Tuesday, September 30, 2014

CDC Statement On Dallas Ebola Case

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# 9031

 


The CDC has posted the following statement on today’s announced Ebola case in Dallas, Tx.

 

First Imported Case of Ebola Diagnosed in the United States

 

CDC confirmed on September 30, 2014, through laboratory tests, the first case of Ebola to be diagnosed in the United States in a person who had traveled to Dallas, Texas from West Africa. The patient did not have symptoms when leaving West Africa, but developed symptoms approximately five days after arriving in the United States.

The person sought medical care at Texas Health Presbyterian Hospital of Dallas after developing symptoms consistent with Ebola. Based on the person’s travel history and symptoms, CDC recommended testing for Ebola. The medical facility isolated the patient and sent specimens for testing at CDC and at a Texas lab participating in CDC’s Laboratory Response Network. CDC and the Texas Health Department reported the laboratory test results to the medical center to inform the patient. Local public health officials have begun identifying close contacts of the person for further daily monitoring for 21 days after exposure.

The ill person did not exhibit symptoms of Ebola during the flights from West Africa and CDC does not recommend that people on the same commercial airline flights undergo monitoring, as Ebola is only contagious if the person is experiencing active symptoms. The person reported developing symptoms several days after the return flight.

CDC recognizes that even a single case of Ebola diagnosed in the United States raises concerns. Knowing the possibility exists, medical and public health professionals across the country have been preparing to respond. CDC and public health officials in Texas are taking precautions to identify people who have had close personal contact with the ill person and health care professionals have been reminded to use meticulous infection control at all times.

We know how to stop Ebola’s further spread: thorough case finding, isolation of ill people, contacting people exposed to the ill person, and further isolation of contacts if they develop symptoms. The U.S. public health and medical systems have had prior experience with sporadic cases of diseases such as Ebola. In the past decade, the United States had 5 imported cases of Viral Hemorrhagic Fever (VHF) diseases similar to Ebola (1 Marburg, 4 Lassa). None resulted in any transmission in the United States.

 

Dallas,Tx Patient Tests Positive For Ebola

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# 9130

 

In what is shaping up to be the worst-kept news embargo of all time, this afternoon the CDC has announced that the first undiagnosed Ebola case has arrived in the United States, and has tested positive after being isolated in a Dallas, Texas hospital since yesterday.

 

Now, before anyone is tempted to head down to the bunker, this was an expected development and one for which hospitals and public health departments across the country have been preparing for some time. 

 

While it is conceivable that an Ebola infected visitor could pass on the virus to close contacts here in the United States, the risks of seeing a significant outbreak here are considered low.  We have a public health infrastructure in place that can do contact tracing and health monitoring for the incubation period of up to 21 days.


At this time there are no other suspected cases in Texas.


The CDC’s timeline has the patient leaving Liberia on September 19th, and arriving on the 20th. At that time, the patient was not symptomatic.  Several days later the patient became unwell (24th), and apparently went to a hospital or clinic on the 26th, but was not diagnosed with the disease (early symptoms are often non-specific), and sent home.  

 

Two days later the patient returned to the hospital with more severe symptoms and was placed into isolation.  Very few details regarding the patient, his possible exposures in Liberia, and his condition have been released.

 

The news conference – which should be archived on the CDC Media site in the next couple of days - included statements and answers from:

 

Thomas Frieden, M.D., M.P.H,

Director, Centers for Disease Control and Prevention

David Lakey, M.D.,

Commissioner, Texas Department of State Health Services

Edward Goodman, M.D., FACP, FIDSA, FSHEA

Hospital Epidemiologist, Texas Health Presbyterian Hospital Dallas

Zachary Thompson, M.A.

Director, Dallas County Health and Human Services

 

As Dr. Thomas Frieden stated in this news conference, as long as the Ebola epidemic continues to rage in West Africa, we have to be prepared for the possibility of  additional cases like this showing up in the United States.



The Texas Department of Health has released the following statement:

 

Texas Confirms Ebola Case

News Release


September 30, 2014

A Texas hospital patient has tested positive for Ebola, making the patient the first case diagnosed in the United States. The test was conducted at the state public health laboratory in Austin. The Centers for Disease Control and Prevention confirmed the positive result.

The patient is an adult with a recent history of travel to West Africa. The patient developed symptoms days after returning to Texas from West Africa and was admitted into isolation on Sunday at Texas Health Presbyterian Hospital in Dallas.

The Texas Department of State Health Services is working with the CDC, the local health department and the hospital to investigate the case and work to prevent transmission of the disease. The hospital has implemented infection control measures to help ensure the safety of patients and staff.

Ebola is a severe, often fatal disease. Early symptoms of Ebola include sudden fever, fatigue and headache. Symptoms may appear anywhere from 2 to 21 days after exposure.

Ebola is spread through direct contact with blood, secretions or other bodily fluids or exposure to contaminated objects, such as needles. Ebola is not contagious until symptoms appear.

The CDC recommends that individuals protect themselves by avoiding contact with the blood and body fluids of people who are ill with Ebola. DSHS also encourages health care providers to ask patients about recent travel and consider Ebola in patients with fever and a history of travel to Sierra Leone, Guinea, Liberia, and some parts of Nigeria within 21 days of the onset of symptoms.

Saudi MOH 1 New MERS Case – Sept 30th

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# 9129

 

The Saudi MOH has announced their 11th MERS Case of September, this time from Al Madinah, involving a 70 year-old male with camel exposure.  


Earlier today, we learned that Austria has Reported their 1st Imported MERS Case (ex- KSA).


This  uptick in cases has come just as the annual Hajj – which will attract more than 2 million religious pilgrims to Saudi Arabia for the month of October – begins.

 

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Three Early Release MMWRs On The Ebola Outbreak

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# 9127

 

The CDC has released a series of three early release MMWRs today on the Ebola outbreak in Africa.  One on the ongoing outbreak in Liberia, Guinea and Sierra Leone, while the other two concentrate on the rapid responses to Nigeria’s and Senegal’s imported cases. 

Below you’ll find links, and the CDC’s capsule descriptions for each document.

 

MMWR Early Release

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Ebola Virus Disease Outbreak — West Africa, September 2014
Incident Management System Ebola Epidemiology Team, CDC; Ministries of Health of Guinea, Sierra Leone, Liberia, Nigeria, and Senegal; Viral Special Pathogens Branch, National Center for Emerging and Zoonotic Infectious Diseases, CDC.
MMWR 2014;63(Early Release):1-2


Updated data on the Ebola virus disease outbreak in West Africa indicate that, as of September 23, a total of 6,574 cases had been reported from five West Africa countries (Guinea, Liberia, Nigeria, Senegal, and Sierra Leone). The highest reported case counts were from Liberia (3,458 cases), Sierra Leone (2,021), and Guinea (1,074).


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Ebola Virus Disease Outbreak — Nigeria, July–September 2014
Faisal Shuaib, DrPH, Rajni Gunnala, MD, Emmanuel O. Musa, MBBS, et al.
MMWR 2014;63(Early Release):1-6
On July 20, an acutely ill traveler from Liberia arrived at the international airport in Lagos, Nigeria, and was confirmed to have Ebola virus disease after being admitted to a private hospital. The Federal Ministry of Health, with the Lagos State government and international partners, activated an Ebola Incident Management Center as a precursor to the current Emergency Operations Center to rapidly respond to this outbreak. The index patient died on July 25; as of September 24, there were 19 laboratory-confirmed Ebola cases and one probable case in two states, with 894 contacts identified and followed during the response.


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Importation and Containment of Ebola Virus Disease — Senegal, August–September 2014
Kelsey Mirkovic, PhD, Julie Thwing, MD, Papa Amadou Diack, MD.
MMWR 2014;63(Early Release):1-2
On August 29, 2014, Senegal confirmed its first case of Ebola virus disease in a Guinean man, aged 21 years, who had traveled from Guinea to Dakar, Senegal, in mid-August to visit family. Senegalese medical and public health personnel were alerted about this patient after public health staff in Guinea contacted his family in Senegal on August 27. This report describes the investigation and containment measures that followed.

 

The CDC has also published a the following statement, summarizing what (for now, at least) appears to have been a successful containment campaign in Senegal and Nigeria. 

 

 

Ebola outbreak is nearing possible end in Nigeria

Strong emergency operations center, polio eradication experience keys to success

The Ebola outbreak in Nigeria appears to be nearing a possible end thanks to a rapid response coordinated by Nigeria’s Emergency Operations Center with assistance from international partners, including the U.S. Centers for Disease Control and Prevention (CDC). The official end to an Ebola outbreak comes when two of the 21-day incubation periods for Ebola virus have elapsed without any new cases.

During the outbreak there were 19 laboratory-confirmed and one probable Ebola cases in two Nigerian states. Nearly 900 patient contacts were identified and followed; all but three have completed 21 days of follow-up without Ebola symptoms.  There have been no new cases since August 31 and the last three patient contacts will exit their 21-day follow-up on October 2 – strongly suggesting the outbreak in Nigeria has been contained.  A report on Nigeria’s response to the outbreak appears in a Sept. 30 early release issue of CDC’s Morbidity and Mortality Weekly Report (MMWR).

"Although Nigeria isn’t completely out of the woods, their extensive response to a single case of Ebola shows that control is possible with rapid, focused interventions,” said CDC Director Tom Frieden, M.D, M.P.H. “Countries throughout the region as well as Nigeria need to take rapid steps to prepare for possible cases of Ebola in order to prevent outbreaks in their country.”

(Continue . . . )

 

Given the gravity of the situation in the three hardest hit nations of Guinea, Liberia, and Sierra Leone the apparent successful containment of Ebola in Nigeria and Senegal provides some welcome good news.

Egyptian MOH: 4th H5N1 Case Of 2014

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Note: While the MOH has only announced 4 cases this year, FluTrackers has a fifth case reported by Ministry of Health of Beheira governorate, which would bring the total to 5.

# 9126

 

While we haven’ heard much about H5N1 in Egypt in recent months, we’ve continued to see FAO reports of outbreaks in Egyptian poultry, and so it isn’t terribly surprising that overnight the Egyptian MOH has issued the following (machine translated) statement on their 4th reported human H5N1 infection of the year.

 

Minister of Health: Injured bird flu .. and in stable condition

Dr. Adel Adawi, Minister of Health and Population injury a new case of bird flu to a baby girl at the age of 3 months from the Giza governorate, pointing out that it is the fourth case of injury this year.


The Minister of Health that the date of onset of the disease is due to on Monday 22/09/2014 where she was suffering from a case (fever - sore throat - cough - vomiting), where the girl's parents went to the outpatient clinic at the Hospital of the Abbasid released on 25/9 / in 2014, and he asked the people of the situation indicate exposure to dead birds, have been isolated little girl at the hospital on suspicion of bird flu, then was taken from the throat swab on the same day were sent the sample to the central laboratory of the Ministry of Health and Population and the girl began to take Tamiflu, as well as the work of the rays normal Sadr hailed the show a pneumonia Ayman, was the result of the sample positive for the disease were confirmed case experimentally in the central laboratory to be positive for the avian influenza virus (A / H5N1), and was the work of Ohotai issued to follow the situation where it was found that the situation is improving and the overall situation is stable.

Source: Center for Media

 


Although H5N1 has taken a bit of a back seat to MERS-CoV, Ebola, and H7N9 it remains endemic in wild birds and poultry in both Asia and the Middle East, continues to evolve into new clades, and continues to pose a threat both to agricultural interests and (on occasion) to human health.


The most recent WHO Update: Influenza at the human-animal interface (H5N1), advises:

Overall public health risk assessment for avian influenza A(H5N1) viruses: Whenever influenza viruses are circulating in poultry, sporadic infections or small clusters of human cases are possible, especially in people exposed to infected poultry or contaminated environments. These influenza A(H5N1) viruses do not currently appear to transmit easily among people. As such, the risk of community-level spread of these viruses remains low.

 

That said, reserachers continue to watch H5N1, along with a growing cadre of recently emerged avian flu viruses (H7N9, H5N6, H10N8) for any signs that they are becoming better adapted to human physiology.

Report: Hansen’s Disease (Leprosy) In Mississippi

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# 9125

 

With the advent of modern antibiotics - Hansen’s Disease, aka Leprosy – has been vastly reduced around the globe over the past couple of decades, although more than 200,000 new cases are still reported each year (see WHO Prevalence of leprosy).  

 

While limited cases of drug resistant Leprosy have been reported (see Primary Multidrug-Resistant Leprosy, United States), this infection remains largely treatable. The World Health Organization has this to say about MDT (Multi-Drug Therapy) and resistance.

 

MDT and drug resistance

Is the threat of rifampicin-resistant leprosy a serious problem?

There are a few isolated reports of rifampicin-resistant leprosy; these are mainly from areas where rifampicin was given as monotherapy, either alone or in combination with dapsone, to dapsone-resistant patients. At the moment, the problem of rifampicin-resistant leprosy is not a serious one; however, selective non-compliance with dapsone and/or clofazimine by patients may facilitate the selection of rifampicin-resistant strains.

 

Although  rare, the United States still sees about 150-220 cases each year. Indigenous cases are primarily associated with contact with armadillos – for some, a southern delicacy – and known reservoir for the bacteria: Mycobacterium leprae (see my 2011 blog  Hint: Don’t Order The `Possum On the Half Shell’)

Nine-banded Armadillo -wikipedia


Here in the United States, Hansen’s disease is studied and tracked  by the HHS’s National Hansen's Disease (Leprosy) Program.  Some excerpts from their homepage:

 

A genetic study at the National Hansen’s Disease Program reports that armadillos may be a source of infection in the southern United States. The Program advises:

  • The risk of transmission from animals to humans is low, but armadillos are wild animals and should be treated as such, with all proper precautions.
  • Individuals should decide for themselves whether or not to interact with these animals and, if so, what precautions to take.

Hansen's Disease (Leprosy) Facts

  • Most (95 percent) of the human population is not susceptible to infection with M. leprae, the bacteria that causes Hansen's disease (leprosy).
  • Treatment with standard antibiotic drugs is very effective.
  • Patients become noninfectious after taking only a few doses of medication and need not be isolated from family and friends.
  • Diagnosis in the U.S. is often delayed because health care providers are unaware of Hansen's disease (leprosy) and its symptoms.
  • Early diagnosis and treatment prevents nerve involvement, the hallmark of Hansen's disease (leprosy), and the disability it causes.
  • Without nerve involvement, Hansen's disease (leprosy) is a minor skin disease.
  • 213 new cases were reported in the U.S. in 2009 (the most recent year for which data are available).
  • Most (97 or 65%) of these new cases were reported in
    • California
    • Florida
    • Hawaii
    • Louisiana
    • Massachusetts
    • New York
    • Texas

All of which brings us to a fascinating new  Mississippi State Department of Health report, released yesterday, on the prevalence of Hansen’s disease in that state. Some excerpts follow:

Mississippi Morbidity Report


Volume 30, Number 5 September 2014


Hansen’s Disease (Leprosy) in Mississippi


Background: Leprosy, also known as Hansen's disease, is a chronic infectious disease of the skin and peripheral nerves caused by the bacteria Mycobacterium leprae (M. leprae). The infection, with an average incubation period between 8 and 12 years, is seen mainly in poor countries and rarely seen in developed nations. In the United States, 213 new cases of leprosy were reported in 2009 [1]. Approximately 75 percent of these reported cases occurred among immigrants. However, endemic acquisition foci exist in parts of the south-central U.S., primarily in Louisiana, Mississippi, Florida, and Texas [1].

<SNIP>

Transmission: Although the mode of transmission of M. leprae has not been proven, person-to-person aerosol spread from infected nasal secretions is posited in most cases worldwide. However, there is increasing evidence that a very small number of cases may be classified as zoonotic infections in countries where nine-banded armadillos (Dasypus novemcinctus) are found in the wild. As the wild nine-banded armadillos are the only identified species in the U.S. that can serve as a reservoir for M. leprae in nature and has a range that includes the Southeastern U.S., it has been postulated that they may be spreading the bacteria into the environment and transmitting infection to humans in the U.S. south [2]. Human indigenous leprosy cases have been described in the same geographic regions where infected armadillos have been reported, mainly Texas and Louisiana and Mississippi [3]

<SNIP>

Epidemiology of Hansen’s disease in Mississippi: A total of 53 cases of Hansen’s disease have been reported in Mississippi from 1922 to 2013. The majority of the cases (43) have been classified as indigenous cases, defined as occurring in individuals living for more than 12 years in Mississippi prior the diagnosis(see Figure 1). Ten cases were classified as non-indigenous due to foreign birth (in a country with endemic Hansen’s disease) or residency in MS of less than 12 years. Of the indigenous cases, the median age among the reported cases is 69 years, with ages of cases ranging from 23 to 87 years at time of diagnosis. A majority of the reported cases are male (77%); 86% of the cases are Caucasian and 14% are African-American.
 

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Cases of indigenous leprosy have been identified in many parts of the state, with the majority occurring in south Mississippi and the Delta. Armadillos positive for M. leprae have been identified in two areas in Mississippi, the Delta and in Northeastern Mississippi. (Figure 2). Of sixteen indigenous cases with information on prior armadillo exposure, eight (50%) reported prior contact with armadillos. Information pertaining to the nature of the exposures was not available

Conclusions: Hansen’s disease is a rare but increasing diagnosis among Mississippi residents. Increased reports of Hansen’s disease in Mississippi may reflect an increasing incidence, improved reporting or improved diagnostics. The majority of cases were identified in patients older than 62 years of age and 50% with available data reported previous contact with armadillos. Medical providers should consider a diagnosis of Hansen’s disease in patients with persistent skin lesions, particularly if associated with localized loss of sensation or a history of exposure to armadillos.

Submitted by: Luis Marcos, MD, MPH; Paul Byers, MD; Jannifer Anderson, RN; and Thomas Dobbs MD, MPH

 

While not a huge public health problem today, this report is a good reminder for doctors that while you should always first `think horses’ when you hear hoof beats, every once in awhile there’s a zebra hidden in the herd.

America’s Preparathon! : It Started Like Any Other Day

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# 9124

 

 

Today marks the end of National Preparedness Month, where FEMA and Ready.gov and a coalition of thousands of others (including AFD) have worked all month to promote better disaster preparedness for Americans.  On twitter the hashtags #NPM14 and #NatlPrep will lead you to find many of these efforts.

 

We know – often because we’ve been there – that disasters do strike, and that the advantage goes to the prepared.

 

The popularity of Doomsday Preppers on the National Geographic Channel  has a lot of people believing that preppers are all getting set for the impending apocalyptic collapse of society.  But for the vast majority of us who embrace the preparedness lifestyle - it is the far more common localized disaster that spurs us on:

 

. .. hurricanes, tornadoes, ice storms, blizzards, earthquakes, floods (and yes, even a pandemic)  . . . along with even more limited emergencies like house fires, car accidents, or personal accident and injury.

 

These types of events happen with surprising regularity - and unlike an abrupt 30 degree shift of the earth’s crust or the eruption of the Yellowstone Super Volcano - are something being prepared for is actually likely to help.  The following 4 minute video called `It Started Like Any Other Day’  illustrates three such examples:

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There are many legitimate disaster threats out there – and many can strike without warning -  which is why FEMA, READY.GOV, and many other agencies constantly promote personal, family, and business preparedness.

 

As a former paramedic, I can’t stress enough the importance of having a good first aid kit at home, and another one in your car.  And just as importantly, learning how to properly use one.

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Taking a first-aid course, and CPR training, are both investments that could pay off big someday, for you, and for your loved ones. 

 

And every home should have no less than a 72-hour supply of emergency food and water, for all of its occupants (including pets!).  This is a bare minimum, here in the United States many agencies and organizations recommend that households work towards having a 10-day supply of food, water, and emergency supplies on hand.

 

In When 72 Hours Isn’t Enough, I highlighted  a colorful, easy-to-follow, 100 page `survival guide’ released by Los Angeles County, that covers everything from earthquake and tsunami preparedness, to getting ready for a pandemic.

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While admittedly California-threat specific, this useful guide may be downloaded here (6.5 Mbyte PDF).

 

And speaking of California threats, if you live in a seismically active region (and that includes most of the nation) you need to visit Shakeout.org before October 16th to learn how you, your family and your co-workers can take part in this year’s important earthquake drill.

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Although I’ve covered a great many specifics for becoming better prepared (see NPM14: Infrastructure Failure Preparedness & NPM14: When You’ve Got To `Get Out Of Dodge’ In A Hurry), there is one prep I consider to be the most important of all.

 

Having – and being – a `disaster buddy’.

 

In NPM14: In an Emergency, Who Are You Going To Call?, I wrote about that - A `Disaster Buddy’ is simply someone you have prearranged that you can call on during a crisis, and who in turn, can call on you if they need help.

 

Much in the way that community fire departments, EMS, and law enforcement agencies have a `mutual aid’ agreement with nearby communities, you should foster the same kind of arrangement with your friends, family, and neighbors.

 

In the parlance of paramedics, cops, firefighters and the military . . .  you have their back, and in return, they have yours.”  Now - before a disaster occurs - is the time to sit down and talk to your friends, family, and neighbors about how you will help one another during a personal or community wide crisis.

 

While  National Preparedness Month comes to an end today, the task of becoming better prepared doesn’t end with September – it is a year-round responsibility.  To help you on your way, you can retrieve a list of this year’s NPM blogs by clicking this link.

 

And for more  potentially life saving preparedness information, I invite you to visit:

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

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

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

Austria Reports 1st Imported MERS Case (ex- KSA)

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# 9123

 

 

For two weeks we’ve been watching a slow uptick in MERS cases in Saudi Arabia, with concerns that with the immense amount of travel to and from Saudi Arabia for the Hajj this month, the virus might be afforded more opportunities to spread other areas of the globe.  

 

Overnight the Austrian Ministry of Health announced their first imported case of MERS, that of a Saudi National who recently arrived from KSA.

 

This translation from the BMG (Bundesministerium für Gesundheit) (h/t Sharon Sanders on @FluTrackers)

 

MERS-CoV (Middle East Respiratory Syndrome - Corona Virus)

First MERS CoV case in Austria

The BMG was informed on 29 September on a confirmed female MERS CoV case. It is a citizen of Saudi Arabia, which has traveled a few days ago to Austria. She is currently being cared for in isolation of a Vienna hospital. All possible contact persons are currently being identified and informed about the disease as well as other measures. Of the world since the beginning of the outbreak more than 800 reported cases occurred in a total of 12 in the EU, where it has happened to secondary cases in close human-human contacts. A further spread could be prevented in the countries concerned through appropriate protective measures. These measures are being carried out in Austria.

 

Although enhanced surveillance for possible MERS cases among travelers coming from the Middle East has been in place for some time, with the recent lull in cases, and a greater concentration on the Ebola threat in Western Africa, MERS has taken a bit of a back seat. 


Today’s reports reminds us that there are multiple global public health threats that require vigilance (including Ebola, MERS & Avian flu), and suggests public health agencies around the world are going to have their hands full in the coming months.

 

For Americans contemplating making the Hajj this year, the CDC urges practicing enhanced precautions and provides specific travel advice , including required and recommended vaccinations.

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Monday, September 29, 2014

Referral: Mackay On The Widening `Control Gap’

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# 9122

 

Dr. Ian Mackay –  presents graphs today showing an intriguing Ebola outbreak trend, and offers a plausible reason behind it, in his latest blog called:

 

The control gap...

v1.0 290914

I have a theory.


This theory is meant only to apply to disease outbreak/epidemic/pandemic situations, and then only to those which include fatal cases.


This theory of mine has only emerged since I've been plotting Ebola virus cases numbers from the West African epidemic. I precede the explanation with the caveat that there is very probably already a well developed, well-known actual epidemiology term to describe this theory. But I'm not a trained epidemiologist and this is just a blog, so please forgive me my ignorance.


The theory goes that when a gap grows between the number of new cases being reported and the number of deaths or laboratory confirmations in that population, despite the outbreak having been going for a while, this represents an indication that control of the situation is slipping, or has been lost.

(Continue . . . )

 

ECDC Rapid Risk Assessment For EV-D68

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# 9121

 

The outbreak of EV-D68 – an (up-till-now) rarely seen non-polio enterovirus infection – continues in North America with more than 40 states and several provinces in Canada reporting cases.

 

While most of those infected (primarily children) will only experience a mild-to-moderate `cold’, a small percentage have been made sick enough to require hospitalization and even require ventilatory support (see CDC Update On EV-D68 – Sept 25th).


Late on Friday the EV-D68 story took another turn when the CDC announced it was investigating – along with Colorado Health officials – a cluster of 9 children presenting with neurological illness of unknown etiology, and that EV-D68 was on the short list of possible causes (see CDC HAN: Acute Neurologic Illness with Focal Limb Weakness of Unknown Etiology in Children).

 

Although primarily associated with respiratory symptoms, EV-D68 has been tentatively implicated in neurological presentations in the past, including last winter (see Acute Flaccid Paralysis Cases In California) . An investigation is now underway to determine the cause of this cluster in Denver, and to see if there are similar cases in other regions of the country.

 

While small outbreaks of EV-D68 have been reported in the past – particularly in Asia, the Pacific, and in parts of Europe – this North American outbreak is the largest ever documented.

 

That said, EV-D68 is rarely tested for, and generally not considered a `notifiable disease’, and so its actual incidence around the globe is probably greatly underappreciated.

 

Taking note of these events, and knowing that infectious diseases perfectly capable of crossing oceans, the ECDC has today released their Rapid Risk Assessment: Enterovirus 68 detections in the USA and Canada.

 

The result is a detail-rich history of the virus,  a terrific chart of older outbreaks over the past decade, and an extensive list of journal references and citations.

 

I’ve only posted their main conclusions, so follow the link to read the report in its entirety.  When you come back, I’ll have a bit more on one possible reason why this outbreak may be spreading so rapidly.


Enterovirus 68 detections in the USA and Canada

Main conclusions


From mid-August to 24 September 2014, a total of 220 people from 32 US states were confirmed to have respiratory illness caused by EV-D68. Canada has also experienced an increase in severe respiratory illness associated with EV-D68 cases since mid-August 2014.
  • An epidemiological link across the clusters reported in several US states has not yet been established, and it cannot be ruled out that the virus is circulating independently in several locations.
  • To date, EU/EEA countries have not reported a growing number of acute respiratory infections or an increased number of hospital admissions.
  • Sporadic cases of EV-D68 have been documented in several EU/EEA countries in recent years. In 2014, EV-D68 was detected in at least four EU/EEA countries but no epidemic clusters of severe disease have been reported; none of the Member States has so far issued an Early Warning and Response System (EWRS) notification.
  • The likelihood for cases to be laboratory-confirmed in EU/EEA countries is low because most countries do not routinely screen for EV-D68, and the disease is not notifiable.
  • If all other respiratory pathogen detections were negative, or if rhino-/enterovirus was detected initially, EV-D68 should be considered the causative pathogen of the disease. More systematic testing of severe respiratory illness cases for EV-D68 could be considered in EU/EEA countries to better document the circulation of this virus.
  • EU/EEA countries need to remain vigilant and consider strengthening respiratory sample screening for enteroviruses and enterovirus typing.
  • Based on the current information, EU/EEA countries have a moderate risk of EV-D68 transmission because the circulation of this strain in the population is low.

 

 

Buried within this report is a one-line mention and a reference to a study, published late last year, which looked at recent genetic changes to EV-D68:

 

Recent research has suggested a change in the antigenicity and receptor properties of EV-D68, which now preferably binds to upper respiratory tract sialic acid receptors as opposed to the earlier lower respiratory tract binding [14].

 

The study, published in the Journal of Virology, finds that the EV-D68 virus has evolved into at least three lineages and that they all bind preferentially to α2-6 SAs – the same receptor cell used to great effect by seasonal influenza viruses. They also suggest that relatively recent changes in its antigenicity and/or receptor binding properties may be increasing its prevalence around the globe.

 

Antigenic and Receptor Binding Properties of Enterovirus 68

Tadatsugu Imamuraa, Michiko Okamotoa, Shin-ichi Nakakitab, Akira Suzukia, Mariko Saitoc, Raita Tamakia, Socorro Lupisang, Chandra Nath Roya, Hiroaki Hiramatsuf, Kan-etsu Sugawarad, Katsumi Mizutae, Yoko Matsuzakid, Yasuo Suzukif and Hitoshi Oshitania

ABSTRACT

Increased detection of enterovirus 68 (EV68) among patients with acute respiratory infections has been reported from different parts of the world in the late 2000s since its first detection in pediatric patients with lower-respiratory-tract infections in 1962. However, the underlying molecular mechanisms for this trend are still unknown. We therefore aimed to study the antigenicity and receptor binding properties of EV68 detected in recent years in comparison to the prototype strain of EV68, the Fermon strain.

We first performed neutralization (NT) and hemagglutination inhibition (HI) tests using antisera generated for EV68 strains detected in recent years. We found that the Fermon strain had lower HI and NT titers than recently detected EV68 strains. The HI and NT titers were also significantly different between strains of different genetic lineages among recently detected EV68 strains.

We further studied receptor binding specificities of EV68 strains for sialyloligosaccharides using glycan array analysis. In glycan array analysis, all tested EV68 strains showed affinity for α2-6-linked sialic acids (α2-6 SAs) compared to α2-3 SAs. Our study demonstrates that emergence of strains with different antigenicity is the possible reason for the increased detection of EV68 in recent years. Additionally, we found that EV68 preferably binds to α2-6 SAs, which suggests that EV68 might have affinity for the upper respiratory tract.

IMPORTANCE Numbers of cases of enterovirus 68 (EV68) infection in different parts of the world increased significantly in the late 2000s. We studied the antigenicity and receptor binding properties of recently detected EV68 strains in comparison to the prototype strain of EV68, Fermon. The hemagglutination inhibition (HI) and neutralization (NT) titers were significantly different between strains of different genetic lineages among recently detected EV68 strains.

We further studied receptor binding specificities of EV68 strains for sialyloligosaccharides using glycan array analysis, which showed affinity for α2-6-linked sialic acids (α2-6 SAs) compared to α2-3 SAs. Our study suggested that the emergence of strains with different antigenicities was the possible reason for the increased detections of EV68 in recent years. Additionally, we revealed that EV68 preferably binds to α2-6 SAs. This is the first report describing the properties of EV68 receptor binding to the specific types of sialic acids.

 

An intriguing and plausible – but as yet, unproven – explanation for the rapid and (as far as we know) unprecedented spread of EV-D68 in North America.

 

But one that will require considerable laboratory analysis and study to prove one way or another.

Sunday, September 28, 2014

Saudi MOH: 5th MERS Case From Taif This Month

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# 9120

 

Taif, located just 60 miles east of the Holy City of Mecca – the primary destination for roughly 2 million religious pilgrims who will make the Hajj next week – has reported its fifth MERS case in just over 2 weeks. 

 

The first case was reported on September 12th, while the last – a Health care worker – was announced on Monday the 22nd.

 

Today, the MOH is announcing another HCW – a 40 y.o. male expat – has been infected in Taif, and is currently isolated in the ICU.   This makes the 10th MERS case announced by KSA’s MOH since September 12th, which represents a small, but worrisome uptick in cases after a relatively quiet summer.

 

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NPM14: Infrastructure Failure Preparedness

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Basic kit : NWS radio, First Aid Kit, Lanterns, Water & Food & cash  

 

Note: This is day 28  of National Preparedness Month. Follow this year’s campaign on Twitter by searching for the #NatlPrep & NPM14 hash tag.

 

# 9119

 

Historically, for most of us living in North America, our biggest disaster threats come from severe weather (tornadoes, floods, blizzards & hurricanes), wildfires, or earthquakes.  But as we become more urbanized, and increasingly dependent upon aging, oft times fragile infrastructures, the threats we face are likely to evolve over time.

 

A prime example, which lasted but a few days last August, was contamination of the water supply for Toledo, Ohio and surrounding areas with a harmful toxin produced by microcystis algae (see Water, Water, Everywhere But Not A Drop To Drink). 

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Unlike most disaster scenarios (and Michael Bay movies) cities weren’t destroyed, and lives weren’t lost.  But had the algae bloom lasted longer, or remained near the water intakes on Lake Erie for a few more days, the societal and economic impacts would have been much greater.

 

Despite warnings from NOAA that it could happen (it had previously, on a smaller scale) – few were prepared with enough water on hand to last their households even three days.

 

Lest you think this is a freak occurrence, every four years the ASCE (American Society of Civil Engineers) releases a report card on America’s infrastructure, and their latest (2013) warns that our cumulative GPA for infrastructure sits at only a D+, and two of our most vulnerable infrastructures are drinking water and the electrical grid.


The truth is, parts of our ageing electrical grid are more than 100 years old, and even newer components are vulnerable to everything from severe weather to solar storms to cyber attacks. And there are thousands of miles of rusting century-old water mains running under the streets of Los Angeles, New York, Boston, and elsewhere. 

 

There are 84,000 dams (average age 52 years) in this country, and 100,000 miles of levees.  Both rate a not-so-reassuring D on the ASCE report card, and many are in grave need of repairs and upgrades. While we usually normally pay little attention to these structures, as they age, they can pose hidden risks to those who live near them.

 

Add in a precipitating event – like an earthquake, hurricane, or flood – and the risks of failure only increase.

 

In terms of widespread impact, a prolonged widespread power outage has the greatest potential for disruption. It is the job of the North American Electric Reliability Corporation (NERC) to "ensure the reliability of the North American bulk power system", a mandate given to it in 2006 as a result of the 2003 Northeast blackout which affected more than 50 million people in the United States and Ontario, Canada. 

 

In  2009, NERC issued a public notice warning that the grid was `vulnerable’ to cyber attack, and that same year  the National Academy of Sciences produced a 134 page report on the potential damage that a major solar flare could cause in Severe Space Weather Events—Understanding Societal and Economic Impacts (see Solar Storms, CMEs & FEMA).

 

Last October, in GridEx 2013 Preparedness Drill, we looked at a major drill to determine their ability to respond to a full grid-down situation, caused by a cyber-attack.  Despite attempts to `harden’ the electrical grid against attacks, last July Bloomberg News reported:

 

U.S. Power Grid Vulnerable to Attack: Congressional Research Service

A coordinated and simultaneous attack on the nation's electricity grid could have “crippling” effects including widespread extended blackouts and “serious economic and social consequences,” according to a federal report on the physical security of high-voltage transformer substations.

 

Of course, it doesn’t take a cyber-attack, solar storm, or EMP to take down the grid for millions of people for days or even weeks at a time.  We’ve seen that happen from ice storms, hurricanes, and blizzards in the past.  A major earthquake could do so, as well.  

Without electricity, gas pumps won’t work, credit & debit cards are useless (got cash?), and refrigerated foods may quickly begin to spoil (in your home, and in the store).  For those who depend on electric heat during the winter or those who rely on medical devices – like oxygen generators – a prolonged outage could have deadly implications.

 

Interruptions in food deliveries, closed pharmacies, 911 system failures, cell phone & internet disruptions, hospitals and emergency services operating on generators and a finite supply of fuel . . .  well, you get the picture.

 

Which pretty much described the scene I found in New Orleans when I helped my brother retrieve his belongings from the French Quarter six weeks after Hurricane Katrina inundated the city, and more recently, for the residents of New York and New Jersey who went a week or longer without power after `super storm’ Sandy struck two years ago.  

 

Admittedly, in most cases, power would be restored in a few days. But the difference between a prolonged outage being an inconvenience and an absolute nightmare can often hinge on your level of preparedness.

 

If an infrastructure failure struck your region today, and the power went out, stores closed their doors, and water stopped flowing from your kitchen tap for the next 7 days  . . .  do you have:

 

  • A battery operated NWS Emergency Radio to find out what was going on, and to get vital instructions from emergency officials?
  • A decent first-aid kit, so that you can treat injuries?
  • Enough non-perishable food and water on hand to feed and hydrate your family (including pets) for the duration?
  • A way to provide light (and in cold climates, heat) for your family without electricity?   And a way to cook?  And to do this safely?
  • An emergency plan, including meeting places, emergency out-of-state contact numbers, and in case you must evacuate, a bug-out bag?
  • Spare supply of essential prescription medicines that you or your family may need?
  • Enough emergency cash to get you through a week or more without access to an ATM or the use of a credit/debit card?

If your answer is `no’, you have some work to do.  A good place to get started is by visiting either  Ready.gov or the FEMA.gov websites.

Saturday, September 27, 2014

CDC: Checklist For EMS Ebola Preparedness

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# 9118

 

The CDC has been busy over the summer producing interim guidance, and checklists for specific groups, for dealing with the potential introduction of Ebola into the United States.   While a large outbreaks are not anticipated in most developed countries, the importation of individual cases – with the potential of limited spread to others – cannot be ignored.

 

On Monday of next week, NACCHO will hold a webinar to go over the Hospital Checklist Preparedness For Ebola.

Last night the CDC released two more checklists:

September 26, 2014 - Checklist for Healthcare Coalitions for Ebola Preparedness[PDF - 4 pages]

September 26, 2014 - Detailed Emergency Medical Services (EMS) Checklist for Ebola Preparedness[PDF - 6 pages]

 

Since EMS organizations are far more likely to have initial contact with potential Ebola cases,  I’ll restrict today’s blog to their checklist.   You’ll want to download the entire (6-page) PDF document.

 

Detailed Emergency Medical Services (EMS) Checklist for Ebola Preparedness

The U.S. Department of Health and Human Services (DHHS) Centers for Disease Control and Prevention (CDC) and Office of the Assistant Secretary for Preparedness and Response (ASPR), in addition to other federal, state, and local partners, aim to increase understand ing of Ebola and encourage U.S.-based EMS agencies and systems to prepare for managing patients with Ebola and other infectious diseases. Every EMS agency and system, including those that provide non-emergency and/or inter-facility transport, should ensure that their personnel can detect a person under investigation (PUI) for Ebola, protect themselves so they can safely care for the patient, and respond in a coordinated fashion. Many of the signs and symptoms of Ebola are non-specific and similar to those of other common infectious diseases such as malaria, which is commonly seen in W est Africa. Transmission of Ebola can be prevented by using appropriate infection control measures.


This checklist is intended to enhance collective preparedness and response by highlighting key areas for EMS personnel to review in preparation for encountering and providing medical care to a person with Ebola. The checklist provides practical and specific suggestions to ensure the agency is able to help its personnel detect possible Ebola cases, protect those personnel, and respond appropriately.


Now is the time to prepare, as it is possible that individuals infected with Ebola virus in W est Africa may travel to the U.S., develop signs or symptoms of Ebola , and seek medical care from EMS personnel.


EMS agencies, in conjunction with their medical directors, should review infection control policies and procedures and incorporate plans for administrative, environmental, and communication measures.


The checklist format is not intended to set forth mandatory requirements or establish national standards. It is a list of activities that can help each agency prepare. Each agency is different and should adapt this document to meet its specific needs. In this checklist, EMS personnel refers to all persons, paid and volunteer who provide pre-hospital emergency medical services and have the potential for direct contact exposure (through broken skin or mucous membranes) with an Ebola patient’s blood or body fluids, contaminated medical supplies and equipment, or contaminated environmental surfaces.

This detailed checklist for EMS is part of a suite of HHS checklists. This guidance is only for EMS agencies and systems; the CDC’s Interim guidance for EMS includes information for individual providers and for 9-1-1 Public Safety Answering Points.

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(Continue . . . )

For additional guidance on Ebola for healthcare settings, the CDC has put together an impressive list of documents which may be accessed at:

Information for Healthcare Workers

CDC HAN: Acute Neurologic Illness with Focal Limb Weakness of Unknown Etiology in Children

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# 9117

 

There are a fair number of possible causes for a cluster of acute neurological illness in children, ranging from vector-borne encephalopathies like West Nile Virus, to a variety of polio and non-polio enteroviruses. In recent years, EV-71 has been linked to a number of clusters of AFP (acute flaccid paralysis) around the globe, particularly in Asia, Australia, and the Pacific (see Australia: Acute Flaccid Paralysis & EV71).

 

A month ago, when the EV-D68 virus was first identified in a cluster of sick kids in the Midwest (see Kansas City Outbreak Identified As HEV 68), I mentioned that this rarely reported non-polio enterovirus had been detected in two of five children who developed a rare polio-like syndrome last winter (see Acute Flaccid Paralysis Cases In California) .

 

While this may have simply been an incidental finding, due to the history of other non-polio enteroviruses to cause neurological illness, EV-D68 infection was considered at least plausible cause for these illnesses. The CDC has frequently stated that  `EV-D68 causes primarily respiratory illness, although the full spectrum of disease remains unclear.’

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The EV-D68 virus has now spread to more than 40 states, and has likely sickened tens of thousands of children, but until now we’d not heard any credible reports of EV-D68 infected children developing neurological symptoms. Testing for the virus, however, is both difficult and time consuming – and the battery of tests required to rule out other causes of neurological illness can take considerable time – and so there are often lags in reporting.

 

Given the recent surge in enterovirus infections across the nation, and their history of occasionally producing neurological illness, it is not altogether surprising that health authorities in Denver, Colorado have now reported a cluster of children presenting with acute neurological symptoms following recent respiratory infections.

 

To date, four of nine have tested positive for the EV-D68 virus. 


With the caveat that the etiology remains unknown, the CDC is anxious to identify other recent cases or clusters, and to nail down the cause (or causes) of these illnesses. 

 

Last night the CDC issued the following HAN (Health Alert Network)  Advisory to clinicians, with instructions on reporting and recommendations for testing. 

 

Acute Neurologic Illness with Focal Limb Weakness of Unknown Etiology in Children

Summary

The Centers for Disease Control and Prevention (CDC) is working closely with the Colorado Department of Public Health and Environment (CDPHE) and Children’s Hospital Colorado to investigate a cluster of nine pediatric patients hospitalized with acute neurologic illness of undetermined etiology. The illness is characterized by focal limb weakness and abnormalities of the spinal cord gray matter on MRI. These illnesses have occurred since August 1, 2014 coincident with an increase of respiratory illnesses among children in Colorado. The purpose of this HAN Advisory is to provide awareness of this neurologic syndrome under investigation with the aim of determining if children with similar clinical and radiographic findings are being cared for in other geographic areas. Guidance about reporting cases to state and local health departments and CDC is provided. Please disseminate this information to infectious disease specialists, intensive care physicians, pediatricians, neurologists, radiologists/neuroradiologists, infection preventionists, and primary care providers, as well as to emergency departments and microbiology laboratories.

Background

The CDPHE, Children’s Hospital Colorado, and CDC are investigating nine cases of acute neurologic illness among pediatric patients. The cases were identified during August 9–September 17, 2014 among children aged 1–18 years (median age 10 years). Most of the children were from the Denver metropolitan area. All were hospitalized. Common features included acute focal limb weakness and specific findings on magnetic resonance imaging (MRI) of the spinal cord consisting of non-enhancing lesions largely restricted to the gray matter. In most cases, these lesions spanned more than one level of the spinal cord. Some also had acute cranial nerve dysfunction with correlating non-enhancing brainstem lesions on MRI. None of the children experienced altered mental status or seizures. None had any cortical, subcortical, basal ganglia, or thalamic lesions on MRI. Most children reported a febrile respiratory illness in the two weeks preceding development of neurologic symptoms. In most cases, cerebrospinal fluid (CSF) analyses demonstrated mild-moderate pleocytosis (increased cell count in the CSF) consistent with an inflammatory or infectious process. CSF testing to date has been negative for West Nile virus and enteroviruses, including poliovirus. Nasopharyngeal specimens were positive for rhinovirus/enterovirus in six out of eight patients that were tested. Of the six positive specimens, four were typed as EV-D68, and the other two are pending typing results. Testing of other specimens is still in process. Eight out of nine children have been confirmed to be up to date on polio vaccinations. Epidemiologic and laboratory investigations of these cases are ongoing.

The United States is currently experiencing a nationwide outbreak of EV-D68 associated with severe respiratory disease. The possible linkage of this cluster of neurologic disease to this large EV-D68 outbreak is part of the current investigation. CDC is seeking information about other similar neurologic illnesses in all states, especially cases clustered in time and place. CDC has particular interest in characterizing the epidemiology and etiology of such cases.

Recommendations

  • Patients who meet the following case definition should be reported to state and local health departments:

    Patients ≤21 years of age with

    1. Acute onset of focal limb weakness occurring on or after August 1, 2014;

    AND

    1. An MRI showing a spinal cord lesion largely restricted to gray matter.
  • State and local health departments should report patients meeting the case definition to CDC using a brief patient summary form (www.cdc.gov/non-polio-enterovirus/investigation/). State health departments should send completed summary forms to CDC by email at limbweakness@cdc.gov.
  • Providers treating patients meeting the above case definition should consult with their local and state health department for laboratory testing of stool, respiratory, and cerebrospinal fluid specimens for enteroviruses, West Nile virus, and other known infectious etiologies.
  • Health departments may contact CDC for further laboratory and epidemiologic support by phone through the CDC Emergency Operations Center (770-488-7100), or by email at limbweakness@cdc.gov. Confirmation of the presence of EV-D68 currently requires typing by molecular sequencing.

Friday, September 26, 2014

MMWR: Updated Preparedness and Response Framework for Influenza Pandemics

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Hypothetical Influenza Outbreak Curve

 

# 9016

 

Last year the World Health Organization Unveiled New Pandemic Guidance, replacing their old pandemic phase system (3 pre-pandemic phases+ 3 pandemic phases+2 post-pandemic phases) with a more streamlined 4-phase system.

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As you’ll note, this system utilizes `soft’ transitions from one phase to the next, indicating that changes may happen slowly, or at different rates in different regions, rather than abruptly.  The interpandemic phase is a time for preparedness, while the response is ramped up once an alert is sounded.

 

Yesterday the CDC published a new pandemic preparedness and response framework that aligns the CDC’s pandemic phase system more closely with the WHO’s, although there are some differences.

 

According the the CDC, this update `provides greater detail and clarity regarding the potential timing of key decisions and actions aimed at slowing the spread and mitigating the impact of an emerging pandemic’.


This is a fairly lengthy update, and so I’ve only posted the summary.  Follow the link below to read it in its entirety.  When you return, I’ll have a bit more.

 

Updated Preparedness and Response Framework for Influenza Pandemics

Recommendations and Reports

September 26, 2014 / 63(RR06);1-9

Prepared by Rachel Holloway1, Sonja A. Rasmussen, MD1, Stephanie Zaza, MD2, Nancy J. Cox, PhD3, Daniel B. Jernigan, MD3, with the Influenza Pandemic Framework Workgroup

1Influenza Coordination Unit, Office of Infectious Diseases

2Division of Adolescent and School Health, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

3Influenza Division, National Center for Immunization and Respiratory Diseases

Corresponding preparer: Sonja A. Rasmussen, MD, CDC. Telephone: 404-639-2297; E-mail: srasmussen@cdc.gov.

Summary

The complexities of planning for and responding to the emergence of novel influenza viruses emphasize the need for systematic frameworks to describe the progression of the event; weigh the risk of emergence and potential public health impact; evaluate transmissibility, antiviral resistance, and severity; and make decisions about interventions. On the basis of experience from recent influenza responses, CDC has updated its framework to describe influenza pandemic progression using six intervals (two prepandemic and four pandemic intervals) and eight domains.

his updated framework can be used for influenza pandemic planning and serves as recommendations for risk assessment, decision-making, and action in the United States. The updated framework replaces the U.S. federal government stages from the 2006 implementation plan for the National Strategy for Pandemic Influenza (US Homeland Security Council. National strategy for pandemic influenza: implementation plan. Washington, DC: US Homeland Security Council; 2006. Available at http://www.flu.gov/planning-preparedness/federal/pandemic-influenza-implementation.pdf ).

The six intervals of the updated framework are as follows: 1) investigation of cases of novel influenza, 2) recognition of increased potential for ongoing transmission, 3) initiation of a pandemic wave, 4) acceleration of a pandemic wave, 5) deceleration of a pandemic wave, and 6) preparation for future pandemic waves. The following eight domains are used to organize response efforts within each interval: incident management, surveillance and epidemiology, laboratory, community mitigation, medical care and countermeasures, vaccine, risk communications, and state/local coordination.

Compared with the previous U.S. government stages, this updated framework provides greater detail and clarity regarding the potential timing of key decisions and actions aimed at slowing the spread and mitigating the impact of an emerging pandemic. Use of this updated framework is anticipated to improve pandemic preparedness and response in the United States. Activities and decisions during a response are event-specific. These intervals serve as a reference for public health decision-making by federal, state, and local health authorities in the United States during an influenza pandemic and are not meant to be prescriptive or comprehensive. This framework incorporates information from newly developed tools for pandemic planning and response, including the Influenza Risk Assessment Tool and the Pandemic Severity Assessment Framework, and has been aligned with the pandemic phases restructured in 2013 by the World Health Organization.

(Continue . . . )

Despite their (mostly cosmetic) differences, both the CDC and the WHO stress that the time before the next pandemic strikes is a time for preparedness.   While there’s a perception that pandemics only come around every few decades, and most are – if not mild, at least manageable -  there are no guarantees how long it will be before the next severe one arrives.

Earlier this month, in NPM14: Because Pandemics Happen I wrote about both the history of pandemics, and the concerns held by some of the highest offices in the land over the potential impact of the next pandemic.

 

Many agencies consider pandemics to be among the top threats to national and global security.

 
While most people think that their state or federal government are prepared to handle the next pandemic, the Feds continue to remind us that they can’t handle a major disaster – including a pandemic – without the help of everyone involved.

 

Which is why September of every year is declared National Preparedness Month, where  FEMA and Ready.gov encourage everyone to prepare for a variety of disaster situations.  

 

And it’s not just me saying it.  This from Flu.gov.

 

Pandemic Flu

The federal government cannot prepare for or respond to the challenge of a flu pandemic alone. Your community can develop strategies that reduce the impact and spread of pandemic flu.

Faith-Based & Community Organizations Pandemic Influenza Preparedness Checklist (PDF – 68.91 KB)

Lista de Preparacion para una Pandemia de Gripe Tanto para Organizaciones Comunitarias como Religiosas (PDF – 268 KB)

Community Strategy for Pandemic Influenza Mitigation (PDF – 10.3 MB)

Plan Now to Be Ready for the Next Flu Pandemic (PDF – 213.55 KB)

The Next Flu Pandemic: What to Expect (PDF – 226.83 KB) (excerpts below)

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Their advice (and this is for before a pandemic threat becomes imminent).

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