

An accompanying editorial by Caroline Breese Hall is available at InfluenzaVirus: Here, There, Especially Air?.  Both, alas, are behind pay walls.

 

Fortunately we have a fairly detailed press release to look at, which summarizes the key findings thusly.

 

1) Researchers found that patients with influenza can emit small, influenza virus-containing particles into the surrounding air during routine patient care, potentially exposing health care providers to influenza virus up to 6 feet away from infected patients.

 

2) Five patients (19 percent) in study were "super-emitters" who emitted up to 32 times more virus than others. Patients who emit a higher concentration of influenza virus also reported greater severity of illness.

 

3) The findings suggest that more research on how influenza is transmitted is needed and that current influenza infection control recommendations for health providers may need to be reevaluated.

 

I’ve a few excerpts from the press release below, but follow the link to read it in its entirety.

 

Infectious Diseases Society of America

Patients can emit small, influenza-containing particles into the air during routine care

[EMBARGOED FOR JAN. 31, 2013] A new study suggests that patients with influenza can emit small virus-containing particles into the surrounding air during routine patient care, potentially exposing health care providers to influenza. Published in The Journal of Infectious Diseases, the findings raise the possibility that current influenza infection control recommendations may not always be adequate to protect providers from influenza during routine patient care in hospitals.

 

Werner E. Bischoff, MD, PhD, and colleagues from the Wake Forest School of Medicine in North Carolina screened 94 patients for flu-like symptoms during the 2010-2011 influenza season. Study participants had been admitted to the emergency department (52 patients) or an inpatient care unit (42 patients) of Wake Forest Baptist Medical Center, where vaccination for influenza is mandatory for health care providers.

 

Nasopharyngeal swabs were collected from each patient. Samples were analyzed by rapid testing and by PCR analysis. Air samples were obtained by placing three six-stage air samplers from within 1 foot, 3 feet, and 6 feet of patients. No aerosol-generating procedures—such as bronchoscopy, sputum induction, intubation, or cardiopulmonary resuscitation—were conducted while air sampling took place. During air sampling, the number of patients' coughs and sneezes were counted and assessed for severity. Patients also completed a questionnaire at admission to report symptoms and the number of days they were sick.

 

Of the 94 patients enrolled, 61 patients (65 percent) tested positive for influenza virus. Twenty-six (43 percent) released influenza virus into the air. Five patients (19 percent) emitted up to 32 times more virus than others. This group of patients with influenza, described by the researchers as "super-emitters," suggested that some patients may be more likely to transmit influenza than others. High concentration of influenza virus released into the air was associated with high viral loads in nasopharyngeal samples. Patients who emitted more virus also reported greater severity of illness.

 

The current belief is that influenza virus is spread primarily by large particles traveling up to a maximum of 3 to 6 feet from an infected person. Recommended precautions for health providers focus on preventing transmission by large droplets and following special instructions during aerosol-generating procedures. In this study, Dr. Bischoff and his team discovered that the majority of influenza virus in the air samples analyzed was found in small particles during non-aerosol-generating activities up to a 6-foot distance from the patient's head, and that concentrations of virus decreased with distance. The study addressed only the presence of influenza-containing particles near patients during routine care, not the actual transmission of influenza infection to others.

(Continue . . . )

 

The discovery of `super-emitters’ of influenza isn’t a complete surprise, as we’ve seen evidence of `super-spreaders’ of other diseases.

 

In fact, in epidemiology, there is a concept known as the 20/80 rule – that suggests that 20% of the host population contributes to 80% of the spread of a disease.

 

The most infamous super spreader was Typhoid Mary (Mary Mallon) who was an asymptomatic cook who spread the disease to scores of people early in the last century, and who spent much of her life in quarantine.

The concept of super-spreaders made headlines again during the SARS epidemic, where a handful of infected individuals appeared to cause an inordinately high number of secondary cases (see MMWR Severe Acute Respiratory Syndrome --- Singapore, 2003).

 

Despite decades of research, our knowledge of how influenza spreads, and what barriers work well to protect HCWs, remains limited.

 

But today’s study isn’t the first study suggesting a greater role in the aerosolized transmission of influenza (as opposed to large-droplet transmission).

 

In November of 2010, in Study: Aerosolized Transmission Of Influenza, we saw a report on the nosocomial spread of influenza believed to be caused by infectious aerosols spread by an imbalanced indoor airflow.

 

Another study (see Study: Aerosolized Influenza And PPEs) from March of 2012, looked at the effectiveness of various types of PPEs.

 

Researchers simulated the aerosolization of influenza viruses and measured the protective qualities of surgical masks and respirators by constructing a simulated  exam room using `coughing and breathing manikins’.

The major findings:

A surgical mask, as normally worn by HCWs, only blocked 56.6% of infectious virus particles.

 

But . . . if you tightly seal the surgical mask against the face , you can achieve a level of protection approaching that of a well fitted N95 respirator (94.8% versus 99.6%).

 

And a poorly fitted N-95 respirator provided little more protection (66.5%) than a loosely fitted surgical mask.

A few other relevant studies we’ve looked at previously include:

 

PPEs & Transocular Influenza Transmission

Study: Longevity Of Viruses On PPEs

IOM: PPEs For HCWs 2010 Update

 

Complicating matters immensely, while our Strategic National Stockpile contains more than 100 million  N95 and surgical masks (see Caught With Our Masks Down), the demand for PPEs during a serious pandemic would far exceed the supply. 

 

At one time the HHS estimated the nation would need 30 billion masks (27 billion surgical, 5 Billion N95) to deal with a major pandemic (see Time Magazine A New Pandemic Fear: A Shortage of Surgical Masks).

 

Which means that during a global pandemic – when the demand for PPEs will skyrocket – we run the risk of being caught with our masks down again.

EID Journal: The Emergence Of `Totally Resistant TB’

 

(From the WHO 2011 TB Progress Report)

 

# 6896

 

 

The existence of TDR-TB (Totally Drug Resistant Tuberculosis) has been fraught with controversy since the term first sprang into the headlines a little more than a year ago (see Crofsblog India: New TB strain is "totally drug-resistant" (updated)).

The story concerned at least 12 patients treated at an Indian hospital that had been diagnosed with `TDR-TB’. 

 

Not - as has been seen in the past - MDR-TB (multi-drug resistant tuberculosis), and XDR-TB (extensively drug resistant Tuberculosis), but tuberculosis that was supposedly resistant to all known drugs.

 

Varyingly resistant forms of TB have come about primarily as the result of incomplete, irregular, or inappropriate treatment and management of infected patients. Patient compliance for long-term treatment has consistently been a major obstacle.

 

Until now – as difficult as treatment might have been - there has always been some combination of antibiotics that could be used to treat even the most resistant of TB cases.

 

The emergence of a totally resistant form of the disease would be a game-changer, and so these reports began to set off alarm bells around the world.

 

A few days later, in ECDC Comment On Drug Resistant TB In India, we saw calls to avoid using the term TDR-TB until it could be better defined. 

 

From the ECDC report New drug resistant form of tuberculosis reported in India.

 

Total drug resistant TB is a relative notion and depends on the local drugs available and tested on. This term/expression should either be avoided or should be defined worldwide. The World Health Organization (WHO) has internationally-endorsed treatment recommendations for the treatment of drug-susceptible, MDR-TB and XDR-TB.

 

During this time, Maryn McKenna – Flublogia’s favorite scary disease girl – wrote extensively about these developments on her Superbug Blog:

 

Totally Resistant TB: Earliest Cases in Italy

• By Maryn McKenna January 12, 2012

India Reports Completely Drug-Resistant TB

• By Maryn McKenna January 9, 2012 

Totally Drug-Resistant TB: A Patient Is Missing

• By Maryn McKenna January 14, 2012 

 

That same week, in Resistant TB: The Limits Of Surveillance & Reporting, I wrote about the World Health Organization’s initial response to these reports (they did not currently recognize TDR-TB due to reasons stated in their TDR-TB FAQ), along with an article in the Indian Express suggesting that TDR-TB cases may be more widespread than reported. 

 

By the end of January, India’s government was denying the existence of untreatable TB in their country (see Referral: McKenna On India’s Denial Of TDR-TB), a response not dissimilar to their denials of NDM-1.

 

In March of 2012, the World Health Organization  released a statement on the supposed TDR-TB, titled  More evidence and better diagnostics needed before redefining severe forms of drug-resistant TB says WHO.

 

The `TDR-TB’  story simmered quietly for the next few months, that is, until October of 2012, when in EID Journal: Challenges To Defining TDR-TB we looked at an EID Journal article called:

NOTE: Corrected Link

 

Challenges and Controversies in Defining Totally Drug-Resistant Tuberculosis

Peter Cegielski , Paul Nunn, Ekaterina V. Kurbatova, Karin Weyer, Tracy L. Dalton, Douglas F. Wares, Michael F. Iademarco, Kenneth G. Castro, and Mario Raviglione

(Excerpt)

Susceptibility tests for several drugs are poorly reproducible. Few laboratories can test all drugs, and there is no consensus list of all anti-TB drugs. Many drugs are used off-label for highly drug resistant TB, and new drugs formulated to combat resistant strains would render the proposed category obsolete. Labeling TB strains as totally drug resistant might lead providers to think infected patients are untreatable. These challenges must be addressed before defining a new category for highly drug-resistant TB

 

All of which brings us to a new EID Journal article (abstract reparagraphed for readability), published yesterday, called:

 

Emergence and Spread of Extensively and Totally Drug-Resistant Tuberculosis, South Africa

Marisa Klopper, Robin Mark Warren, Cindy Hayes, Nicolaas Claudius Gey van Pittius, Elizabeth Maria Streicher, Borna Müller, Frederick Adriaan Sirgel, Mamisa Chabula-Nxiweni, Ebrahim Hoosain, Gerrit Coetzee, Paul David van Helden, Thomas Calldo Victor, and André Phillip Trollip

Abstract

Factors driving the increase in drug-resistant tuberculosis (TB) in the Eastern Cape Province, South Africa, are not understood. Using a convenience sample of 309 drug-susceptible and 342 multidrug-resistant (MDR) TB isolates, collected July 2008–July 2009, we characterized them by spoligotyping, DNA fingerprinting, insertion site mapping, and targeted DNA sequencing.

 

Analysis of molecular-based data showed diverse genetic backgrounds among drug-sensitive and MDR TB sensu stricto isolates in contrast to restricted genetic backgrounds among pre–extensively drug-resistant (pre-XDR) TB and XDR TB isolates.

 

Second-line drug resistance was significantly associated with the atypical Beijing genotype. DNA fingerprinting and sequencing demonstrated that the pre-XDR and XDR atypical Beijing isolates evolved from a common progenitor; 85% and 92%, respectively, were clustered, indicating transmission.

 

Ninety-three percent of atypical XDR Beijing isolates had mutations that confer resistance to 10 anti-TB drugs, and some isolates also were resistant to para-aminosalicylic acid.

 

These findings suggest the emergence of totally drug-resistant TB.

 

 

For those unfamiliar with para-aminosalicylic acid (PAS), it’s an older drug discovered in 1944, and one of the first drugs to effectively treat TB.  Its use as a first-line drug treatment was discontinued when newer antibiotics – like Rifampin - became available.

 

PAS is still used in treating XDR-TB although its value is limited and there are problems with toxicity.

 

Whether we should label them XDR-TB or TDR-TB may be debatable, but what is not is that we continue to see an erosion in our arsenal of effective drugs as new, resistant forms of TB emerge and spread.

 

As reported in last week’s MMWR, getting the best drugs to treat resistant TB can be difficult, even here in the United States (Interruptions in Supplies of Second-Line Antituberculosis Drugs — United States, 2005–2012).

 

Semantics aside, if you are unlucky enough to be infected by one of these resistant TB strains - and no effective drug is available to you  – then the fine distinction over whether it is XDR or TDR TB is of little practical consequence to you.

Meanwhile, In Egypt . . .

 

Credit FAO/EMPRES

 

# 6895

 

Since the Arab Spring revolution of 2011 and the subsequent political turmoil, getting timely bird flu news out of Egypt has been challenging. Media outlets appear less inclined to report on outbreaks than they were a few years ago.

 

Nevertheless, the newshounds at FluTrackers have managed to keep pretty good track of recent poultry outbreaks in this thread.  A few very recent examples include:

 

Highly Pathogenic Avian Influenza H5N1, Egypt, poultry (FAO, January 23 2013, edited): Qena

 

Egypt- Bird flu H5N1 outbreaks in poultry in Menoufia governorate

 

Execution of 7000 birds after an outbreak of bird flu in Luxor

 

Fears of the return of bird flu to Beni Suef after the death of large amounts of birds

 

Last month, in Egypt: A Paltry Poultry Vaccine, we looked at a new study – conducted by the Virology department at St. Jude Children’s Research Hospital -  appearing in the journal Poultry Science, that gauged the effectiveness of six commercially available H5 poultry vaccines currently deployed in Egypt.

 

Of the 6 vaccines tested, only one (based on a locally acquired H5N1 seed virus) actually appeared to offer protection.

 

So while not making many international headlines of late, bird flu obviously remains endemic in poultry - and a serious concern - in Egypt.

 

The last WHO confirmed human H5N1 case reported out of Egypt was last July (see WHO Avian influenza – situation in Egypt – update), the 11th such report of 2012. 

 

Very early this morning, via a barebones FAO/EMPRES report, we saw what appears to be a report of a confirmed human H5N1 infection in Al Buhayrah (behera), Egypt.

 

With so little data available, it seemed prudent to wait to see if more information would surface before blogging it.

 

Over the past few hours I’m happy to report the newshounds of FluTrackers have found two stories  (h/t Sharon Sanders & Laidback Al) in the Arab media that appear to corroborate this FAO report.

 

Details are still scant, and the machine translations a bit awkward, but both articles indicate that a woman died last recently in Beheira from an H5N1 infection.

 

This report from youm7.com.

 

Health: low mortality rate "bird flu" in Egypt 63%

Tuesday, January 29, 2013 - 18:27

 

The Ministry of Health and Population, the number of deaths bird flu virus decreased in Egypt by 63%, and by comparing the number of deaths from the disease in the period from January 2012 to January 2013, which amounted to 6 cases only the latest of a lady in Beheira, died last Saturday, in the same period from the previous year.

 

The ministry statement, that the total number of deaths from bird flu, since it emerged in Egypt in 2006 and so far reached 61 cases

 

And this report from albedaiah.com.

 

Health: recording the first death from bird flu during 2013 .. The infection rate drops 63%

 

Albedaiah at: Tuesday, January 29, 2013 - 18:21

The Ministry of Health and Population and the death of a woman in Beheira this week due to bird flu, bringing the total dead during the year since January 2012 to January 2013 is 6 cases, a decrease of 63% from the same period of the previous year.

Bringing the total number of deaths since the disease appeared in Egypt in 2006 is 61 cases.

 

The World Health Organization recently changed the way it reports on human infections with the H5N1 virus and posted the following notice.

 

Henceforward, WHO will publish information on human cases with H5N1 avian influenza infection on a monthly basis on the Influenza webpage.

 

Cases of human infection with H5N1 will only be reported on Disease Outbreak News for events that are unusual or associated with potential increased risks.

 

So we may have to wait awhile before we know if this is truly a confirmed H5N1 fatality.

FAO Warns On Complacency

Photo Credit – FAO

# 6894

 

With bird flu prominently back in the spotlight this week, the timing of the following announcement from the FAO probably couldn’t be better.

 

Despite gains in the battle against the H5N1 virus (see chart below) in recent years, the ongoing global economic downturn has prompted many nations to cut back on their surveillance and testing for animal diseases.

 

Declining human cases since 2005-2006  - Influenza at the human–animal interface – Sept 2012

 

 

Today the the UN Food and Agriculture Organization (FAO) issued a statement warning of the dangers of complacency when it comes to serious global threats, like H5N1 (h/t Giuseppe Michieli on FluTrackers).

 

 

FAO urges stronger measures on global health threats

World risks new bird flu surge if countries drop their guard

With animal disease threats, prevention is better than cure

29 January 2013, Rome - The world risks a repeat of the disastrous 2006 bird flu outbreaks unless surveillance and control of this and other dangerous animal diseases is strengthened globally, FAO warns.

 

"The continuing international economic downturn means less money is available for prevention of H5N1 bird flu and other threats of animal origin.  This is not only true for international organizations but also countries themselves," says FAO Chief Veterinary Officer Juan Lubroth.  "Even though everyone knows that prevention is better than cure, I am worried because in the current climate governments are unable to keep up their guard."

Continued strict vigilance is required, however, given that large reservoirs of the H5N1 virus still exist in some countries in Asia and the Middle East, in which the disease has become endemic. Without adequate controls, it could easily spread globally as it did at its peak in 2006, when  63 countries were affected.

Investing makes sense

Investing more in prevention makes economic sense given the huge toll inflicted by a full-scale pandemic. Between 2003 and 2011 the disease killed or forced the culling of more than 400 million domestic chickens and ducks and caused an estimated $20 billion of economic damage.

 

Like several animal diseases, H5N1 can also be transmitted to humans. Between 2003 and 2011, it infected over 500 people and killed more than 300, according to the World Health Organization.

 

"I see inaction in the face of very real threats to the health of animals and people," Lubroth says.

 

This is all the more regrettable as it has been shown that appropriate measures can completely eliminate H5N1 from the poultry sector and thus protect human health and welfare. Domestic poultry are now virus-free in most of the 63 countries infected in 2006, including Turkey, Hong Kong, Thailand and Nigeria. And, after many years of hard work and international financial commitment, substantial headway is finally being made against bird flu in Indonesia.

(Continue . . . )

Cambodia: WHO/MOH Statement On 4th & 5th H5N1 Cases

Base map credit – Wikipedia

 

# 6893

 

Overnight (U.S. time) the Western Pacific Regional Office (WPRO) of the World Health Organization, and the Cambodian Ministry of Health released a statement clarifying the current H5N1 case count in that country.

 

The number of cases detected over the past three weeks now stands at five, with four of them fatalities. While these 5 cases are spread across 4 provinces, they are generally located in the southern region of the country.

 

You’ll find details on the first three cases here, along with my coverage here and here.  An epidemiological investigation into how these cases came about is underway.

 

 

Fourth and fifth new human cases of avian influenza H5N1 in Cambodia in 2013

Joint news release of the Ministry of Health of the Kingdom of Cambodia and World Health Organization

PHNOM PENH, 29 January 2013 - The Ministry of Health (MoH) of the Kingdom of Cambodia wishes to advise members of the public that two new more cases of avian influenza has been confirmed positive for the H5N1 virus.

 

The fourth case is a 17-month-old girl from Prey Nheat village, Prey Nheat commune, Kong Pisey district in Kampong Speu province has been diagnosed with H5N1 influenza on 26th January 2013 by Institut Pasteur du Cambodge. She developed symptoms on 13th January 2013 with fever, cough, runny nose, and vomiting. She was initially treated by local private practitioners. Her condition worsened and she was admitted to Kantha Bopha Hospital on 17th January with fever, cough, somnolence, and dyspnoea. Unfortunately, despite intensive medical care, she died on 28th January. There is evidence of recent deaths among poultry in the village and the girl had history of coming into contact with poultry prior to becoming sick.

 

In the fifth case, a 9-year-old girl from Thmei village, Thmei commune, Toeuk Chhou district, Kampot province has been diagnosed with H5N1 influenza on 28th January 2013 by Institut Pasteur du Cambodge. She became sick on 19th January, 2013 suffering with fever and cough. She was initially treated by local private practitioners. Her condition worsened and she was admitted to Kantha Bopha Hospital with fever cough, somnolence and dyspnoea on 27th January. Despite intensive medical care, the patient died on 28th January. There is evidence of recent deaths among poultry in the village. This girl is the twenty-six person in Cambodia to become infected with H5N1 virus, and the fifth person this year and the twenty-three person to die from complications of the disease. Of all the twenty six cases, 17 were children under 14, and seventeen of the twenty six confirmed cases occurred in females.

 

"Avian influenza H5N1 is still a threat to the health of Cambodians. This is the fourth and the fifth cases of H5N1 infection in human in early this year, and children still seem to be most vulnerable. I urge parents and guardians to keep children away from sick or dead poultry, discourage them from playing in areas where poultry stay and wash their hands often. If they have fast or difficulty breathing, they should be brought to medical attention at the nearest health facilities and attending physicians be made aware of any exposure to sick or dead poultry." said HE Mam Bunheng, Minister of Health.

 

The Ministry of Health's Rapid Response Teams (RRT) have gone to the hospitals and the field to identify the patient’s close contacts, any epidemiological linkage among the three cases and initiate preventive treatment as required. In addition, public health education campaigns are being conducted in the villages to inform families on how to protect themselves from contracting avian influenza. The government's message is - wash hands often; keep children away from poultry; keep poultry away from living areas; do not eat sick poultry; and all poultry eaten should be well cooked.

(Continue . . .)

 

 

Given the number of cases in recent weeks, and the call for greater scrutiny and testing of hospitalized patients, it would not be unreasonable to expect that more cases may turn up.

 

The standard caveat remains, that so far H5N1 remains primarily adapted to avian physiology, and only rarely infects humans.

 

While the investigations continue, so far, there are no indications of human-to-human spread among these recent cases in Cambodia.

 

As I wrote last Saturday in cases in Health Vigilance For The Chinese New Years, concerns over infectious disease always run higher during this annual holiday. This time of year people and poultry are on the move across much of Asia, and so we’ll be watching carefully for signs of increase or geographic spread of H5N1 infections over the next few weeks.

HPA: Unusual Number Of PVL Pneumonia Cases In the UK

Credit CDC

 

# 6892

 

In an article called Warning over killer pneumonia linked to flu, Rebecca Smith, Medical Editor for The Telegraph writes today that a rare type of bacterial pneumonia – one that usually only accounts for 30 to 40 cases each year in the UK - has been identified in 18 cases of community acquired pneumonia between December 6th and January 7th.

 

The culprit is a strain of Staphylococcus aureus that carries a gene for PVL (Panton-Valentine leukocidin) – which is a potent cytotoxin that can destroy human neutrophils (white blood cells), spark severe infections, and cause necrotizing pneumonia.

 

PVL producing genes have been detected in at least 14 different strains of S. aureus (cite BMJ), but are found in less than 2% of all S. aureus bacteria. It is most commonly associated with aggressive skin and soft tissue infections (SSTIs), but it is also the cause of a small number of severe (usually community-acquired) pneumonia cases each year. 

 

S. aureus is a very common bacteria that is carried asymptomatically by as much as 30% of the population  – including some strains with the PVL gene – as part of the normal bacterial flora of their skin and mucus membranes (see Coffee, Tea, or MRSA?).

 

The HPA website describes PVL (updated July 2012) this way:

 

PVL-associated Staphylococcus aureus

Panton-Valentine Leukocidin (PVL) is a toxic substance produced by some strains of Staphylococcus aureus which is associated with an increased ability to cause disease.

 

Although several other countries have encountered widespread problems with PVL-related disease, infections caused by PVL remain uncommon in the UK and, to date, most have been caused by bacteria which are sensitive to a range of antibiotics.

 

PVL has been seen in the UK since the 1950s and 60s but cases continue to be seen here only in small numbers. There is currently no UK-based evidence to suggest that children are more vulnerable than other groups to PVL-related infections or that these infections are acquired or spread through playgrounds.

 

The risk to the UK general public of becoming infected with PVL Staphylococcus aureus is small but the Agency is actively working alongside healthcare colleagues to raise awareness of this infection, as well as ensuring appropriate research continues to monitor trends in infection.

 

PVL genes can be found in  both methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) strains.  According to today’s article in The Telegraph.

 

The 18 cases have all needed intensive care and several required sophisticated life-support known as ECMO, where oxygen is pumped into the blood outside the body because the lungs are overwhelmed with infection.

 

The patients ranged in age from four to 63 years with a median age of 41 and most have flu-like symptoms before developing pneumonia. In five cases the bug had spread between family members.

 

The Telegraph article refers to an HPA bulletin on these cases, but I’ve been unable to locate it as of this writing.  I’ll update this post with a link when it becomes available.

 

From the Annals of Intensive Care in 2011, we get some interesting research on PVL pneumonia, that looked at 32 case reports, with an overall mortality rate of 41%. 

 

They describe the infection:

 

Community-acquired necrotizing pneumonia due to S. aureus-secreting PLV toxin is a highly lethal infection, affecting a young and healthy population group [5]. The hallmarks are an influenza-like prodrome, leukopenia, rapid progression to septic shock, and respiratory distress, with multilobar necrosis and haemoptysis [5,6,14].

 

The Open Access article is available at:

Community-acquired necrotizing pneumonia due to methicillin-sensitive Staphylococcus aureus secreting Panton-Valentine leukocidin: a review of case reports

Lukas Kreienbuehl^1*, Emmanuel Charbonney² and Philippe Eggimann

 

In examining the records of 32 patients, they concluded:

 

Conclusions

Necrotizing pneumonia due to PVL-secreting S. aureus mandates prompt recognition and specific treatment to prevent premature death in immunocompetent patients.

 

Early suspicion should be triggered by the presence of influenza-like prodrome, leucopenia, rapid progression to septic shock, respiratory distress with multilobar necrosis, and hemoptysis.

 

For PVL-secreting MSSA-necrotizing pneumonia, influenza-like prodrome may be associated with fatal outcome, whereas previous SSTI may reduce mortality. Further studies based on a larger patient number are necessary to confirm this finding.

 

Today’s story from the UK mention 5 cases of family transmission, which is somewhat reminiscent of a story we followed last spring at the end of what was an otherwise lackluster 2011-12 flu season.

 

Our attention was briefly directed towards three members of a family (out of five who fell ill) that died from a respiratory infection in Calvert County, Maryland (see Calvert County: Update On Fatal Cluster Of Respiratory Illness).

 

While these deaths made national headlines and spurred considerable speculation as to the viral cause, in the end we learned that it was seasonal H3N2 influenza, exacerbated by a MRSA (or necrotizing) pneumonia co-infection.

 

According to The Telegraph article, the HPA is not worried this will to turn into an epidemic, but since early diagnosis is crucial, they are urging that, “Healthcare personnel should remain vigilant for such cases, especially during the influenza/ respiratory virus season.”

 

The HPA provides the following HCP guidance for the treatment of PVL pneumonia on their website.

 

Steering Group on Healthcare Associated Infection; Guidance on the diagnosis and management of PVL-associated Staphylococcus aureus infections (PVL-SA) in England, 2nd Edition. 2008

 

Management of PVL-Staphylococcus aureus, Health Protection Agency, Local and Regional Services; Recommendations for Practice 2010

 

Staphylococcus aureus, Health Protection Agency (HPA)

Cambodia: AP Reports 2 More H5N1 Fatalities

 

# 6890

 

The Associated press is reporting that both children reported earlier as being hospitalized (see Irin News: Reporting 4th Cambodian H5N1 Case) with the H5N1 virus in Cambodia have now died.

 

This from the Vancouver Sun.

 

Cambodia reports 2 new fatal cases of bird flu in humans, surpassing total for all of 2012

By The Associated Press January 28, 2013 8:40 AM

PHNOM PENH, Cambodia - Two more children have died in Cambodia of bird flu, bringing the number of fatal cases to four since the start of this year.

The Cambodian office of the U.N.'s World Health Organization said a 17-month-old girl from central Kampong Speu province and a 9-year-old girl from southern Kampot province died Monday after being hospitalized

(Continue . . . )

 

 

If confirmed, it will mean of the 16 known human infections reported out of Cambodia since 2010, none have survived.  And since the first human case was reported in 2005, just 2 of 25 known victims will have survived (a dismal 92% fatality rate).

 

In a report carried earlier today on Crofsblog (see Cambodia: More details on the fourth H5N1 case) an article in The Phnom Penh Post Fourth bird flu case confirmed quotes a local medical expert as saying:

 

Due to less-rigorous monitoring of the disease in other hospitals, the cases seen in Kantha Bopha hospital were likely just the “tip of the iceberg”, said Dr Philippe Buchy, head of the virology unit at the Institut Pasteur du Cambodge, the medical research centre that tested the recent cases.

 

As I pointed out this morning in Irin News: Reporting 4th Cambodian H5N1 Case, there is always a degree of ambiguity when it comes to detecting and counting cases of H5N1 - or any other disease – particularly in low resource countries.

VOA News On 4th Cambodian H5N1 Case

 

# 6889

 

A second reliable news source, the  Voice of America, corroborates the report of the 4th Cambodian H5N1 case in recent weeks, which I blogged about earlier this morning (see Irin News: Reporting 4th Cambodian H5N1 Case for details).

 

This from the VOA.

 

 

New Bird Flu Case Raises Fears in Cambodia

Robert Carmichael

January 28, 2013

PHNOM PENH — Two Cambodians have already died from bird flu in 2013, making a worrying start to the year.

 

Now a two-year-old Cambodian girl is in a serious condition in Phnom Penh after being hospitalized with the H5N1 virus, also known as avian, or bird, flu.

 

Sonny Inbaraj Krishnan, the communications officer for the World Health Organization in Phnom Penh, says the development has health professionals concerned.

“This is the fourth case this month of human influenza H5N1," Krishnan said. "Last year we had three cases, so within one month in the new year we've got four cases, and we're quite concerned about that.”

 

(Continue . . .)

Bangladesh: Updating Nipah & The CDC Director’s Visit

Credit – The CDC’s GDDER

# 6888

 

I wrote at length yesterday on the Nipah virus, and the current outbreak in Bangladesh (see Bangladesh: Nipah Returns, so I’ll not bother repeating those points this morning. 

 

What is new this morning is a report from Xinhua News indicating that three more Nipah cases (two fatal) have been reported in Bangladesh, and the arrival on Saturday of U.S. CDC Director Thomas Frieden in Dhaka to discuss their plans to assist that nation in strengthening disease surveillance.

 

First the report from Xinhua on the latest Nipah cases.

 

Virus Nipah strikes back in Bangladesh, claims 8 more lives within one week

2013-01-28 10:00:41 GMT2013-01-28 18:00:41(Beijing Time) by Naim-Ul-Karim

 

DHAKA, Jan. 28 (Xinhua) -- Bangladesh on Monday reported eight more deaths from infection with the deadly Nipah virus within one week as the bat-borne disease has struck early and hard.

 

The country's Institute of Epidemiology, Disease Control & Research (IEDCR) confirmed two more deaths Sunday from the Nipah infection, tallying the toll at eight from Jan. 22.

 

"Outbreak of the deadly Nipah virus has claimed eight lives since January 22," Mahmudur Raman, head of the IEDCR, told Xinhua Monday.

 

"As of today, there are 11 cases from eight Bangladesh districts including Dhaka and eight of them died," he said, adding "Three Nipah-infected patients remain critically ill."

(Continue . . .)

 

The Institute of Epidemiology, Disease Control and Research (IEDCR) in Bangladesh has far more to deal with than just the Nipah virus. The 150+ million inhabitants of Bangladesh are also subject to H5N1 bird flu, Dengue, Anthrax, and Chikungunya, along with many other diseases.

 

The United States has been providing ongoing technical, financial, and logistical support to Bangladesh for several years to assist them in upgrading their disease detection and surveillance systems.  Hence the visit this past weekend by the CDC’s Director.

The news site BDNews24 has details of Director Frieden’s 2-day visit.  Follow the link to read:

 

 

Bangladesh to be 'Global Disease Detection site'

Senior Correspondent,  bdnews24.com

Published: 2013-01-27 14:56:52.0 Updated: 2013-01-27 18:24:00.0

The US Centres for Disease Control and Prevention (CDC) is strengthening its ties with Bangladesh as part of its initiative to protect the global community from the urgent public health threats.

(Continue . . . )

 

 

Improving disease surveillance, detection, and prevention in those regions where emerging diseases are most apt to occur is not only the humanitarian thing to do, it also helps to keep the world from being blind-sided by emerging infectious disease threats.

 

We’ve far too many `blind spots’ around the world where a novel virus could emerge, and take hold in the population, before it could be identified and (hopefully) contained.

 

To counter that threat, the CDC has developed a Global Disease Detection and Response division (GDDER).

 

 

Global Health - Global Disease Detection and Emergency Response

The Division of Global Disease Detection and Emergency Response (GDDER) protects Americans and the global community from urgent public health threats and provides public health relief for humanitarian emergencies. Activities include:

• Detecting and containing emerging health threats
• Deploying CDC experts 24 hours a day, 7 days a week at host country requests for technical assistance and other support
• Building capacity by providing technical assistance in support of International Health Regulations (IHR)
• Promoting policies for public health and bio-security
• Improving the health of populations affected by complex humanitarian emergencies.

 

According to the GDDER website, nations are selected by the following criteria:

 

• Public health significance: The country has a high population density or history of infectious diseases or expected potential for emerging diseases;
• Country commitment: The country supports and values partnership with CDC and will actively engage in collaborative activities and identify new partners;
• Established CDC presence: The country has an established, effective working relationship with CDC and supports CDC staff in-country;
• Established regional reach: The country has the infrastructure and regional stature to serve as regional resource, or is already acting as a regional leader in other arenas;
• International partner presence: The country has other U.S. Government agencies and international partners operating in-country.

The GDDER is a program that will hopefully not only help alert us of an emerging infectious disease threat, but that may also provide a chance to stop it in its tracks before it can spread.

While there are no guarantees of success, this is a public health advantage that previous generations could only have dreamed of.

Irin News: Reporting 4th Cambodian H5N1 Case

 

 

 

IRIN (Integrated Regional Information Networks)was founded in 1995, and is part of the UN Office for the Coordination of Humanitarian Affairs.  While technically a part of the UN, it maintains editorial independence, and its reports do not necessarily reflect the views of the United Nations and its agencies, not its member states.

 

# 6887

 

UPDATED : We now have a second news source on this story VOA News On 4th Cambodian H5N1 Case

 

Burying the lede just a little, a report appears in Irin News this morning on an awareness campaign on bird flu prevention in Cambodia, that bumps the number of new cases from the three we learned about on Friday (see WHO/ Cambodian MOH Statement On H5N1 Cases) to four.

 

Caveat: A quick scan of the Cambodian MOH  and Cambodian CDC sites, and other news sources this morning, has yet to turn up confirmation of this report.

 

Irin News, is generally a pretty reliable source, but I would view this report with caution until we get official confirmation (see update VOA News On 4th Cambodian H5N1 Case).

 

The story indicates that a second case was confirmed yesterday (Jan 27th) from Kampong Speu Province, when a 17-month old girl tested positive. 

 

We have no word on her condition, although the article continues to cite two fatal cases.

 

Some excerpts from the report, but follow the link to read it in its entirety. I’ll have more when you return.

 

 

Cambodian bird flu deaths prompt awareness drive

PHNOM PENH, 28 January 2013 (IRIN) - Health authorities in Cambodia will bolster public awareness campaigns on H5N1 avian influenza after four people became infected in January, resulting in two fatalities.

 

“Ongoing public awareness campaigns need to be reinforced through TV and radio,” Sok Touch, director of Cambodia’s Communicable Disease Control Department (CDC), told IRIN on 28 January, calling on people to be vigilant. “We’re planning on doing this immediately as there is no room for complacency.”

 

The four cases of H5N1 avian influenza, commonly known as bird flu, are the first confirmed in Cambodia this year. There were three recorded cases (all fatal) in 2012.

Since 2005, 24 people have been infected resulting in 21 deaths, according to WHO, with over half of the infections in children under 14.

According to a joint statement from the Ministry of Health and World Health Organization (WHO) on 25 January, an eight-month-old boy from the capital Phnom Penh recovered after being infected with bird flu, while a 15-year-old girl from southwestern Takeo Province and a 35-year-old man from southwestern Kampong Speu Province died after contracting the virus.

The CDC said the boy had contact with chickens at a market, but the girl from Takeo and the man from Kampong Speu both fell ill after cooking dead chickens gathered from their villages.

A fourth case, also in Kampong Speu, was confirmed by the Ministry of Health on 27 January, when a 17-month-old girl tested positive for H5N1.

“We are working closely with the Ministry of Health to enhance surveillance of H5N1,” said Sonny Krishnan, communications officer with WHO in Phnom Penh, adding that WHO did not know yet if there was a link between the cases of the girl and 35-year-old man.

(Continue . . .)

 

 

If confirmed by the World Health Organization, this 4th reported case will make the 25th known human infection from Cambodia, 21 of which have been fatal.

 

How many human H5N1 infections (and deaths) have really occurred in Cambodia, and around the world, is a matter of some debate.

 

While the evidence for there being a lot of mild cases is sparse (see The Great CFR Divide), it does seem likely that we are missing some number of cases.

 

Last year, in WHO: 2012 World Health Statistics Report, we looked at the lack of disease and mortality information available from many low-resource countries.

 

Among low income countries, only about 1% of deaths (and their causes) are recorded, while just 34 countries – representing 15% of the world’s population – produce high quality cause-of-death documentation.

 

 

The truth is there  much ambiguity regarding the true prevalence of nearly all diseases around the world.

 

In 2010, at a time when the WHO estimated there to be roughly 15,000 malarial deaths each year in India, a study appeared in The Lancet which claimed the real death toll was likely 10-fold higher (see Lancet: India's Invisible Malaria Burden).

 

Millions of people die each year around the world without ever receiving modern medical care, much less sophisticated lab testing for exotic diseases. Living in mostly rural areas of developing countries, they are often buried quickly with no cause of death identified.

 

So while we carefully track individual cases of H5N1 infection, we do so with the knowledge that we are probably not counting all of the cases that occur.

 

Although we continue to see scattered human infections around the globe, and the virus continues to evolve (see H5N1: An Increasingly Complex Family Tree), for now H5N1 is primarily a threat to poultry and to a lesser extent (in parts of Asia and the Middle East) to people who have direct contact with infected birds.

 

The virus remains poorly adapted to human physiology, and despite ample opportunities to cause illness in humans, only causes rare, sporadic infections.

 

The concern, of course, is that over time the virus will adapt further and pose a pandemic threat to humans. So we watch its progress with great interest, looking for any signs that the virus is better adapting to human hosts.

Bangladesh: Nipah Returns

Credit WHO

 

# 6886

 

A couple of years ago, when film maker Steven Soderbergh made the pandemic thriller `Contagion’, he availed himself of the scientific expertise of epidemiologist Ian Lipkin - director of Columbia University’s Center for Infection and Immunity in New York - who served as technical advisor for the film.

 

Rather than use a traditional influenza virus for their fictional pandemic, Professor Lipkin painstakingly created a fictional MEV-1 pandemic virus based on a mutated Nipah virus.

 

As I wrote in The Scientific Plausibility of `Contagion’, while the Nipah virus isn’t currently a pandemic threat - it is possible, that with a few choice mutations in the right places - that could change.

 

The first known Nipah outbreak occurred in Malaysia in 1998, when the virus infected local swine herds (presumably by bats), and spread to hundreds of people causing the loss over 100 lives. The virus was then exported via live pigs to Singapore, where 11 more people died.

 

Since then, the Nipah virus – which is normally hosted by fruit bats of the Pteropodidae family – has only sparked limited outbreaks in Southeast Asia, with Bangladesh being the most commonly affected country.

 

Usually the virus jumps to humans through the consumption of raw (uncooked) date palm juice, which is `tapped’ much in the same way as maple trees are in this country for their syrup.

 

Bats can roost in these trees and will occasionally contaminate the collected juice with their urine or feces, which each winter leads to stories like the one below from The Daily Star:

 

Sunday, January 27, 2013

 

6 died so far of Nipah

Staff Correspondent

Six of the eight people infected with Nipah virus this month have died so far, Institute of Epidemiology, Disease Control and Research (IEDCR) confirmed on Friday.

 

The dead are from Dhaka, Rajbari, Jhenidah, Naogaon, Natore and Gaibandha.

 

Yesterday, a man was in a critical condition at a private hospital in the capital.

 

On January 11, eight of his family drank raw date juice brought from Bhaluka, Mymensingh.

 

IEDCR Director Prof Mahmudur Rahman said, "Examination of his blood sample confirmed on Wednesday that he was infected with Nipah virus."

 

His eight-year-old son died of the virus on Tuesday.

 

Examinations of blood samples of the six others found no evidence of infection.

 

In Natore, a mother passed away while her eight-month-old baby has been infected.

(Continue . . .)

 

 

To date fewer than 200 cases have been reported in Bangladesh, but of those, roughly 75% have died.

 

While the  initial jump to humans is usually associated with drinking raw date juice, once it gets into the human population, it can spread from human-to-human.

 

How it is transmitted from one person to another isn’t well understood, although it is thought to be mostly through direct contact with respiratory secretions or other bodily fluids. 

 

Nosocomial (in-hospital) transmission has been reported on several occasions.

 

In 2007 researchers published a study that looked at an outbreak in a Bangladeshi village during 2004, that found evidence of H-2-H transmission. 

 

The following comes from the CDC EID Journal.

 

Volume 13, Number 7–July 2007

Research

Person-to-Person Transmission of Nipah Virus in a Bangladeshi Community

Emily S. Gurley,Joel M. Montgomery, M. Jahangir Hossain, Michael Bell,Abul Kalam Azad, Mohammed Rafiqul Islam, Mohammed Abdur Rahim Molla, Darin S. Carroll,† Thomas G. Ksiazek, Paul A. Rota, Luis Lowe, James A. Comer, Pierre Rollin, Markus Czub,Allen Grolla, Heinz Feldmann, Stephen P. Luby, Jennifer L. Woodward, and Robert F. Breiman

Abstract

An encephalitis outbreak was investigated in Faridpur District, Bangladesh, in April–May 2004 to determine the cause of the outbreak and risk factors for disease. Biologic specimens were tested for Nipah virus. Surfaces were evaluated for Nipah virus contamination by using reverse transcription–PCR (RT-PCR).

 

Thirty-six cases of Nipah virus illness were identified; 75% of case-patients died. Multiple peaks of illness occurred, and 33 case-patients had close contact with another Nipah virus patient before their illness. Results from a case-control study showed that contact with 1 patient carried the highest risk for infection (odds ratio 6.7, 95% confidence interval 2.9–16.8, p<0.001).

 

RT-PCR testing of environmental samples confirmed Nipah virus contamination of hospital surfaces. This investigation provides evidence for person-to-person transmission of Nipah virus. Capacity for person-to-person transmission increases the potential for wider spread of this highly lethal pathogen and highlights the need for infection control strategies for resource-poor settings.

 

 

While most human infections present with encephalitic symptoms, those few who develop respiratory difficulties appear to be the ones most able to infect others – raising the possibility of large-droplet transmission.

 

The World Health Organization has this to say about limiting transmission of the virus in their NIPAH VIRUS FAQ.

 

Reducing the risk of infection in people

In the absence of a vaccine, the only way to reduce infection in people is by raising awareness of the risk factors and educating people about the measures they can take to reduce exposure to the virus.

 

Public health educational messages should focus on the following.

• Reducing the risk of bat-to-human transmission. Efforts to prevent transmission should first focus on decreasing bat access to date palm sap. Freshly collected date palm juice should also be boiled and fruits should be thoroughly washed and peeled before consumption.
• Reducing the risk of human-to-human transmission. Close physical contact with Nipah virus-infected people should be avoided. Gloves and protective equipment should be worn when taking care of ill people. Regular hand washing should be carried out after caring for or visiting sick people.
• Reducing the risk of animal-to-human transmission. Gloves and other protective clothing should be worn while handling sick animals or their tissues, and during slaughtering and culling procedures.

Controlling infection in health-care settings

Health-care workers caring for patients with suspected or confirmed Nipah virus infection, or handling specimens from them, should implement standard infection control precautions.

 

Samples taken from people and animals with suspected Nipah virus infection should be handled by trained staff working in suitably equipped laboratories.

 

 

Over the past 15 years bats have been linked to outbreaks of Nipah, Hendra, and SARS-CoV in humans and are `suspected’ to be at least one of the reservoirs for the Ebola and Marburg viruses.

 

In 2012, for the first time a `bat influenza virus’ was discovered (see A New Flu Comes Up To Bat), and the newly detected novel coronavirus from the Middle East - EMC/2012 – has been tentatively linked to bats as well (see EID Journal: EMC/2012–related Coronaviruses in Bats).

 

Although most researchers expect the next pandemic to come from a swine or avian influenza, other pathogens carried by different species cannot be ignored. 

 

With the exception of the SARS outbreak of 2002-2003, bat-borne pathogens have not produced any large-scale human epidemics (that we know of).

 

But viruses have a habit of changing and evolving over time, making the monitoring of even small outbreaks of relatively rare infectious diseases of more than just academic interest.

 

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

 

EID Journal: Ebola Virus Antibodies From Bats In Bangladesh

Disease Transmission At The Human-Animal Interface

Coronavirus `Closely Related’ To HK Bat Strains

Virology Journal: Ebola Virus In Chinese Bats