CDC Expert Commentary (Video) On Use Of Neuraminidase Antiviral Drugs

Photo Credit – Wikipedia

 

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Internet memes can become powerful and persuasive, but they aren’t always true.  The frenzied attacks on vaccines in general and the 2009 H1N1 vaccine in particular – which opponents literally called `deadlier than the virus’ – continue to this day, but are totally lacking in veracity (see The Monsters Are Due On Vaccine Street).

 

Another popular meme has been the demonization of Tamiflu ® (a neuraminidase inhibitor) as either useless and a huge waste of money, or dangerous (see Daily Mail: Ministers blew £650MILLION on useless anti-flu drugs).

 

Fueling this hysteria have been repeated Cochrane group analyses that have found insufficient evidence that the drug reduces influenza complications in healthy adults, although they limit their analyses to RCTs (Randomized Controlled Trials) of which few exist for this drug.  

 

Observational studies – of which there are many supporting its use – were not included (see Revisiting Tamiflu Efficacy (Again)).

 

Much of the ire surrounding this drug has been garnered through Roche’s long-standing resistance to releasing all of their testing data, and that has led to critical editorials in the BMJ, and frequent excoriation in the British press.

 

As a result, many people have come away with the erroneous impression that these drugs are worthless – or worse.

 

We’ve seen a push back by the CDC (see The CDC Responds To The Cochrane Tamiflu Study  ) and the UK’s PHE (see Revisiting Influenza Antiviral Recommendations), and last January we saw a meta-analysis in The Lancet that supported its use (see CIDRAP News On The Lancet Oseltamivir (Tamiflu ®) Meta-Analysis).

Still the level of mistrust and misinformation surrounding these types of antiviral drugs runs high, and so the CDC – in conjunction with MedScape - has released an 8 minute Expert Commentary – primarily for clinicians -  on their proper use by Dr. Alicia Fry.  

 

Although produced in late April, this video was only posted on the CDC’s Flu website in the past week.

 

CDC Expert Commentary

Neuraminidase Inhibitors: Ready and Able to Tackle the Flu

Alicia Fry, MD, MPH

TRANSCRIPT

 

 

Despite a lack of RCTs, there are studies that show that Tamiflu can significantly reduce morbidity and mortality associated with influenza – particularly with severe, or novel infections. Some we’ve looked at in the past include:

 

• In 2010 we saw an observational study that appeared in JAMA (see Study: Antivirals Saved Lives Of Pregnant Women) that strongly suggested that Tamiflu was life saving for some patients with pandemic flu.
• And again in 2010, in BMJ: Efficacy of Oseltamivir In Mild H1N1, we saw a study which suggested that the administration of oseltamivir may have significantly reduced the incidence of pneumonia among otherwise healthy pandemic H1N1 patients.
• In December of 2012, in Study: The Benefits Of Antiviral Therapy During the 2009 Pandemic we looked at a meta-analysis of 90 observational studies that appeared in the  Journal of Infectious Diseases that spanned nearly 35,000 patients, 85% of whom has laboratory confirmed H1N1.

Their main finding was antiviral therapy - principally oseltamivir - initiated within 48 hours of onset, reduced the likelihood of severe outcomes, namely admission to a critical care unit or death, by 49 to 65%.

And even more impressively (and perhaps, more importantly with HPAI H5 viruses on the rise again), in 2010’s Study: Antiviral Therapy For H5N1, we saw the largest look to date at outcomes of H5N1 patients who either received, or did not receive, antiviral treatment.

• The research appears in the IDSA’s Journal of Infectious Diseases. The bottom line is essentially out of 308 cases studied, the overall survival rate was a dismal 43.5%.
• But . . . of those who received at least one dose of Tamiflu . . .  60% survived . . .  as opposed to only 24% who received no antivirals.

While we would all prefer to have rock-solid, indisputable evidence based on well-mounted RCTs proving the effectiveness of neuraminidase inhibitors like Oseltamivir, the preponderance of evidence we have today indicates that NAIs can have a substantial positive therapeutic effect on influenza, particularly in high risk patients or with novel flu strains.

 

And until something better comes along, they really are the only game in town.

Korean MERS Cluster: Third Day With No New Cases

 

 

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With an incubation period of up to 14 days, it would take up to four weeks without a new case before Korean officials could confidently declare their outbreak over, but the news on that front remains good for the third day in a row.

 

One new death was reported, that of an 81 y.o. female with co-morbidities who was exposed in late May at Samsung Seoul Hospital, and was confirmed infected on June 6th. 

 

She succumbed after more than 3 weeks of hospitalization, making her the 33rd fatality of this outbreak.

There remain more than a dozen cases still listed in `unstable’ condition, and as this report illustrates, deaths are often a trailing indicator with this disease.   Still, the case fatality rate in Korea seems destined to be significantly lower than has been reported previously in the Middle East. 

 

Exactly why that should be the case isn’t clear at this time, although given the quality and abundance of information flowing out of Korea on this outbreak, we should have some reasonable answers soon.

 

 

Homers (Middle respiratory diseases) Daily Tracking

54 people under treatment (29.7%), hospital 95 people (52.2%) died 33 patients (18.1%) with a total of 182 people confirmed

Decreased compared to day three of the treatment, discharge, increased party two people, one people increased deaths, confirmed unchanged

54 stable condition being treated is 41 (75.9%), stable in 13 patients (24.1%)

82 people diagnosed type of hospital patients, family / visits 64 people, hospital workers 36 people

1. General Status

   Department of Health and Human Services Homers central management task force is now 06:00 6.30 days, the patient being treated is a 3 kill juleotgo 54 (29.7%), The hospital said two people stretched hayeotdago increased a total of 95 patients (52.2%).

   One person is dead neuleotgo in 33 patients (18.1%), the third overall diagnosis confirmed no new personnel was unchanged.

   41 people are being treated and the patient's condition stable, unstable 13 people.

(Continue . . . )

 

Liberia Announces 1st Ebola Case In Three Months

Credit CDC PHIL

 

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After a remarkable 42 days without reporting an Ebola infection, on May 9th the WHO Declared The Ebola Outbreak In Liberia Over, making yesterday 93 days without a case report. 

 

That is . . .until last night, when the Liberian government announced the discovery of the corpse of a 17 year-old male in the village of Nedowian in Margibi County that tested positive twice for the Ebola virus before burial. 

 

The man supposedly died on June 24th, after a three day illness (see FrontPageAfrica report), although epidemiological details are both scant and unverified at this time. Contact tracing is now underway, and we should hear more on this case in the next couple of days.

This report from VOA NEWS.

 

Liberia Announces New Ebola Victim

•  VOA News

June 30, 2015 4:26 AM

The corpse of a 17-year-old Liberian has tested positive for the Ebola virus, Liberia's first reported case since the country was declared Ebola-free on May 9.

Liberia's deputy health minister Tolbert Nyenswah stressed Tuesday that there is no need to panic. He said the victim has been safely buried and the team tracing the victim's contacts has already begun work.

The Associated Press reports the 17-year-old male died on June 24.

The Ebola victim died in Margibi County, far from the borders of Guinea and Sierra Leone, the two other nations hardest hit by the virus. Nyenswah said experts are trying to figure out if the victim contracted the virus during travel.

Margibi County is close to the country's international airport, about 50 kilometers south of the capital, Monrovia.

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The latest World Health Organization report shows low levels of Ebola still occurring in neighboring Sierra Leone and Guinea, with 20 cases reported last week between them.

 

Current Situation

• There were 20 confirmed cases of Ebola virus disease (EVD) reported in the week to 21 June, compared with 24 cases the previous week. Weekly case incidence has stalled at between 20 and 27 cases since the end of May, whilst cases continue to arise from unknown sources of infection, and to be detected only after post-mortem testing of community deaths. In Guinea, 12 cases were reported from the same 4 prefectures as reported cases in the previous week: Boke, Conakry, Dubreka, and Forecariah. In Sierra Leone, 8 cases were reported from 3 districts: Kambia, Port Loko, and the district that includes the capital, Freetown, which reported confirmed cases for the first time in over 2 weeks.
• Although cases have been reported from the same 4 prefectures in Guinea for the past 3 weeks, the area of active transmission within those prefectures has changed, and in several instances has expanded. 

 

For now it isn’t at all clear how this 17-year-old came to be infected with the Ebola virus, and until that can be answered – and we see if any of his contacts show signs of infection – it will be impossible to gauge just how big a setback this discovery will be for Liberia’s Ebola eradication efforts.

US House Committee Requests Information On Emergency Preparedness For Avian Influenza

 

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A decade ago avian flu was a hot topic in Washington D.C., and pandemic concerns sparked aggressive (and often mandatory)  preparedness measures at the federal, state, and local levels. The HHS was stockpiling antivirals, hospitals and EMS units were holding frequent drills, and even large corporations were gaming how they would operate in a pandemic environment.

 

Over the next few years the H5N1 virus seemed to stabilize, however, and we experienced an H1N1 pandemic that reassuringly failed to live up to its early hype, and on top of that we’ve endured a 7 year global economic downturn - all of which has chased pandemic concerns from headlines and our top priorities.

 

These past eight months, however, have shown that while obscured by other threats, the pandemic threat has not gone away.  Not only have we watched the largest outbreak of H5N1 on record in Egypt this past year, we suddenly find ourselves waiting for the return of HPAI H5 this fall in both North America and Europe - and while it has remained an epidemic in birds so far – it has a pedigree that raises concerns for public health.

 

With 50 million dead birds this spring, and prospects of seeing more of the same this fall and winter, today a bipartisan committee from Congress has released a statement, and sent letters, to the HHS  and the GAO asking for clarification on how the nation is preparing in light of these threats.

First the statement from the Energy & Commerce Committee of the US House of Representatives, followed by links to the letters.

 

Bipartisan Committee Leaders Press Administration on Preparedness Efforts in Midst of Avian Influenza Outbreak

June 29, 2015

WASHINGTON, DC – Bipartisan leaders of the House Energy and Commerce Committee today sent a letter to Dr. Nicole Lurie, the Assistant Secretary for Preparedness and Response, seeking details regarding the administration’s “emergency preparedness in response to the spread of avian influenza.”

Chairman Fred Upton (R-MI), Ranking Member Frank Pallone, Jr. (D-NJ), Oversight and Investigations Subcommittee Chairman Tim Murphy (R-PA), and Ranking Member Diana DeGette (D-CO) write, “The U.S. is currently suffering from the worst avian influenza outbreak in history.” The United States Department of Agriculture has identified two sub-types of the Highly Pathogenic Avian Influenza (HPAI) that “are spreading, causing widespread economic devastation and the deaths of tens of millions of birds.”

The bipartisan leaders continue, “Influenza has the ability to mutate and potentially threaten public health. On June 2, 2015, the CDC issued a health advisory stating that it ‘considers these newly-identified HPAI H5 viruses as having the potential to cause sever disease in humans’ and made recommendations to clinicians, state health departments, and the public. ... HPAI H5 viruses also have the potential to threaten public health indirectly through pressures on the flu vaccine development process, which still mostly requires chicken eggs.”

The leaders are seeking information regarding the administration’s efforts to prevent disruption to the development of the flu vaccine and to prepare local communities to deal with the potential spread to humans.

Upton, Pallone, Murphy, and DeGette also sent a letter to the Government Accountability Office seeking a review of the federal preparedness efforts surrounding this rapidly spreading disease.

 

Letters to GAO and HHS Regarding Avian Flu

June 29, 2015

Excerpt: Influenza has the ability to mutate and potentially threaten public health. On June 2, 2015, the CDC issued a health advisory stating that it ‘considers these newly-identified HPAI H5 viruses as having the potential to cause sever disease in humans’ and made recommendations to clinicians, state health departments, and the public. ... HPAI H5 viruses also have the potential to threaten public health indirectly through pressures on the flu vaccine development process, which still mostly requires chicken eggs.

To read the letter to the GAO, click here.

To read the letter to HHS, click here.

 

Among the questions asked of the HHS are:

 

 

Pandemic preparedness is something I hearken back to in this blog often, and so I’m encouraged that Congress is once again taking the threat seriously.  But  it is also imperative that individuals, families, communities and the private sector plan for pandemic disruptions as well. 

 

Whether it is a mutated HPAI H5 virus carried by migratory birds, or one of the myriad of emerging novel flu viruses gaining traction around the world, a new coronavirus like MERS , or virus X – the one we haven’t identified yet – the odds are great  that we’ll see another (possibly severe) pandemic sometime in the future.

 

The time to consider how to deal with a pandemic is now, while the most options for preparedness remain open.  A few of my more recent pandemic preparedness blogs include:

 

Do You Still Have A CPO?

Pandemic Planning For Business

NPM13: Pandemic Planning Assumptions

The Pandemic Preparedness Messaging Dilemma

The Wellcome Trust-CIDRAP Ebola Vaccine Team B Collaborative Website

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Last February, in CIDRAP/Wellcome Trust: Recommendations For Accelerating The Development Of Ebola Vaccines, we looked at a collaborative report from an expert committee co-chaired by by Wellcome Trust  Director Jeremy Farrar and CIDRAP Director Michael Osterholm, that offered 48 specific recommendations for reaching that goal.

Although the situation is – for now, at least – less dire than it was last winter, the Ebola threat has not gone away.  There remains a great deal of work ahead in order to be ready for the next Ebola outbreak.

Today CIDRAP has announced the launch of a joint web resource with Wellcome Trust – the  Ebola Vaccine Team B website - which will host the latest information on research for the disease.   Also available on the website will be:

• A blog delving into such topics as tracking vaccine clinical trials, keeping manufacturing partners engaged, updates on Team B recommendations
• Frequently updated bibliographies of key reports and resources on Ebola vaccine development
• Situation updates examining vaccine trials
• Listing of Team B vaccine experts
• Ebola updates by the CIDRAP News team

 

Follow the link below to view the entire site:

 

 

Ebola Vaccine Team B

A Joint Project of Wellcome Trust and CIDRAP

Background

TEAM B RESOURCES

Situation Updates

Blog Posts

Ebola News

Bibliographies

Publications

Members

Milestones

 

Wellcome Trust and CIDRAP launched the Ebola Vaccine Team B initiative in November 2014 to assist international efforts to develop in record time safe and effective vaccines against Ebola Virus Disease. The project includes 28 distinguished leaders in public health, medicine, bioethics, pharmaceutical manufacturing, and humanitarian relief. The experts provide a fresh perspective (a Team B analysis) of issues being addressed by international collaborators in the areas of funding, research, development, vaccine efficacy and effectiveness determination, licensure, manufacturing, and vaccination strategy (distribution and administration). To date, Team B has published its findings in two reports:

 

• Recommendations for Accelerating Development of Ebola Vaccines: Report and Analysis

• Fast-Track Development of Ebola Vaccines: Principles and Target Product Criteria

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Colorado’s Recent Spate Of Tularemia Infections

 

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Although Lyme disease, Ehrlichiosis and Rocky Mountain Spotted fever tend to grab the bulk of our attention when it comes to tick borne diseases in North America, there are a number of less well-known nasties including STARI (Southern Tick Associated Rash Illness), Babesia, the recently discovered Heartland and bourbon viruses, and the multi-vectored bacteria called Tularemia.

 

First isolated a little over 100 years ago (1911) in ground squirrels in Tulare County, California - Francisella tularensis  is a gram-negative coccobacillus that is zoonotic and has been reported in every state of the US except Hawaii. It is most prevalent in the south central United States, the Pacific Northwest, and parts of Massachusetts, including Martha's Vineyard.

 

While often a tickborne disease, Tularemia can also be spread via biting flies (deer flies), via direct contact with infected animals, and even through the inhalation of dust or aerosols contaminated with F. tularensis bacteria.  It is even possible to contract the bacteria through drinking contaminated water, although this is fairly rare in the United States.

Hunters are at particular risk because of potential tick exposure and hunting activities such as skinning infected game.  While often called `Rabbit Fever’, many other wild animals are known to carry this bacteria, including muskrats, prairie dogs and other rodents. The CDC warns that domestic cats are very susceptible to tularemia and have been known to transmit the bacteria to humans.

 

Nearly half of all US tularemia infections are reported from the 4-state block of Missouri, Arkansas, Oklahoma, and Kansas.

 

Symptoms (and prognosis) of the disease depends upon the mode of infection.  Deer fly and tick bites usually result in the Ulceroglandular form of the disease, with localized infection and enlarged lymph nodes. Ocular (from touching the eyes with contaminated hands) and Oropharyngeal (from eating or drinking contaminated items) infections are also possible. 

 

The most severe form – pneumonic – can occur when the bacteria are inhaled, or another mode of infection goes untreated and spreads through the bloodstream.  As far as diagnosis and treatment is concerned, the CDC has this to say:

Diagnosis & Treatment

Tularemia can be difficult to diagnose. It is a rare disease, and the symptoms can be mistaken for other more common illnesses. For this reason, it is important to share with your health care provider any likely exposures, such as tick and deer fly bites, or contact with sick or dead animals. Blood tests and cultures can help confirm the diagnosis. Antibiotics used to treat tularemia include streptomycin, gentamicin, doxycycline, and ciprofloxacin. Treatment usually lasts 10 to 21 days depending on the stage of illness and the medication used. Although symptoms may last for several weeks, most patients completely recover.

 

Although not normally considered a hotbed of tularemia infections, last year Colorado unusually reported 16 cases, and this year has already recorded 11 cases.   Prior to 2014, Colorado averaged 3 or 4 cases a year.  The following alert comes from the Colorado Department of Health.

 

 

News: Eleven tularemia cases identified in Colorado this year

Mark Salley, Communications Director | 303-692-2013 | mark.salley@state.co.us

FOR IMMEDIATE RELEASE: June 24, 2015

DENVER — According to the Colorado Department of Public Health and Environment, there havebeen 11 human cases of tularemia in Colorado since May of this year. Sixteen human tularemia cases were reported in 2014, the second highest number of cases in Colorado since 1983 when there were 20 cases. The previous average was fewer than four cases a year.

People can get tularemia if they handle infected animals, such as rabbits, rodents or hares, or are bitten by ticks or deer flies. They also can be exposed by touching contaminated soil, drinking contaminated water or inhaling bacteria.

Anyone who becomes ill after exposure to a sick or dead animal, or after spending time in areas where sick or dead wild animals have been seen, should talk to a health care provider about the possibility of tularemia. Tularemia is treatable with antibiotics.

Symptoms of tularemia include abrupt onset of fever, chills, headache, muscle aches, joint pain, vomiting, dry cough and difficulty breathing. Other symptoms are skin ulcers, swollen and painful lymph glands, inflamed eyes, sore throat, mouth sores, diarrhea or pneumonia. Tularemia often is overlooked as a diagnosis because it is rare, and the symptoms are similar to other diseases. The incubation period (from being exposed to becoming ill) for tularemia is typically 3 to 5 days, but can range from 1 to 14 days.

Individuals who became sick this year reported engaging in activities such as gardening, mowing, soil excavation, construction, ranching and farming. Few reported seeing any sick or dead animals in the days prior to their illness onset. Many of the 2015 patients were ill for several weeks before receiving antibiotic treatment.

To avoid exposure to tularemia, state Public Health Veterinarian Jennifer House recommends people:

• Wear gloves while gardening or landscaping, and wash your hands after these activities.

• Use a dust mask when mowing or doing yard work. Do not mow over animal carcasses.

• Do not go barefoot or wear sandals while gardening, mowing or landscaping.

• Dispose of animal carcasses by using a long-handled shovel to place them in a garbage bag. Put the bag in an outdoor garbage can.

• Wear an insect repellent effective against ticks, biting flies and mosquitoes when hiking, camping or working outdoors. Effective repellants contain 20 to 30 percent DEET, picaridin or IR3535.

• Do not drink unpurified water from streams or lakes or allow your pets to drink surface waters.

• Prevent pets from hunting or eating wild animals. Contact a veterinarian if your pet becomes ill with a high fever and/or swollen lymph nodes.

Saudi MOH: 2 MERS Cases In Riyadh Over Past Two Days

Yesterday & Today

 

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The Saudi MOH was late in posting yesterday’s MERS update, but has made up for it a bit by posting today’s early, so this morning’s post will consolidate the two.  Both are from the Riyadh region, both are in critical condition, and in neither case are we any real information as to their mode of exposure.

Yesterday & Today

On a slightly more positive note, we’ve now gone 4 days without a new case reported from Hofuf (aka `Hofoof’, `Hafuf’), where over the past two months we’ve seen a cluster of roughly 40 cases emerge.

Korean MERS Update: No New Cases Or Deaths

 

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With the exception of seeing two patients released from the hospital (bringing the total under care to 57 people), there were no real changes in the Korean MERS situation in the overnight update.   No additional cases have been reported for 48 hours, and deaths remain constant at 32.

 

Homers (Middle respiratory diseases) Daily Tracking

57 people under treatment (31.3%), hospital discharge 93 (51.1%) died, 32 (17.6%) with a total of 182 people confirmed

Decreased compared to day 2 of treatment, hospital Here two people increases, the death toll unchanged, confirmed unchanged

57 states are stable treatment 43 patients (75.4%), stable in 14 patients (24.6%)

82 people diagnosed type of hospital patients, family / visits 64 people, hospital workers 36 people

1. General Status

   Department of Health and Human Services Homers central management task force is now 06:00 6.29 days, the patient is being treated juleotgo two people in 57 (31.3%), The hospital said two people stretched hayeotdago increased a total of 93 patients (51.1%).

   There was no change to the deaths, 32 (17.6%), there was no new confirmed two days are also confirm the day before against fluctuations do not occur.

   The patient's condition is stable, being treated 43 people, 14 people are unstable.

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WHO H5N1 Update – June 23rd

 

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After reporting nearly 130 H5N1 cases in the first three months of 2015, Egypt has reported only a couple of cases over the past two months – at least according to the figures they have provided to the World Health Organization.   While a slowdown in avian flu transmission would be expected once warmer weather sets in, this abrupt halt in case reports is both unexpected, and difficult to explain.

Since the May 1st report, only 2 additional H5N1 cases have been officially reported to WHO, both young children from Fayoum.  Additionally, Egypt reported two children infected with the avian H9N2 virus (see previous report here).

 

Slowdown or not, the number of H5N1 cases reported out of Egypt in the first 3 months of the year more than doubles the highest number racked up by any country in a 12 month period (previous record was 61 by Vietnam in 2005).   While more cases may return in the fall, for now this reduction in cases is good news.

 

Reporting and surveillance of emerging infectious diseases – even under the best of circumstances – is subject to a number of limitations.  Some cases may be mild, and never get tested, while others may be misdiagnosed. And when surveillance is conducted in a region with limited resources, and an abundance of other problems (social, economic &  political), their completeness or accuracy may suffer further.

So all reported numbers need to be taken with a grain of salt.   

 

These excerpts are  from a WHO report  (posted today) but dated June 23rd.

 

 

Influenza at the human-animal interface

Summary and assessment as of 23 June 2015

Human infection with avian influenza A(H5) viruses

From 2003 through 23 June 2015, 842 laboratory-confirmed human cases of avian influenza A(H5N1) virus infection have been officially reported to WHO from 16 countries. Of these cases, 447 have died.

Since the last WHO Influenza update on 1 May 2015, two new laboratory-confirmed human cases of avian influenza A(H5N1) virus infection was reported to WHO from Egypt, both from Fayoum governorate. A three-year-old female, with illness onset on 8 June was hospitalized on 10 June, and had laboratory-confirmation of infection with an avian influenza A(H5N1) virus on 16 June 2015. A two and a half-year-old male with illness onset on 13 June, was hospitalized on 16 June, and had laboratory confirmation of infection with avian influenza A(H5N1) on 20 June 2015. Both had exposure to poultry, were given oseltamivir, and remain under treatment.

Various influenza A(H5) subtypes, such as influenza A(H5N1), A(H5N2), A(H5N3), A(H5N6) and A(H5N8), continue to be detected in birds in west Africa, Asia, Europe, and North America, according to reports received by OIE. Although these influenza A(H5) viruses might have the potential to cause disease in humans, so far no human cases of infection have been reported, with exception of the human infections with influenza A(H5N1) viruses and the three human infections with influenza A(H5N6) virus detected in China since 2014.

 

Overall public health risk assessment for avian influenza A(H5) viruses: Whenever avian influenza viruses are circulating in poultry, sporadic infections and small clusters of human cases are possible in people exposed to infected poultry or contaminated environments, therefore sporadic human cases would not be unexpected.

With the rapid spread and magnitude of avian influenza outbreaks due to existing and new influenza A(H5) viruses in poultry in areas that have not experienced this disease in animals recently, there is a need for increased vigilance in the animal and public health sectors. Community awareness of the potential dangers for human health are essential to prevent infection in humans. Surveillance should be enhanced to detect human infections if they occur and to detect early changes in transmissibility and infectivity of the viruses.

 

 

Human infections with avian influenza A(H9N2) viruses in Egypt
Two laboratory-confirmed cases of human infection with avian influenza A(H9N2) virus were reported to WHO from Egypt. Both cases occurred in children (a seven-year-old female and a nine-month-old female) from Cairo governorate and both were detected through influenza-like illness (ILI) surveillance. The cases had mild illnesses, were not treated with antiviral medications, and were not hospitalized. One case had exposure to poultry and the second had likely exposure to an environment contaminated with poultry waste.

These are the second and third cases of human infection with influenza A(H9N2) viruses reported from Egypt. Avian influenza A(H9N2) viruses are known to be circulating in poultry populations in Egypt.

Overall public health risk assessment for avian influenza A(H9N2) viruses: Further human cases and small clusters could occur as this virus is circulating in poultry populations across Asia and Middle East. This virus does not seem to transmit easily between humans and tends to result in mild clinical disease, therefore the current likelihood of community-level spread and public health impact of this virus is considered low.

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Korea: No New MERS Cases, 1 Death

 

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Although there are concerns that some occupants of a new hospital have recently been exposed to MERS (see yesterdays’ update), the latest update from the Korean CDC shows no additional cases reported.

 

One additional fatality was reported, and one more person was released from the hospital.

The number of patients under treatment has now dropped to 59, and of these 44 are considered stable.

 

 

Homers ( Middle respiratory diseases ) one days Tracking

- the treatment of 59 patients (32.4%), hospital discharge 91 patients (50.0%) died 32 persons (17.6%) confirmed a total of 182 patients

- day of treatment compared to 2 people feel small , it discharged Now 1 people increased , the death toll first name increases , confirmed unchanged

- it is treated 59 patients stable state is 44 persons (74.6%), unstable 15 patients (25.4%).

- Confirmed type of hospital patients 82 patients , families / visit 64 people , hospital workers 36 people

Korean MERS Cluster Rises To 182, Another Hospital Exposed

 

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Although the number of new MERS cases remains low (just 1 today), there are fresh concerns that a recent fatal case may have spread the virus to yet another medical facility in Eastern Seoul. Our first stop is an excerpt from an AFP report (via The Manila Times ), then on to our daily MERS update from South Korea.

 

 

S. Korea fears MERS may have spread to new hospital

June 27, 2015 3:57 pm

Seoul: South Korea on Saturday said it was closely monitoring a hospital in eastern Seoul over fears that hundreds of people there may have been exposed to the deadly MERS virus.

A 70-year-old woman who caught Middle East Respiratory Syndrome while visiting an infected relative in a different hospital was feared to have spread the virus to the new site.

"We are focusing our efforts in tracing contacts and isolating people who came close to this patient", a senior health ministry official told journalists on Saturday.

The woman died on June 25, two days after she was diagnosed, but due to the virus's 14-day incubation period, anyone she infected may only start showing symptoms in the coming days.

The official said it was too early to say whether the outbreak may be on the wane, given that new cases are expected at the new site.

(Continue . . . )

 

The patient in question appears to be case #173 who was believed exposed on June 5th, but was only confirmed on June 22nd.

The new case reported overnight is also of concern as it is a nurse at a facility (Gangdong Kyung Hee University Hospital) that has now reported five cases in the past 10 days.

 

Roughly 100 potentially exposed dialysis patients are in isolation, and given the timing of their possible exposure, the next week will be critical in determining how big this cluster will become.

Looking for some good news in the latest dispatch, the number of deaths has not increased (31), and the number of patients released has increased to 90 (nearly half of the total infected).   The number of people in (home) quarantine or hospital isolation has dropped to under 2500.

 

Homers ( Middle respiratory diseases ) one days Tracking

- the treatment of 61 patients (33.5%), hospital discharge 90 patients (49.5%) died 31 persons (17.0%) diagnosed with total 182 persons

- day of treatment compared to 8 persons decreased , discharge character 9 persons increased , the death toll unchanged , confirmed 1 persons increased

- it is treated 61 patients stable state is 48 persons (78.7%), unstable 13 patients (21.3%).

- Confirmed type of hospital patients 82 patients , families / visit 64 people , hospital workers 35 people

<1> General Status

□ Department of Health and Human Services Homers central management task force is 6.27 at 06 o'clock today , are treating patients with 61 patients (33.5%) in 8 juleotgo people , who discharged nine patients increased total of 90 patients (49.5%) it said hayeotdago increased .

○ deaths is 31 people (17%) had no change in , confirmed the previous day compared to first gun was increased .

○ condition being treated patients 48 were stable and 13 were unstable .

<3> Status Confirmed

□ 1 suggests there was a new diagnosis .

○ 182 -th confirmed the hospital staff worked in Gangdong Kyung ( nurse ) of the Case , the current epidemiological investigation is underway .

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WHO: UAE Reports 2 Asymptomatic MERS Cases

 

 

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Ten days ago (see WHO: UAE & Saudi MERS Updates) we learned of the UAE’s 5th MERS case of 2015, who was described as:

 

A 65-year-old, non-national male from the Eastern region developed symptoms on 31 May and was admitted to hospital on 6 June. The patient, who has comorbidities, tested positive for MERS-CoV on 14 June. He has no history of exposure to known risk factors in the 14 days prior to onset of symptoms.

 

Although he was described as being in critical condition, on June 18th we learned that he had died (see UAE: Abu Dhabi Announces MERS Fatality, 1 Additional Case?), along with a nearly blind reference to another case.

 

Today the World Health Organization has posted a DON with details on two family contacts of this fatal case – both who tested positive for MERS – and both who have remained asymptomatic while in isolation.    First the WHO report, then I’ll return with a bit more:

 

Middle East respiratory syndrome coronavirus (MERS-CoV) – United Arab Emirates

Disease outbreak news
26 June 2015

On 21 June 2015, the National IHR Focal Point of the United Arab Emirates notified WHO of 2 additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection.

Details of the cases are as follows:

• A 46-year-old, non-national female from the Eastern region was identified through contact screening as she is a family member of a laboratory-confirmed MERS-CoV case reported in a previous DON on 16 June. The patient, who has comorbidities, tested positive for MERS-CoV on 18 June. She has no history of exposure to other known risk factors in the 14 days prior to detection. Currently, she is still asymptomatic in a negative pressure isolation room on a ward.
• An 11-year-old, non-national male from the Eastern region was identified through contact screening as he is a family member of a laboratory-confirmed MERS-CoV case reported in a previous DON on 16 June. The patient, who has no comorbidities, tested positive for MERS-CoV on 18 June. He has no history of exposure to other known risk factors in the 14 days prior to detection. Currently, the patient is asymptomatic in a negative pressure isolation room on a ward.

Contact tracing of household and healthcare contacts is ongoing for these cases.

The National IHR Focal Point of the United Arab Emirates also notified WHO of the death of the MERS-CoV case that was reported in a previous DON on 16 June.

Globally, WHO has been notified of 1,350 laboratory-confirmed cases of infection with MERS-CoV, including at least 480 related deaths.

 

 

MERS, like many viral infections, is capable of producing a broad spectrum of illness – ranging from mild (or even asymptomatic) to severe and life threatening.   Older patients, and those with co-morbidities, tend to do worse with the virus than younger, healthier individuals, although we’ve seen serious morbidity among all cohorts.

Among the unknowns is how many people have actually been infected.   The `official’ number of 1350, is likely a serious undercount, as we normally only hear about the `sickest of the sick’ who are hospitalized and tested.

Contact tracing has unveiled that a percentage of infections are either asymptomatic, or so mild as not to provoke enough concern for the patient to seek medical assistance.  Among known cases, that number is running 10%-20%, but their discovery is more serendipitous than the result of broad-based testing. 

How many there really are, is unknown.

We’ve seen estimates, from a variety of sources. In November of 2013, we looked at a study published in The Lancet that calculated for every case identified, there were likely 5 to 10 that went undetected. 

 

A more recent study, also published in the Lancet, projected 44 951 (95% CI 26 971–71 922) individuals older than 15 years might be seropositive for MERS-CoV in Saudi Arabia.

 

Although it seems likely that asymptomatic (or mildly symptomatic) cases are less infectious than patients with full blown symptoms - they still shed the virus - and so the possibility exists that they might serve as silent vectors of the disease in the community (see Study: Possible Transmission From Asymptomatic MERS-CoV Case). 

 

Unfortunately, after nearly 2 years of waiting we still don’t have a comprehensive case-control study from the Saudis.

 

Which means that many aspects of how this virus spreads in the community remain largely unanswered.

Korea Puts More Teeth In Their Quarantine Laws

 

 

# 10,264

 

In a story that dovetails into my last post about the Korean businessman who traveled to China against his doctor’s advice after being exposed to MERS, South Korea has passed a new law that will eventually add potential prison penalties for anyone evading quarantine or lying about their exposure history.

First an excerpt from today’s NYTs.

 

After MERS, South Korea Authorizes Prison for Quarantine Scofflaws

By CHOE SANG-HUNJUNE 26, 2015

Photo

SEOUL, South Korea

(Excerpt)

The new law, which was passed Thursday and takes effect in six months, gives more authority to public health investigators, empowering them to close down the site of a potential outbreak of infectious disease and to place people there under quarantine. People who defy the orders can be sentenced to up to two years in prison or fined up to 20 million won, or about $18,000. The same penalties can be imposed for lying about one’s potential exposure to infectious disease.

 

This new law also requires health authorities to make public certain information about disease outbreaks, including names and locations of affected hospitals and known exposures to the public. 

 

Both items of information that Korea’s health authorities were roundly criticized for keeping close to their vest during the opening weeks of their MERS outbreak.

Xinhua: China’s Imported MERS Case Released From Hospital

Credit HK Gov

 

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The Korean businessman - son of the 3rd MERS-CoV case and the younger brother of the 4th MERS-CoV case – who traveled against medical advice through Hong Kong on his way to Guangdong Province, has been released from a Chinese hospital after nearly a month of treatment.

In last week’s Eurosurveillance report on China’s Imported MERS Case we learned his condition had improved and doctors were basically waiting for him to test negative for shedding of the virus.

Unlike with Korea’s index case, extensive contact tracing (in China and Hong Kong) has failed to turn up any secondary cases as a result to exposure to this patient during his travels, or hospitalization. 

 

 

China's first MERS patient discharged from hospital

(Xinhua)    16:14, June 26, 2015

 

GUANGZHOU, June 26 -- China's first confirmed Middle East Respiratory Syndrome (MERS) patient was discharged from hospital and returned to the Republic of Korea (ROK) on Friday, the health and family planning commission of Guangdong Province said.

The 44-year-old Korean man tested positive for MERS in Guangdong on May 29.

The man has had no fever for more than 10 days, and has tested negative for MERS twice.

The man had visited a MERS patient at an ROK hospital and expressed discomfort as early as May 21. Despite a doctor recommending that he cancel his travel plans, he flew to Hong Kong on May 26 and entered Huizhou City via Shenzhen.

MERS is a respiratory illness caused by a coronavirus. The first human case emerged in Saudi Arabia in 2012. There is no vaccine or treatment for the disease, which has a fatality rate of about 40 percent.

Korean MERS Cluster: 181 Cases, 31 Deaths

 

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While the Korean MERS cluster is showing encouraging signs of slowing down it may take as many as four weeks (2x’s the 14 day incubation period) without new cases before we can say the outbreak is truly over.  Today, however, another case has been added to the list, along with two deaths (Pt #87 F, 79 & Pt #140 F, 80 – both with major comorbidities).

 

Case #181 is a 26 y.o. male, and is described as a Medical Worker at Samsung Hospital.

As we’ve mentioned before, fatalities are often a trailing indicator as some patients may succumb after days or even weeks of treatment.  The CFR currently sits at 17.1%, but is likely to increase somewhat over time.

 

Homers ( Middle respiratory diseases ) one days Tracking

- the treatment of 69 patients (38.1%), hospital discharge 81 patients (44.8%) died 31 persons (17.1%) diagnosed with total 181 persons

- day of treatment compared to 8 persons decreased , discharge character 7 persons increased , deceased two persons increases , confirmed 1 persons increased

- it is treated 69 patients stable state is 56 persons (81.2%), unstable 13 patients (18.8%).

- Confirmed type of hospital patients 82 patients , families / visit 64 people , hospital workers 35 people

 

 

○ 181 is first diagnosed 135 patients with the diagnosis of a second medical ( doctor ) as , 6.11 ~ 6.15 days he worked at Samsung Seoul Hospital , 6.17 from the date of self-isolation and the case is confirmed during monitoring .

Eurosurveillance: Three MERS Rapid Communications From Korea

 

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We’ve a trio of rapid communications published today in the journal Eurosurveillance that deal with the ongoing MERS outbreak in Korea.   Although I’ve not had time to properly read each of them, I wanted to get links (and short abstracts) up so that others can get started reading them.

Although there is a lot here to absorb, one of the very interesting findings in the first report is that the incubation period (time of last exposure to onset of symptoms) averaged 2 days longer in tertiary cases than in secondary cases, but the time from symptom onset to laboratory confirmation was much shorter.

The authors note:

The shortened duration of symptom-to-laboratory confirmation in tertiary cases may reflect the disease recognition and consecutive earlier testing. However, explanations for a longer incubation period in tertiary infections, compared with secondary infections, require further investigations.

This is the sort of teasing out of epidemiological details we should have been getting from the Saudis all along, but have not.   Eurosurveillance's hat trick of MERS papers is a promising sign that we are apt to learn more about how the MERS virus works from this one outbreak than we have from three years of viral activity in the Middle East.  

 

 

Rapid communications

---

Epidemiological investigation of MERS-CoV spread in a single hospital in South Korea, May to June 2015

by HY Park, EJ Lee, YW Ryu, Y Kim, H Kim, H Lee, SJ Yi

Date of submission: 10 June 2015

---

In this report, we describe 37 MERS-CoV infection cases (1 primary, 25 secondary, 11 tertiary cases) in a single hospital in South Korea. The median incubation period was six days (95% CI: 4–7 days) and the duration between suspected symptom onset and laboratory confirmation was 6.5 days (95% CI: 4–9). While incubation period was two days longer, the duration from suspected symptom onset to confirmation was shorter in tertiary compared with secondary infections.

 

 

 

Preliminary epidemiological assessment of MERS-CoV outbreak in South Korea, May to June 2015

by BJ Cowling, M Park, VJ Fang, P Wu, GM Leung, JT Wu

Date of submission: 15 June 2015

---

South Korea is experiencing the largest outbreak of Middle East respiratory syndrome coronavirus infections outside the Arabian Peninsula, with 166 laboratory-confirmed cases, including 24 deaths up to 19 June 2015. We estimated that the mean incubation period was 6.7 days and the mean serial interval 12.6 days. We found it unlikely that infectiousness precedes symptom onset. Based on currently available data, we predict an overall case fatality risk of 21% (95% credible interval: 14–31).

 

 

The role of superspreading in Middle East respiratory syndrome coronavirus (MERS-CoV) transmission

by AJ Kucharski, CL Althaus

Date of submission: 15 June 2015

---

As at 15 June 2015, a large transmission cluster of Middle East respiratory syndrome coronavirus (MERS-CoV) was ongoing in South Korea. To examine the potential for such events, we estimated the level of heterogeneity in MERS-CoV transmission by analysing data on cluster size distributions. We found substantial potential for superspreading; even though it is likely that R₀ < 1 overall, our analysis indicates that cluster sizes of over 150 cases are not unexpected for MERS-CoV infection.

Maryn McKenna’s TED Talk - What do we do when antibiotics don’t work any more?

 

 

# 10,260

 

Most of my readers are familiar with author, journalist, and blogger Maryn McKenna who now pens the Germination Blog for National Geographic, among her other endeavors. Maryn is also the author of two award winning books, Superbug: The Fatal Menace of MRSA   and Beating Back The Devil  and is working on a third.

Last March Maryn was invited to give a TED Talk on a topic she is well familiar with; the perils of growing antibiotic resistance. 

 

While many of these extraordinary talks are filmed over several days, they are released a few at a time in the months that follow.  Today Maryn’s talk was posted, and so without further ado, I’ll simply step aside and invite you to watch Maryn’s 16 minute TED Talk at the link below.

 

WHAT TO DO WHEN ANTIBIOTICS DON’T WORK ANYMORE?

Penicillin changed everything. Infections that had previously killed were suddenly quickly curable. Yet as Maryn McKenna shares in this sobering talk, we've squandered the advantages afforded us by that and later antibiotics. Drug-resistant bacteria mean we're entering a post-antibiotic world — and it won't be pretty. There are, however, things we can do ... if we start right now.

Saudi MOH: 1 Additional MERS Case In Hofuf

 

# 10,259

 

For more than 2 months, most of the MERS activity in Saudi Arabia has been centered around the town of Hofuf (aka `Hafoof’, `Hafuf’, etc.) in the Northeastern part of the country.   What began with a single case in mid-April grew into a family cluster in early May, and then into a full blown nosocomial outbreak (apparently across more than one hospital) in May and June.

Most, but not all, of the cases have been listed as `contacts’ of a previously indentified case, but the epidemiological situation has been poorly described by the Saudis, and the WHO updates are often vague on the finer details of this outbreak.

 

After several days of no reports, Saudi Arabia announces one more case from Hofuf, this time in a 41 year-old male who is listed as a `household contact’ of another case.  By my count, the number of people in this cluster (since Mid-April) is approaching 40 cases.

A Midsummer’s HPAI H5 Snapshot

 

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Although we haven’t seen a new avian flu outbreak in nearly a week, anyone who has tried to negotiate a bank loan in order to buy a carton of eggs this month knows the impact of H5N2 remains strong.   Even here in central Florida, almost a thousand miles from the closest outbreak, the price of eggs has (in some cases) nearly doubled.

As the summer heat intensifies, the transmission of avian flu decreases.  The wild and migratory birds that tend to carry the virus are spending their summer vacation in their far northern breeding grounds, and – for a time at least – poultry farmers and the food industry can expect a respite.

Three, perhaps four months from now, the concern is that HPAI H5 could be back, and this time it could extend its reach into the eastern and southern states as infected migratory birds head south for the winter. 

While the first detections of North American HPAI H5 took place in early December of last year in the Pacific Northwest, it wasn’t until March and April that the H5N8 virus (and its reassortants H5N2 and H5N1) began to gather steam in the rest of the nation. 

 

It is likely that this `late start’ in the Midwest limited its impact.  Still, the losses, as tallied by APHIS, are considerable; almost 50 million birds lost or destroyed.

 

 

In addition the USDA lists a half dozen captive wild birds (falcons, owls) that have contracted the HPAI virus, along with 75 wild and migratory bird detections (see list here).

 

While no one can be sure who HPAI will play out in North America this fall, speaking before the USA Poultry &Egg Export Council (USAPEEC) last week, John Clifford, the chief veterinary officer of the United States warned the USDA was preparing for a `worst case scenario’.

 

Agrimarketing.com  reported yesterday in  USDA CHIEF VETERINARIAN: AVIAN FLU WILL BE IN ALL FLYWAYS THIS FALL, on his comments, which included:

 

• A worst-case scenario, he said, would involve the highly pathogenic strain of avian influenza returning in migratory wild birds in the fall of 2015 and infections occurring in all poultry sectors - broilers, turkeys and egg layers - and across the country including in the broiler production regions of the Southeastern U.S. and the Upper Midwest and California.
• Clifford said another part of such a scenario is if the H5N2 virus were to genetically reassort to present a different strain than the one presently infecting poultry and wild birds in the U.S.

Stressing the need for better farm biosecurity, Dr. Clifford called HPAI an unprecedented challenge for United States poultry producers. "For the first time, we have high-path avian influenza all around the world in wild ducks. Things have changed and we all need to recognize those changes. This has caught all of us off guard.”

His primary warning was that preparing for HPAI’s return this fall could cost millions, but failing to prepare could cost billions.

 

While the most likely scenario is some kind of repeat – perhaps worse, perhaps not – of what we’ve already gone through these past few months, the potential that HPAI H5 could evolve into new subtypes or variants cannot be dismissed.   

How viruses shuffle their genes (reassort)

 

The H5N8 virus from which H5N2 and a new (North American) H5N1 subtype have emerged appears to be highly promiscuous, and could well be generating additional viral offspring this summer among the migratory birds roosting in the far north. 

 

While evolutionary changes aren’t always bad (some viruses can attenuate or become less `fit’ as they mutate), they can be unpredictable.

 

Which is one of the reasons why,  three weeks ago, we saw the issuance of a CDC HAN:HPAI H5 Exposure, Human Health Investigations & Response, that provided guidance to state and local officials, and clinicians, on how to handle possible human exposure to HPAI H5 viruses.  As they stated in the forward:

 

While these recently-identified HPAI H5 viruses are not known to have caused disease in humans, their appearance in North American birds may increase the likelihood of human infection in the United States.

 

The spread of avian flu over the winter of 2014-15 was unique – not only in North America – but around the world.  H5N8 made its way from Korea and China to western and central Europe,  H5N1 re-emerged in European and African countries that have not seen it in years, and new strains – like H5N6 – continue to emerge in Asia.

In Egypt, H5N1 has not only caused huge losses in their poultry sector, it has sparked the largest human outbreak of that virus since it emerged nearly 20 years ago.  While the full extent of that outbreak isn’t known (see Egypt’s Ongoing Silence On H5N1), at least 160 cases have been reported since last November.

 

All of which has prompted the World Health Organization to issue a warning last February that H5 Is Currently The Most Obvious Avian Flu Threat. 

 

While no one can predict where any of these viruses will end up – as the number of HPAI viruses in circulation around the globe increases - the greater the chances are that someday one will successfully adapt to humans.

Korea Adds 6 More Medical Facilities To Their MERS `Affected’ List

Korean Medical Facilities With MERS Exposures

 

# 10,257

 

One of the contributing factors to Korea’s MERS outbreak has been the habit for many patients to visit multiple clinics or hospitals before settling on a doctor/hospital/or diagnosis. A practice the World Health Organization called `doctor shopping’ in their WHO statement on the Ninth Meeting of the IHR Emergency Committee regarding MERS-CoV.

Many of the MERS cases that have been identified and isolated picked up the virus while visiting crowded ERs, and as often as not, then went on to visit other medical facilities while potentially infectious. 

As a result, while the number of hospitals with actual MERS patients remains under 20, the number of facilities where people may have been exposed has risen to more than 80.  

 

The Korean government English language MERS website where these lists were maintained returns an error now, but Hong Kong’s CHP has posted the following update which notes 6 relatively recent additions.

 

25 June 2015

Korea releases names of six additional health-care facilities affected by MERS 

     The Centre for Health Protection (CHP) of the Department of Health is today (June 25) closely monitoring one additional case of Middle East Respiratory Syndrome (MERS) and six additional MERS-affected health-care facilities newly reported by Korea.

     According to the latest appeal of the health authority of Korea, people who had visited the following health-care facilities during the specified periods and became ill should report to them for follow-up:

• 14/F, Paediatrics Unit of Hallym University Gangdong Sacred Heart Hospital at Gil-dong between June 5 and 9;
• Jongro Guangmyung Pharmacy, Mokchasoo Internal Medicine Clinic at Sangil-dong between June 10 and 12;
• Ilsundang Korean Traditional Medical Clinic at Sangil-dong on June 12;
• Smile Pharmacy, Bon Otorhinolaryngology Clinic at Godeok-dong on June 15;
• Tuntun Pharmacy, Gangdong Neurosurgery Clinic at Myeongil-dong on June 16;
• Withpharm Angel Pharmacy at Gil-dong on June 17; and
• Hallym University Gangdong Sacred Heart Hospital at Gil-dong between the afternoon of June 17 and June 22.

 

(According to the Korean authority, an English translation may not be the official English name. Please refer to the following webpage for the Korean names: www.chp.gov.hk/files/pdf/korean_hospital_list.pdf.)

     "In consideration of the latest information from Korea, we appeal to members of the public who had visited the above health-care facilities during the specified periods to contact the CHP through our hotline (2125 1111) for further assessment," a spokesman for the CHP said.

     Furthermore, according to the preliminary information of the health authority of Korea, the additional case is a patient who had contact with a confirmed case in a hospital in Busan.

     To date, 179 MERS cases have been confirmed by Korea. In addition, another case was exported from Korea to Mainland China.

     "We again urge the public to pay special attention to safety during travel, taking due consideration of health risks of the places of visit," a spokesman for the CHP said.

     "In view of the latest situation in Korea, the public should avoid unnecessary travel to Korea, in particular those with chronic illnesses. Travellers in Korea and the Middle East should avoid unnecessary visits to health-care facilities. In addition, travellers to the Middle East should avoid going to farms, barns or markets with camels, and avoid contact with sick persons and animals, especially camels, birds or poultry," the spokesman advised.

     The CHP will maintain close communication with the World Health Organization and the health authority of Korea. Members of the public and the health-care sector should heighten vigilance and stay alert to the latest situation.

Ends/Thursday, June 25, 2015