Monday, August 31, 2015

Media Reporting 6th MERS Case In Jordanian Cluster

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# 10,472

 

Since the Jordanian Ministry of Health website isn’t posting updates we have to rely upon local media for updates on Jordan’s recent MERS outbreak.  Earlier today I posted on the 5th case in less than a week, and this afternoon we have word on a 6th case.


The first two cases were described as having had recent travel outside of the country (1 to Saudi Arabia, the other not specified) while the latest four all appear to be locally acquired.

 

This report from the Qatar News Agency.

 

Recording 18 HIV infection "Corona" in Jordan

Monday, August 31, 2015

Amman, August 31 / Qena / announced the Jordanian Ministry of Health on the registration of new infection "Corona" to Jordanian woman swallow the age of 74 years, bringing the total number of infections to 18 injured.


Quoted Jordan News Agency, director of communicable diseases at the ministry, Dr. Mohammed Abdullat saying that " infected suffer several diseases such as diabetes, pressure, congestive heart failure and atrial fibrillation.


"He added that the situation is critical for the infected and is in a state of isolation in the hospital who receive the treatment, noting that it was epidemiological investigation of the situation and follow-up contacts from her family and health staff dealing with the situation

 

The pattern we’ve seen many times before – of a patient with MERS admitted to a hospital and the virus spreads to other patients (or employees) - appears to be repeating again in Jordan.

  

While we’ve seen some hospitals successfully cope with a MERS admission without incurring additional cases, a study we looked at in early July  called  Eurosurveillance: Estimating The Odds Of Secondary/Tertiary Cases From An Imported MERS Case) calculated the odds of seeing at least one secondary case derived from an imported case is 22.7% , while the odds of seeing at least one tertiary case is 10.5%.

 

Based on their calculations, the odds of seeing at least 8 cases as the result of a single importation was estimated at non-trivial 10.9%.


A reminder of the importance of continued vigilance at all hospitals for walk-ins of MERS (and other infectious diseases), and of how even a small breach in infection control standards can lead to serious risks to both patients and staff.


For more on preparing hospitals to receive, and safely deal with MERS, Ebola, Avian Flu, and other high-risk patients you may wish to revisit:

 

HHS Selects 9 Regional Ebola & Special Pathogens Treatment Centers

HHS Launches National Ebola Training & Education Center

APIC: Most HCWs Are Removing PPEs Improperly

UNSW: Flu Vaccine Provides Significant Protection Against Heart Attacks

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Photo Credit - CDC PHIL

 

# 10,471


Roughly 18 years ago, a study looked at the rate of heart attacks in the United States, and found that Acute Myocardial Infarctions (AMIs) run as much 53% higher during the winter months than than during the summer.

 

While numerous theories have been offered (holiday stress, cold weather, over-indulgence during the holidays, etc.), a growing number of studies have suggested that  Influenza - and other acute respiratory infections - can act as a trigger for heart attacks (see Study: Influenza And Heart Attacks).  

 

Assuming that flu is a major trigger for heart attacks, then it stands to reason that the flu vaccine ought to provide some measurable level of protection against them.  And over the years we’ve looked at a number of studies that have attempted to quantify that number.

  • In 2010 we saw a study in the CMAJ: Flu Vaccinations Reduce Heart Attack Risk that found that those over the age of 40 who get a seasonal flu vaccine each year may reduce their risk of a heart attack by as much as 19%. Questions were raised over the way this study was conducted (see Vaccine/Heart Attack Study Questioned), and so the results are in dispute.
  • In August of 2013 (see Study: Flu Vaccine May Reduce Heart Attack Risk), we looked at study out of Australia – published in the BMJ Journal Heart, that found compelling – but not exactly conclusive – evidence that flu shots may reduce the risk of heart attacks as much as 45%.
  • In October of 2013 (see JAMA: Flu Vaccine and Cardiovascular Outcomes) we looked at a meta analysis that found among patients who had previously had a heart attack, the receipt of a flu vaccine was linked to a 55% reduction in having another major cardiac event in the next few months.

Complicating matters, those who are most likely have cardiac events (> 65) are also the cohort least likely to derive optimal protection from the flu vaccine (see NFID: The Challenges Of Influenza In Older Adults).  There is some evidence, however, that even when it doesn’t prevent infection, the flu vaccine may reduce the severity of illness (CDC: Flu Shots Reduce Hospitalizations In The Elderly).

 

Building on the 2013 Australian BMJ study mentioned above, researchers at the University of New South Wales have put together a new meta analysis which further supports the link between getting the flu jab, and reducing the risks of having a heart attack.

 

First the link to the study, and a press release, after which I’ll return with a bit more.

Acute myocardial infarction and influenza: a meta-analysis of case–control studies

Open Access

Michelle Barnes, Anita E Heywood, Abela Mahimbo, Bayzid Rahman, Anthony T Newall, C Raina Macintyre

Published Online First 26 August 2015

Abstract

Objective Acute myocardial infarction (AMI) is the leading cause of death and disability globally. There is increasing evidence from observational studies that influenza infection is associated with AMI. In patients with known coronary disease, influenza vaccination is associated with a lower risk of cardiovascular events. However, the effect of influenza vaccination on incident AMI across the entire population is less well established.

Method The purpose of our systematic review of case–control studies is twofold: (1) to estimate the association between influenza infection and AMI and (2) to estimate the association between influenza vaccination and AMI. Cases included those conducted with first-time AMI or any AMI cases. Studies were appraised for quality and meta-analyses using random effects models for the influenza exposures of infection, and vaccination were conducted.

Results 16 studies (8 on influenza vaccination, 10 on influenza infection and AMI) met the eligibility criteria, and were included in the review and meta-analysis. Recent influenza infection, influenza-like illness or respiratory tract infection was significantly more likely in AMI cases, with a pooled OR 2.01 (95% CI 1.47 to 2.76). Influenza vaccination was significantly associated with AMI, with a pooled OR of 0.71 (95% CI 0.56 to 0.91), equating to an estimated vaccine effectiveness of 29% (95% CI 9% to 44%) against AMI.

Conclusions Our meta-analysis of case–control studies found a significant association between recent respiratory infection and AMI. The estimated vaccine effectiveness against AMI was comparable with the efficacy of currently accepted therapies for secondary prevention of AMI from clinical trial data. A large-scale randomised controlled trial is needed to provide robust evidence of the protective effect of influenza vaccination on AMI, including as primary prevention.

 


Some excerpts from the UNSW press release follow:

 

UNSW study finds flu jab provides significant protection against heart attacks

27 Aug 2015

Dan Wheelahan

If you’re over 50 and get the flu jab, you’ll not only help to keep the dreaded lurgy at bay but you could also reduce your risk of a heart attack.

That is the advice of UNSW researchers after their study estimated a vaccine effectiveness of 29% in preventing heart attacks which is on par with other heart attack preventative measures.

Previous studies have estimated the effectiveness of statins for the secondary prevention of heart attacks at 25%, anti-hypertensives (15-18%) and smoking cessation interventions (26%).

Researchers in the School of Public Health and Community Medicine (SPHCM) conducted a systematic review and meta-analysis of 16 international case control studies to estimate the association of influenza and vaccination with heart attacks.

They found significant associations between influenza infection and heart attacks, with heart attack patients twice as likely to have recently had the flu. Their review also confirmed existing evidence, including their own 2013 study, which found that the flu vaccination could lower the risk of a heart attack by 45%.

The study was published today in the journal Heart.

(Continue . . . )

 

Although the `street creds’ of the flu vaccine took a major hit last winter after the late arrival of a `mismatched’ H3N2 virus (see CDC: Updated Estimated Seasonal Flu Vaccine Effectiveness), most years the flu vaccine provides a `moderate’ level of protection.  Something on the order of 40%-60% Vaccine Effectiveness (VE).

 

As we’ve discussed before, there is a pressing need for better flu vaccines (see CIDRAP: The Need For `Game Changing’ Flu Vaccines).While far from perfect - the flu shots we have remain the best preventative action you can take against the flu.


And while not conclusive (more research is needed),  the evidence suggests it may also be one of the best preventative actions you can take against having a heart attack as well.  

 

Which is more than enough reason that I’ll be rolling up my sleeve again this year for the flu shot.

Saudi MOH: Riyadh Adds 6 More MERS Cases

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# 10,470

 

The MERS outbreak in Riyadh isn’t showing any signs of abating on this last day of August, with 6 additional cases announced in the latest update.   Five of the six are listed as `contacts with confirmed or suspected cases’ – likely part of the ongoing nosocomial outbreak – with one outlier with no known contact.


One case  - a 33 y.o. female – is listed as a healthcare worker.   Two recoveries and two deaths are also reported.

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Based on the following ECDC chart – which is already 13 cases behind - August 2015 will go down as the third heaviest MERS month for the Saudis, and the most active month since June 2014. .

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Credit ECDC 20th MERS Risk Assessment

Saudi MOH Statement On Past Week’s Riyadh MERS Outbreak

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#10,469

 

Beneath the cryptic case line-listing that appears on the Saudi MOH’s daily MERS update is the promise that `More information on the exposure history will be posted on the weekly update’.  

 

Given the parsimonious nature of these daily reports, additional information would indeed be welcome.

 

While the MOH does indeed post a weekly summary, these recaps rarely shed any light on the promised `exposure history’ of these cases, and instead (as seen below) highlights the MOH’s response and offers general reassurance to the public.
 

 

MOH: ‘34 MERS-CoV Cases Reported Last Week’

31 August 2015

In its weekly press release, the Ministry of Health (MOH) announced that 34 confirmed cases of the Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) have been reported over the past week, from August 23rd to 29th, 2015, corresponding to Dhul-Qi‘dah 8th to 14th, 1436H (the 35th International Week), including 33 cases in Riyadh, and one case in Najran.

“During the same period, 1.655 samples were tested for Coronavirus at the MOH laboratories across the Kingdom, including 15 cases at the MOH hospitals and 19 other cases at the other health sectors. The number of visits by Rapid Response Teams-IPC was 12, while the total number of visits by public health teams to persons in contact with positive cases was 34,” indicated the Ministry, adding that the number of persons, who were in contact with positive cases at homes was 295, and the number of visits by the Ministry of Agriculture (MOA) was one.

Besides, the Ministry announced that 606 cases, out of the total of 1.175confirmed cases, have been cured, at a rate of 1.6%. There are 57 other cases still receiving treatment, and 9 cases have been quarantined at home.

Within the same vein, the Command and Control Center (CCC) keeps on its efforts around the clock by carrying out epidemiological surveillance tasks, making sure that all governmental and private health facilities abide by infection control measures, as well as coordinating with the relevant governmental sectors, international health organizations, including the World Health Organization (WHO), and think-tanks to follow up all developments regarding Coronavirus.

Over and above, the Ministry keeps on its efforts and full coordination with the Ministry of Agriculture (MOA), to launch anti-Coronavirus awareness campaigns at the gathering places of camels to urge camels’ owners and shepherds to be careful and take protective measures when dealing with camels.

Finally, the MOH highlighted that it will remain committed to the preset preparations and cooperative efforts with other parties, including the Saudi community and healthcare staff, who represent the cornerstone in this regard.

Jordan Reports 5th MERS Case In A Week

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#10,468

 

After going 8 months without reporting any coronavirus cases, on Wednesday of last week we learned of a Jordanian MERS case – described as a man in his 60s –  who reportedly has since died. The following day another case - a 38 y.o. male – was announced.

 

While details are scant, both reportedly had recent travel out of the country.  Their relationship, if any, has not been disclosed. 

 

On Friday, we saw Media Reports Of Two Additional MERS Cases In Jordan (Updated), both listed as contacts of one of the first two cases.  The Jordanian MOH website has remained silent on these cases, but over the weekend posted two long statements (in Arabic) on the control of MERS.

 

Committee Epidemiology confirms the safety measures to deal with Koruna

Health stresses the need to follow health guidelines to reduce the respiratory disease

 

Overnight we’ve a report from PETRA, the Jordanian News Agency, of a 5th case – which while not expressly stated, appears to be the result of nosocomial transmission.

 

New MERS case recorded in Jordan

By Petra - Aug 30,2015 - Last updated at Aug 30,2015

AMMAN — A new case of Middle East Respiratory Syndrome (MERS) coronavirus-related infection has been registered in the Kingdom, the Health Ministry said Sunday.

The diagnosed 56-year-old patient suffers from diabetes, blood pressure-related diseases and kidney failure, said Mohammad Abdullat, director of the ministry’s communicable diseases control department.

The patient also recently underwent open-heart surgery, Abdullat added. A team from the directorate is supervising the private hospital’s measures to prevent the spread of the infection and is also following up on the situation of the patient’s relatives and the medical staff who examined him. Since the MERS virus was first registered in Jordan in 2012, 17 cases have been recorded.

 

You’ll note that the claim that 17 cases have been recorded in Jordan differs from the count offered by the ECDC, which sat at 19 before this latest cluster began. 


This difference of 7 cases appears to be due the Jordanians not including 7 cases retrospectively identified in 2014 as infected from the first known hospital cluster of April 2012 (see Serological Testing Of 2012 Jordanian MERS Outbreak).

 
Curious, as this study was conducted in cooperation with Jordanian MOH, and Jordan’s MERS investigation team.
 

Sunday, August 30, 2015

J. Virol: Novel Reassortant Human-like H3N2 & H3N1 Influenza A Viruses In Pigs

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#10,467

 

Swine are highly susceptible to a variety of flu viruses (human, swine, avian) - and are viewed as excellent `mixing vessels’, allowing viruses to reassort into new hybrid strains.  Swine Influenza Viruses (SIVs) are not a reportable or regulated animal disease in the United States, but the USDA does conduct limited voluntary surveillance for SIV in the US.

 

The USDA describes this program thusly: `This surveillance is not conducted to define prevalence - the goal is to identify viruses that may be circulating in swine, and gain knowledge to contribute to improved animal health diagnostics and vaccines.’

 

Just shy of a year ago, in  USDA IAV-S Surveillance Program Detects Novel H3N1 In US Swine, we learned that a new reassortant SIV had been detected in two states.  While swine H3N1 has been known to circulate in pigs for nearly a decade (see EID Journal 2006 article Novel Swine Influenza Virus Subtype H3N1, United States) this latest variant was a combination of both human and swine influenza viruses.

 

The USDA sent out an email to all SIV (swine influenza virus) approved NAHLN (National Animal Health Laboratory Network) labs on September 14th  (see H3N1 Identified in Swine in Two States), which described the virus as carrying `a novel human seasonal HA gene from contemporary human viruses and are distinct from our current swine H3 viruses.’

 

They warned:

A review of Genbank data indicates there may be more human-like H3 genes (in either H3N1 or H3N2) circulating in U.S. swine subtypes than what the USDA surveillance data has captured. Potential spread of H3N1 or H3N2 that carries the human-like H3 could have significant impact in swine herds due to poor herd immunity as well as potential public health ramifications. Preliminary findings by the USDA-ARS from testing of one of these H3N1 isolates with the human-like H3 gene in swine indicate the virus is fully virulent, causing typical influenza disease.

 

As we saw with the 2009 H1N1 pandemic virus, reassortant influenza viruses can kick around swine herds for years or even decades – picking up mutations or mixing with other viruses –  without posing a threat to humans. Most end up evolutionary failures, but every once in awhile, a genetic winner emerges.

 

Over the past decade we’ve been watching a variety of swine variant viruses (H1N1v, H1N2v,H3N2v) making tentative leaps into human hosts, with a new case reported just last Friday.  So far, these cases remain sporadic, and human-to-human transmission appears rare.

 

All of which brings us to a new study, published last week in the Journal of Virology (alas, behind a pay wall), that describes two distinct novel reassortants (H3N1 and H3N2) that possess human-like H3, and the internal genes from the 2009 H1N1 pandemic virus.

 

They describe both of these novel subtypes as “. . . virulent and can sustain onward transmission in pigs, and the naturally occurring mutations in the HA were associated with antigenic divergence from H3 IAV from human and swine’ and goes on to warn that  ``. . . the potential risk of these emerging swine IAV to humans should be considered”.

 

The Abstract from PubMed.gov follows:

 

J Virol. 2015 Aug 26. pii: JVI.01675-15. [Epub ahead of print]

Novel reassortant human-like H3N2 and H3N1 influenza A viruses detected in pigs are virulent and antigenically distinct from endemic viruses.

Rajão DS1, Gauger PC2, Anderson TK1, Lewis NS3, Abente EJ1, Killian ML4, Perez DR5, Sutton TC6, Zhang J2, Vincent AL7.

Author information
Abstract

Human-like swine H3 influenza A viruses (IAV) were detected by the USDA surveillance system. We characterized two novel swine human-like H3N2 and H3N1 viruses with HA genes similar to human seasonal H3 strains and the internal genes closely related to 2009 H1N1 pandemic viruses. The H3N2 NA was of the contemporary human N2 lineage, while the H3N1 NA was of the classical swine N1 lineage.

Both viruses were antigenically distant from swine H3 viruses that circulate in the U.S. and from swine vaccine strains, and also showed antigenic drift from human seasonal H3N2. Their pathogenicity and transmission in pigs were compared to a human H3N2 with common HA ancestry. Both swine human-like H3 viruses efficiently infected pigs and transmitted to indirect contacts, whereas the human H3N2 was much less efficient.

To evaluate the role of genes from the swine isolates on their pathogenesis, reverse genetics-generated reassortants between the swine human-like H3N1 and the seasonal human H3N2 were tested in pigs. Gene segment contribution to virulence was complex with the swine HA and internal genes showing effect in vivo. The experimental infections indicate that these novel H3 viruses are virulent and can sustain onward transmission in pigs, and the naturally occurring mutations in the HA were associated with antigenic divergence from H3 IAV from human and swine.

Consequently, these viruses could have a significant impact on the swine industry if they cause more widespread outbreaks, and the potential risk of these emerging swine IAV to humans should be considered.

IMPORTANCE:

Pigs are important hosts in the evolution of influenza A viruses (IAV). Human-to-swine transmissions of IAV have resulted in the circulation of reassortant viruses containing human-origin genes in pigs, greatly contributing to the diversity of IAV in swine worldwide. New human-like H3N2 and H3N1 viruses that contain a mix of human and swine gene segments were recently detected by the USDA surveillance system. The human-like viruses efficiently infected pigs and resulted in onward airborne transmission, likely due to multiple changes identified between human and swine H3 viruses. The human-like swine viruses are distinct from contemporary U.S. H3 swine viruses and from the strains used in swine vaccines, which could have a significant impact on the swine industry due to lack of population immunity. Additionally, public health experts should consider appropriate risk assessment for these emerging swine H3N1 for the human population.

Copyright © 2015, American Society for Microbiology. All Rights Reserved.

 


While avian influenza has been getting the bulk of our attention the past couple of years, swine influenza viruses – while usually less virulent -  are also worrisome because they probably have less of a `leap’ to make in order to adapt to human physiology.  

 

For more on swine as potential `flu factories’, you may wish to revisit:

 

Live Markets & Novel Flu Risks In The United States

Keeping Our Eyes On The Prize Pig

EID Journal: Influenza A Viruses of Human Origin in Swine, Brazil

H5N2: The Other Biosecurity Concern

Saudi MOH: 3 New MERS Cases, 4 Deaths

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#10,466

 

The Saudi MOH update today indicates two more MERS cases in Riyadh, one of whom is a healthcare worker, and both are listed as contacts of previously confirmed cases.   


A third case, listed as a 67 y.o. male from Hail – located some 700 km north of Riyadh – is listed as a contact of a previous case.  A tad curious since this is the first case we’ve seen from Hail in quite some time.

 

The report goes on to list 4 deaths from Riyadh, and 3 recent recoveries.

 

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Saturday, August 29, 2015

J.Virol.: Experimental Infectivity Of H3N8 In Swine

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Credit ECDC – 125 years of  Pandemic  History

 

# 10,465

 

The H3N8 subtype of influenza A is of particular interest to influenza researchers for several reasons. 

  • First, as the chart above illustrates, H3N8 is strongly suspected to have sparked human epidemics and a pandemic around the turn of the 20th century.
  • Second, avian H3N8 remains endemic in birds.
  • Third, about 50 years ago H3N8 jumped unexpectedly to horses in Miami, and since the 1970s appears to have supplanted the old equine H7N7  and is now  the only equine-specific influenza circulating the globe.
  • Fourth, in 2004 the equine H3N8 virus mutated enough to jump to canines, and began to spread among greyhounds in Florida (see EID Journal article Influenza A Virus (H3N8) in Dogs with Respiratory Disease, Florida).
  • Fifth, in 2011 avian H3N8 was found in marine mammals (harbor seals), and 2012’s  mBio: A Mammalian Adapted H3N8 In Seals,  provided evidence that this virus had recently adapted to bind to alpha 2,6 receptor cells, the type found in the human upper respiratory tract.
  • Sixth, the mBio findings were further confirmed last year in when Nature Communications: Respiratory Transmission of Avian H3N8 In Ferrets, confirmed that this `virus has an increased affinity for mammalian receptors, transmits via respiratory droplets in ferrets and replicates in human lung cells.

 

Add in that in the short history of studying influenza, only H1, H2, and H3 subtypes have taken hold in the human population (see Are Influenza Pandemic Viruses Members Of An Exclusive Club?), and there are many who believe what went around 110 years ago could possibly come around again.


All of which makes the findings of the following study particularly interesting. 

     

Cross-species infectivity of H3N8 influenza virus in an experimental infection in swine

J Virol. 2015 Aug 26. pii: JVI.01509-15. [Epub ahead of print]

Solórzano A1, Foni E2, Córdoba L3, Baratelli M3, Razzuoli E4, Bilato D5, Martín Del Burgo MÁ6, Perlin DS1, Martínez J7, Martínez-Orellana P3, Fraile L8, Chiapponi C2, Amadori M5, Del Real G6, Montoya M9

Abstract

Avian influenza A viruses have gained increasing attention due to their ability to cross the species barrier and cause severe disease in humans and other mammal species as pigs. H3 and particularly H3N8 viruses, are highly adaptive since they are found in multiple avian and mammal hosts. H3N8 viruses have not been isolated yet from humans; however a recent report showed that equine influenza A viruses (IAV) can be isolated from pigs, although an established infection has not been observed so far in this host.

To gain insight into the possibility of H3N8 avian IAV to cross the species barrier into pigs, in vitro experiments and an experimental infection in pigs with four H3N8 viruses from different origins (equine, canine, avian and seal) were performed. As positive control, a H3N2 swine influenza virus A was used. While equine and canine viruses hardly replicated in the respiratory apparatus of pigs, avian and seal viruses replicated substantially and caused detectable lesions in inoculated pigs without previous adaptation. Interestingly, antibodies against HA could not be detected after infection by hemaglutination inhibition test (HAI) with the avian and seal virus.

This phenomenon was observed not only in pigs but also in mice immunized with the same virus strains. Our data indicated that H3N8 IAV from wild aquatic birds have the potential to cross the species barrier and establish successful infections in pigs that might spread unnoticed using HAI as diagnostic tool.

IMPORTANCE SECTION:

Although natural infection of humans with an avian H3N8 influenza A virus has not yet been reported, this influenza A virus subtype has already crossed the species barrier. Therefore, we have examined the potential of H3N8 from canine, equine, avian and seal origin to productively infect pigs.

Our results demonstrated that avian and seal viruses replicated substantially and caused detectable lesions in inoculated pigs without previous adaptation. Surprisingly, we could not detect specific antibodies against HA in any H3N8-infected pigs. Therefore, special attention should be focused towards viruses of the H3N8 subtype as they could behave as stealth viruses in pigs.

 

 

While H3N8 doesn’t currently appear to be established in swine populations, for much of the world testing of pigs is rarely (if ever) done.  In 2009 we did see evidence of H3N8 detected in Chinese swine in the middle of the last decade (see Isolation and molecular characterization of equine H3N8 influenza viruses from pigs in China).

 

For more background on this increasingly promiscuous virus, you may wish to revisit:

EID Journal: Equine H3N8 In Mongolian Bactrian Camel
Study: Dogs As Potential `Mixing Vessels’ For Influenza

Saudi MOH Announces 2 Additional MERS Cases

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#10,663

 

The number of new MERS cases being reported out of Riyadh has dropped in recent days, which may be an indication that the affected hospitals are starting to get a handle on containing the outbreak.  Today Riyadh only reports 1 new case, while once again we see a sporadic case from Najran.

 

The Najran case had already expired by the time his was announced by the MOH.

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Whether this is a sign that the outbreak in Riyadh is ending – or is just a temporary lull – August 2015 will go down as the third heaviest MERS month for the Saudis, and the most active month since June 2014. .

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Credit ECDC 20th MERS Risk Assessment

This spike is notable also because the hot summer months have not previously been associated with heavy MERS activity on the Arabian peninsula. The seasonality of MERS outbreaks – previously believed to favor spring outbreaks – has proven less predictable during 2015.

Friday, August 28, 2015

CDC FluView: 1 Novel H1N1v Case Reported From Iowa

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# 10,462

 

For the 4th time this year, the CDC is reporting the detection of a novel swine variant virus in a human.  Human infections with these swine-origin viruses are only rarely reported, but presumably happen more often than we know because testing for novel viruses is very limited.


The first two swine variant infections this year were H1N1v (see here and here), while the third case reported just a month ago, was H3N2v.

 

The CDC describes Swine Variant viruses in their Key Facts FAQ.

What is a variant influenza virus?

When an influenza virus that normally circulates in swine (but not people) is detected in a person, it is called a “variant influenza virus.” For example, if a swine origin influenza A H3N2 virus is detected in a person, that virus will be called an “H3N2 variant” virus or “H3N2v” virus.

 

Up until about six years ago the CDC only received 1 or 2 swine variant infection reports each year.  In 2010, that number jumped to 8, and in 2011 to 12.  In 2012 we saw more than 300 cases – mostly mild - and nearly all associated with exposure to pigs at state and local agricultural fairs. 

 

Of the 376 swine variant infections reported in the United States, that vast majority (350+)  have been of the H3N2v variety. Far behind, in second place, is H1N1v.   A bit surprisingly, of the 4 cases discovered this year, 3 have been of the less common H1N1v variety.


This update from today’s FluView report.

 

Novel Influenza A Viruses:

One human infection with a novel influenza A virus was reported by the state of Iowa. The person was infected with an influenza A (H1N1) variant (H1N1v) virus and was hospitalized as a result of their illness. No human-to-human transmission has been identified and the case reported close contact with swine in the week prior to illness onset.

Early identification and investigation of human infections with novel influenza A viruses are critical so that risk of infection can be more fully appreciated and appropriate public health measures can be taken. Additional information on influenza in swine, variant influenza infection in humans, and strategies to interact safely with swine can be found at http://www.cdc.gov/flu/swineflu/index.htm.

 

While occasional cases are not particularly alarming, we keep an eye on these viruses because they belong to the same subtypes as do human flus (H1, H2 & H3), and presumably would  need less of an evolutionary leap to adapt to humans than avian flu strains. 

 

The CDC’s FAQ states:

Why are human infections with variant viruses of concern?

Influenza viruses that infect pigs may be different from human influenza viruses. Thus, influenza vaccines made against human influenza viruses are generally not expected to protect people from influenza viruses that normally circulate in pigs. In addition, because pigs are susceptible to avian, human and swine influenza viruses, they potentially may be infected with influenza viruses from different species (e.g., ducks and humans) at the same time. If this happens, it is possible for the genes of these viruses to mix and create a new virus that could spread easily from person-to-person. This type of major change in the influenza A viruses is known as antigenic shift. Antigenic shift results when a new influenza A virus to which most people have little or no immune protection infects humans. If this new virus causes illness in people and can be transmitted easily from person-to-person, an influenza pandemic can occur. This is what happened in 2009 when an influenza A H1N1 virus with swine, avian and human genes emerged in the spring of 2009 and caused the first pandemic in more than 40 years.

 

With the fall county and state fair season getting full swing, we’ll be watching to see if more cases are detected this fall. 

 

While infections have been generally mild (with a few exceptions), fairgoers should consider taking a little extra care washing their hands, particularly around the animal exhibits. The CDC’s webpage Take Action to Prevent the Spread of Flu Between People and Pigs at Fairs provides additional advice.

 

For more on swine variant influenza, you may wish to revisit:

Keeping Our Eyes On The Prize Pig

Waiting For The Next Flu To Drop

Fair Biosecurity & H3N2 In North Dakota Show Pigs

ECDC Rapid Risk Assessment On MERS-CoV – August 28th

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# 10,561

 

With the rise in MERS cases in Saudi Arabia over the past month, and now four MERS cases reported in Jordan – the concerns over whether this year’s Hajj will help spread the virus are understandably rising.  

 

Today the ECDC released their 20th Rapid Risk Assessment on the virus, warning that sporadic importations of the virus into EU countries can be expected, along with the risks of  further nosocomial transmission.


As this report indicates, we don’t have a complete picture of what is going on with MERS in Saudi Arabia, or any other countries in the Middle East.   The number, and role of asymptomatic carriers is likewise unknown.

 

The full RRA can be downloaded as a PDF File, and is well worth doing for its detailed epidemiological analysis and graphics.   Below you’ll find the press release/summary.

 

Updated Rapid Risk Assessment on MERS in light of Riyadh hospital outbreak

28 Aug 2015

​A large nosocomial outbreak of MERS in Riyadh, Saudi Arabia has triggered an update of ECDC’s rapid risk assessment, in order to assess whether this event changes the risk of international spread or increases the risk to EU citizens living in or travelling to Saudi Arabia. The update also includes an assessment of the risk of infection and introduction into the EU associated with pilgrims visiting Saudi Arabia during the forthcoming Hajj.


Given the substantial number of people travelling between the Middle East, which continues to report the majority of MERS cases, and EU countries, imported, sporadic cases to Europe can be expected.


Over 110 new cases and 30 deaths have been reported globally so far for August 2015 alone, almost all of them from Saudi Arabia. When compared to previous years, the increase in reported MERS cases in August is unexpected and is mainly explained by a large, ongoing outbreak linked to one Riyadh hospital.

 

The extent to which other healthcare facilities in Riyadh are affected is unknown, as is the number of asymptomatic individuals who may be infected with MERS-CoV.

 

The role of hospitals as amplifiers of MERS-CoV infection is well known, so the strict and timely application of comprehensive infection prevention and control measures is imperative.


Sporadic, imported cases can be expected in EU/EEA Member States, and is associated with a risk of nosocomial spread. This highlights the need for awareness among healthcare workers, early detection through functioning testing algorithms, preparedness planning and stringent infection control precautions.

Media Reports Of Two Additional MERS Cases In Jordan (Updated)

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(See update at bottom)

 

#10,460

 

Earlier this week we learned of two Jordanian MERS cases – reportedly a man in his 60s  and a 38 y.o. male – both with recent travel out of the country.  Yesterday the media reported the death of the 60-something patient. 

 

Today, there are fresh media stories indicating two additional cases have been detected, although I have found no official statement  to that effect.  

 

The ages and conditions are different, and these media reports have incremented the number of Jordanian cases to 16, both of which strongly suggests these represent the 3rd and 4th case reported this week. 

 

The relationship – if any – between any of these patients has not been mentioned. Unlike the first two cases,  today’s report contains no indication of recent travel abroad by these cases.

 

As always, Caveat Lector.   I’ll continue to look for more information, but here is one of the recent reports.

 

 

Registration of two cases of new Pfyrus "Corona" in Jordan

Announced here today for the registration of new HIV Koruna two goals in Jordan, bringing the total number of casualties since the first appearance of the disease in 2012 to 16 injured.

It quoted Jordan News Agency of communicable diseases at the Ministry of Health of Jordan, Dr. Mohammed Abdullat saying that scored the body of a citizens Jordanians of the first of them 78 years old and suffering from cancer and his health is nothing wrong and the second 47-year-old Mkhalt injury installed describing his health as good.

The Jordanian Ministry of Health has registered two goals new virus "Corona" on Monday and Tuesday after the last stop for more than a year for the registration of the disease casualties in Jordan


UPDATED  11:45 EDT 8/28

 

My thanks to Sharon Sanders of FluTrackers for this updated report from the Jordanian News Agency PETRA.   It indicates that these two new cases were detected through epidemiological contact tracking of the original cases.

 

Health Balchorona recorded two goals, bringing the total number to 16 cases

Oman August 28 (PETRA)-the total number of HIV infections in koruna Jordan since the first case of the disease in 2012 to 16 injured after registering new infections on Thursday, according to the Director of communicable diseases at the Health Ministry Dr Mohammad Al-abdallat.

Abdallat said in a statement issued by the Ministry's Information Center said on Friday: "the latest from citizens first reaches 78 years and is suffering from cancer and his condition is critical and 47-year-old is the second contacts for injuring the health status, describing proven good.

He added that the discovery of the injury came as a result of contact follow-up epidemiological survey Directorate teams dates of follow-up and monitoring of contacts were finally discovered.

The Health Ministry has recorded new HIV infections koruna on Monday and Tuesday after more than a year of record casualties in Jordan.

-(PETRA) a t/h a 28/8/2015-02:44 pm

 

Meanwhile the ECDC tweeted the following advice about a half hour ago, with a graphic showing the number of travelers expected to transit between Europe and Saudi Arabia over the next couple of months.

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NEJM: Ebola in the United States — Public Reactions and Implications

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# 10,559

 

Eleven months ago America woke up to learn that the first imported Ebola case had been hospitalized and isolated  - after first seeking treatment in a local emergency room three days earlier – in a Dallas hospital. Ten days later, the first of two nurses to contract the virus – Nina Pham – tested positive.


The first few weeks of October were chaotic, with the 24/7 news cycle pounding the Ebola story for ratings, politicians using the crisis to grab headlines and votes, and internet conspiracy sites speculating in the most lurid way that we would all soon be infected.

 

Understandably, the American public’s concern (and distrust) grew with each passing day. Fighting for their attention was a three-ring circus of media hype, disinformation, and paranoia – one we looked at in A Look Down The Ebola Rabbit Hole  and  All The Ebola News Not Fit To Print.

 

Complicating matters, around the same time that the CDC was releasing `worst-case’ estimates of 550,000 and 1.4 million Ebola cases in Liberia and Sierra Leone by the end of January cases in Africa, they were also trying to minimize the American public’s fear of the virus.

image

Except from CDC Infographic

As an example, in August of 2014 the CDC released a reassuring infographic (see above) that - among other things - stated that `You can’t get Ebola through Air’, which immediately set off an internet firestorm of disbelief and derision. While `technically correct’   (Ebola is not an airborne virus) - it overly simplified the threat - which I considered a communications misstep (see The Ebola Sound Bite & The Fury).  

 

In response to the `airborne’ debate  Dr. Ian Mackay produced a series of excellent blogs on how the Ebola virus can be transmitted (see VDU Blog: Droplets vs Airborne - Demystifying Ebola Transmission and Mackay On Ebola: Blood, Sweat & Tears). 

 

But the vast majority of Americans were getting their information from ratings-hungry news organizations, or social media outlets, not from science based blogs.  The public’s trust in official statements took yet another hit when, in late October, the CDC Announced Stricter PPE Recommendations For Ebola - after two Dallas nurses were infected.


Of course, Ebola did not spread in the United States, and after an early false start, hospitals did  figure out how to safely treat patients.  Just as the CDC predicted. Gradually, the public’s level of concern subsided.  

 

But the experience showed how fragile public’s trust of the government can be, and how important it is to get the messaging `right’.  As we’ve discussed so often in the past, overly simplistic or reassuring messaging  can easily backfire (see Sandman & Lanard On Ebola Crisis Communications Lessons).

 

Looking back on all of this, and how things might be handled better the next time a public health crisis like Ebola arrives on our shores, is a perspective article that appeared yesterday in the New England Journal of Medicine.  A good read, and after you return, I’ll have a bit more.

 

Perspective

Ebola in the United States — Public Reactions and Implications

Gillian K. SteelFisher, Ph.D., Robert J. Blendon, Sc.D., and Narayani Lasala-Blanco, Ph.D.

N Engl J Med 2015; 373:789-791August 27, 2015DOI: 10.1056/NEJMp150629

Although there had been only two cases of Ebola transmission inside the United States and both patients had survived, a November 2014 opinion poll revealed that the U.S. public ranked Ebola as the third-most-urgent health problem facing the country — just below cost and access and higher than any other disease, including cancer or heart disease, which together account for nearly half of all U.S. deaths each year (see Table S1 in the Supplementary Appendix, available with the full text of this article at NEJM.org).

(Continue . . . )

 

The timing of Ebola’s arrival in the United States – 2 months before the mid-term elections – undoubtedly added to the public’s level of enmity, but the degree of distrust of science seems to grow worse with each passing year.

 

While many scientists decry this trend as a return to a backwards `flat earth’ mentality, it is sadly at least partially earned.

 

Back in early 2012, in Science at the Crossroads, I wrote about this decline the public’s trust in science. While I cited a number of reasons for this disturbing trend, prime among them has been the abrupt rise in the number of scientific papers that have been retracted sometimes for outright fraud - over the past decade. 

 

In a presentation made in March 2012 (see Dysfunctional Science) before a committee of the National Academy of Sciences, journal editors Arturo Casadevall and Ferric C. Fang warned that the number of retraction notices for scientific journals has increased more than 10-fold over the last decade, while the number of journals articles published has only increased by 44%.

 

Add in the parade of FDA approved drugs that we’ve seen withdrawn for safety reasons after years of use, allegations of biased industry funded clinical trials (see RCTs: All That’s Gold Standard Doesn’t Glitter), and a string of high profile government lab `incidents’ involving Ebola, H5N1, anthrax and smallpox and it’s little wonder that a white lab coat doesn’t engender as much confidence as it once did.

 

These recent lab accidents have led to calls from major journals to improve biosafety, and to even consider blocking certain types of potentially dangerous experiments unless a substantial benefit can be shown that offsets the risks. (see The Laboratory Bio-Safety Backlash Continues and Thebulletin.org: Making Viruses Deadlier – An Accident Waiting To Happen.). 

 

While scientists engaged in this type of work insist that the risks are negligible (see Scientists For Science: GOF Research `Essential’ & Can be Done `Safely’), many others  (see Updating The Cambridge Working Group) are less convinced.

 

Meanwhile a perplexed and increasingly worried public watches on, not knowing which side to believe.

 

As a child of the space age, raised on the science writings of Willy Ley and Isaac Asimov, I am about as `pro-science’ as they come, and will continue to promote it in this blog. But I also realize that science has some serious work to do if hopes to regain its previous high standing with the public.

 

And for everyone’s sake, that’s a change that needs to come sooner rather than later.

Saudi MOH Reports 2 New MERS Cases In Riyadh

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#10,558

 

The Saudi MOH reports the lowest number of new cases in more than 10 days, with only 2 new MERS infections reported in Riyadh today.  While a good sign, we’ll have to wait a few days to see if this is a trend.


Of the two, only one is listed as a having had contact with a known MERS case.  Additionally, one death was reported.

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Thursday, August 27, 2015

Media Reports: Jordanian MERS Patient Died

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#10,557

 

Since the Jordanian Ministry of Health’s website remains silent on the two imported MERS cases reported yesterday and today (see here and here), we are pretty much dependent upon local media sources for updates.   While I much prefer to rely upon official sources, we sometimes have to use what is available.

 

Over the past several hours multiple Arabic media outlets have reported the MERS case announced yesterday – a male in his 60s with recent travel to Saudi Arabia – has died.  Yesterday he was listed in critical condition.


As always with media reports, Caveat Lector.  We should get a better idea of the events surrounding these two cases when the World Health Organization posts an update.  

 

Jordan: the death and injury of critical virus Coruna

UK today - 

Citizen died from a wound infection (Corona) in a hospital in Amman Thursday.

The citizen, aged 60 years, health status is very critical after he returned from a neighboring country, a carrier of the virus, which was admitted to the hospital and was placed on a ventilator, but died after his condition worsened, according to communicable diseases at the Ministry of Health, Dr. Mohammed Abdullat director.

And between Abdullat no other injury in critical condition.

He explained that the number of cases registered in Jordan amounted to 14 cases recorded since the first case of the virus in 2012.

 

 

Health: first death captured a SK

On: August 27, 2015 1:07   [Hala sanchit-news]

The Ministry of Health announced the first case of death captured Sunday's koruna entered the Kingdom days before Saudi Arabia, according to a spokesman for the Ministry, Hatem alazrei.

Added alazrei for "Hala" news that the deceased had entered Jordan infected of the virus, noting that the first death recorded by Jordan because illness koruna in 2015.

The Ministry of health Wednesday recorded its second case of viral koruna, stressing that this virus vaccine is unavailable.

He noted the need to take precautions to avoid contracting the virus, and avoids social behaviours and practices that help in the transmission where the shift is long and contact is not as quick as in seasonal influenza.

WHO Saudi MERS Update – August 27th

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Credit WHO

# 10,456

 

We’ve another lengthy WHO GAR update on the ongoing MERS outbreak in Saudi Arabia.  Today’s update lists 13 cases recorded between August 22nd and August 23rd.  Due to the length of this update, I’ve elected to briefly chart the cases (see spreadsheet below), rather than print the entire update.

 

Although 7 had direct contact with a known case,  5 appear to be the unlucky recipients of  `collateral infection’  while admitted to, or visiting a local hospital.  One case is listed as having no known risk exposure.

 

Three case  are healthcare workers, but only one is described as having provided care to a known MERS case.  As we’ve seen previously, the actual chain of transmission within hospitals is often unclear.  

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Follow the link below for the full details on this update.

 

 

Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Saudi Arabia

Disease outbreak news
27 August 2015

Between 22 and 23 August 2015, the National IHR Focal Point for the Kingdom of Saudi Arabia notified WHO of 13 additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection. Twelve (12) of these reported cases are associated with a MERS-CoV outbreak currently occurring in a hospital in Riyadh city.

(SNIP DETAILS OF CASES)

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

The National IHR Focal Point for the Kingdom of Saudi Arabia also notified WHO of the death of 1 MERS-CoV case that was reported in a previous DON on 26 August (case no. 19).

Globally, since September 2012, WHO has been notified of 1,474 laboratory-confirmed cases of infection with MERS-CoV, including at least 515 related deaths.

Hong Kong Investigates Outbreak Of HFMD In An Adult Institution

Thumbnail of Vesicular eruptions in A) hand, B) foot, and C) mouth of a 6.5-year-old boy from Turku, Finland, with coxsackievirus (CV) A6 infection. Several of his fingernails shed 2 months after the pictures were taken. D) Onychomadesis in a 10-year-old boy from Seinäjoki, Finland, 2 months after hand, foot and mouth disease with CVA6 infection. Photographs courtesy of H. Kujari (A–C) and M. Linna (D).

Vesicular eruptions in A) hand, B) foot, and C) mouth of a 6.5-year-old boy from Turku, Finland, with coxsackievirus (CV) A6 infection.  Credit - CDC EID Journal


# 10,455

 

We’ve a slightly unusual report today out of Hong Kong’s CHP describing  21 recent adult Hand, Foot & Mouth Disease cases at an institution in Wong Chuk Hang, Hong Kong. While adult infection with the non-polio enteroviruses (NPEVs) known to cause HFMD are not unheard of, large clusters of adult cases are pretty rare.

 

First the HK CHP report – which does not identify the virus behind this outbreak – then I’ll return with a bit more on recent outbreaks of NPEVs.

 

 

CHP investigates hand, foot and mouth disease outbreak in institution

The Centre for Health Protection (CHP) of the Department of Health is today (August 27) investigating an outbreak of hand, foot and mouth disease (HFMD) in an institution in Wong Chuk Hang, Hong Kong, and hence appealed to the public to maintain strict personal and environmental hygiene.


The affected persons are 21 men aged from 18 to 30. They have developed fever, oral ulcers, and rash on their hands and feet since August 11. All of them have sought medical attention and none required hospitalisation. They have been in stable condition all along.


"Upon receipt of a report from the institution, officers of the CHP have immediately commenced epidemiological investigations, including a site visit and providing health advice to the management of the institution on necessary infection control and preventive measures. The institution has been under medical surveillance. Investigations are ongoing," a spokesman for the CHP said.

 

"HFMD is usually caused by enteroviruses (EVs) such as Coxsackie virus and EV71. It is clinically characterised by maculopapular rash or vesicular lesions occurring on the palms, soles and other parts of the body such as the buttocks and thighs. Vesicular lesions and ulcers may also be found in the oral cavity. Sometimes patients present mainly with painful ulcers at the back of the mouth, namely herpangina, without rash on the hands or feet," the spokesman explained.

To prevent HFMD, members of the public, particularly management of institutions, should take heed of the following preventive measures:

  • Maintain good air circulation;
  • Wash hands before meals and after going to the toilet;
  • Keep hands clean and wash hands properly, especially when they are dirtied by respiratory secretions, such as after sneezing;
  • Cover the nose and mouth while sneezing or coughing and dispose of nasal and oral discharges properly;
  • Stay at home until fever and rash have subsided and all vesicles have dried up.

The public may visit the CHP's page on HFMD and EV71 infection

(www.chp.gov.hk/en/view_content/16354.html) for more information.

Ends/Thursday, August 27, 2015
Issued at HKT 18:30

 

 

HFMD is normally a mild childhood illness, most commonly caused by the Coxsackie A16 virus (and more rarely by Coxsackie A10 ) here in the United States. In recent years, we’ve also seen the emergence of the Coxsackie A6 virus which has been linked to somewhat more severe HFMD cases (see 2012’s MMWR: Coxsackievirus A6 Notes From The Field).

 

But it has been Enterovirus 71 that has been linked to the most severe cases of HFMD – particularly across Asia - with serious outbreaks recorded over the past 18 years in places like China, Taiwan, Malaysia, Hong Kong, Vietnam and Cambodia (see Updating The Cambodian EV71 Story).

 

This Hong Kong outbreak is unusual for two reasons.  First, it involves more than 20 adults, and second, it is occurring in between the two classic yearly peaks of  Hong Kong’s HFMD season. According to Hong Kong’s CHP: The usual peak season for HFMD and EV71 infection is from May to July. In the past few years, a smaller winter peak also occurred from October to December.


While EV-71 is considered the greatest of the HFMD virus threats, over the past few years we’ve seen a few reports suggesting adults may be more susceptible to the Coxsackie A6 virus. (See Journal of Clinical Virology  Coxsackievirus A6-related hand foot and mouth disease: Skin manifestations in a cluster of adult patients).

 

The MMWR’s Notes from the Field: Severe Hand, Foot, and Mouth Disease Associated with Coxsackievirus A6 — Alabama, Connecticut, California, and Nevada, November 2011–February 2012 published  March 30, 2012 cited an unusually high number of adult infections.

 

Of the 63 patients, 40 (63%) were aged <2 years, and 15 (24%) were adults aged ≥18 years; 44 (70%) of the patients had exposure to a child care facility or school, and eight (53%) of the 15 adults had contact with children in child care where cases of HFMD were reported, or provided medical care or were related to a child with HFMD. Rash and fever were more severe, and hospitalization was more common than with typical HFMD.

 

While EV-71 remains the HFMD virus of greatest concern across Asia, in recent years we’ve seen outbreaks associated with CV-A6 reported in Singapore, Taiwan, Japan, and China (Cite).  

 

It will be interesting to see if the test results confirm Coxsackie A6 as the culprit in this outbreak, or if this is an unusual presentation of one of the other HFMD causing viruses.