Sunday, January 31, 2016

EID Journal: Zika's Evolution And Spread To The Western Hemisphere

Credit ECDC

Epidemiological update

- See more at: http://ecdc.europa.eu/en/press/news/_layouts/forms/News_DispForm.aspx?ID=1350&List=8db7286c-fe2d-476c-9133-18ff4cb1b568&Source=http%3A%2F%2Fecdc%2Eeuropa%2Eeu%2Fen%2FPages%2Fhome%2Easpx#sthash.GNv94r0o.dpufE

Epidemiological update

- See more at: http://ecdc.europa.eu/en/press/news/_layouts/forms/News_DispForm.aspx?ID=1350&List=8db7286c-fe2d-476c-9133-18ff4cb1b568&Source=http%3A%2F%2Fecdc%2Eeuropa%2Eeu%2Fen%2FPages%2Fhome%2Easpx#sthash.GNv94r0o.dpuf















#10,949


The parallels between the evolution and progression of Zika and Chikungunya are nothing less than striking. 


Until the middle of the last decade both were relatively obscure, neglected tropical diseases, which were limited to sparking small low-impact outbreaks in east and central Africa. Both produced (generally mild) dengue-like symptoms, and both launched themselves on their respective world tours around the same time via the Indian Ocean/Pacific island route.

Chikungunya was the first out of the gate, making a surprise leap to the Indian Ocean island of RĂ©union in 2005. There, it infected nearly 1/3rd of the island’s 770,000 residents (see 2006 EID article Chikungunya Disease Outbreak, Reunion Island) in just a matter of months.


From there it quickly cut a swath across the Indian ocean, into southeast Asia, and into the Pacific.


It arrived on the  French Part of St. Martins in the fall of 2013, likely carried in by an infected tourist, and quickly spread across the Caribbean and into South and Central America. In the two years since it arrived in the Americas, it has likely infected more than 2 million people.


Zika appears to have arrived in Brazil in 2014, probably carried in by a viremic visitor from the South Pacific, where the virus had slowly been spreading since 2007 (see 2009 EID Journal Zika Virus Outside Africa by Edward B. Hayes).


As its symptoms are generally milder than both CHKV and Dengue, it wasn't until the summer of 2015 that Brazil recognized it was in the midst of a Zika epidemic.

But by October it was reported in Columbia, and over the next four months, it appeared in more than 2 dozen countries and territories across the Caribbean, South and Central America. It is likely already present in many other regions, but has yet to be picked up by surveillance. 

It has only been since November that suspicions have been raised that Zika infection might not be quite as benign as previously believed (see WHO To Convene IHR Emergency Committee Meeting On Zika).


This rapid spread, and possible shift in virulence, has led to speculation that the Zika virus has changed somehow from its milder African version; transmitting more efficiently via mosquitoes or perhaps replicating more efficiently in human hosts.  


Nearly two months ago, in Paper: Zika Adaptations To Humans Helped Spark Global Spread, we looked at a study - yet to be peer reviewed - by researchers at the University of Sao Paulo and the Pasteur Institute of Dakar (Senegal) who believe they have uncovered genetic changes in the Zika virus that occurred after the virus reached the South Pacific in 2007, that may make it better adapted to human physiology.


While we've yet to see any definitive proof that such a change has occurred, in the past few days the subject has come up repeatedly in the media.

A few days ago the Harvard University School of Public Health ran an article called Zika virus in Brazil may be mutated strain while the New Scientist recently carried a report called Did Zika’s recent mutations let it explode as a global threat?


Today, a report from the Anadolu Agency also touches on this idea, with an interview with a Ugandan researcher who believes the virus has adapted to humans during its trek across the Pacifc.

Uganda virus expert says Zika adapting to humans


A top scientist at the Uganda-based facility that first identified the Zika virus has told Anadolu Agency that the bug is multiplying and becoming more adaptable to humans.

Dr. Julius Lutwama, senior principal research officer at the Uganda Virus Research Institute, said the virus outbreak in the Americas can only be reduced by supportive treatment and through controlling disease-carrying mosquitoes.

“There are two strains of the Zika virus, which include the African Zika virus and the Asian strain, which are slightly different,” he said.

“The strain that is causing problems in the Americas comes from Asia, went to Micronesia, Polynesia and moved to South America.” 

Again, all of this is far from settled science, but it is worth noting that CHKV appears to have benefited from a mutation in the middle of the last decade that allowed it to spread more  efficiently by the Aedes Albopictus mosquito (see A Single Mutation in Chikungunya Virus Affects Vector Specificity and Epidemic Potential).

We have, quite frankly, very little research in the literature on Zika - at least when you compare it to what's available for Dengue, Chikungunya, or West Nile Virus.  That will change over time, now that Zika is viewed as potentially more dangerous than previously believed, but good research takes time. 

Below you'll find an early example, via the CDC's EID Journal. A letter reviewing the expansion of Zika out of Africa (and its similarities to CHKV), along with phylogenic analysis of early samples collected in the Americas.

It doesn't answer the question as to whether the virus has recently `adapted' to humans or mosquitoes, but it does find the Zika virus has evolved into 3 distinct genotypes (East Africa, West Africa, and Asia) and that the Asian genotype is the one that has arrived in the Americas.

Follow the link to read:


Volume 22, Number 5—May 2016


Letter


Phylogeny of Zika Virus in Western Hemisphere, 2015


To the Editor: Zika virus (ZIKV) belongs to the genus Flavivirus, family Flaviviridae, and is transmitted by Aedes spp. mosquitoes. Clinical signs and symptoms of human infection with ZIKV include fever, headache, malaise, maculopapular rash, and conjunctivitis.
ZIKV was first isolated in 1947 from the blood of a febrile sentinel rhesus monkey during a study of yellow fever in the Zika Forest of Uganda (1). During the next 20 years, ZIKV isolates were obtained primarily from East and West Africa during arbovirus surveillance studies in the absence of epidemics. During those 20 years, cases of ZIKV infection were detected sporadically; however, given the clinical similarity of ZIKV and dengue virus infections and the extensive cross-reactivity of ZIKV antibodies with dengue viruses, it is possible that ZIKV was associated with epidemics that were incorrectly attributed to dengue viruses. Beginning in 2007, substantial ZIKV outbreaks were reported first in Yap Island (Federated States of Micronesia), then in French Polynesia, and then in other Pacific Islands (24).

Genetic studies have revealed that ZIKV has evolved into 3 distinct genotypes: West African (Nigerian cluster), East African (MR766 prototype cluster), and Asian. It has been postulated that the virus originated in East Africa and then spread into both West Africa and Asia ≈50–100 years ago (5). In early 2015, cases of ZIKV infection were detected in Rio Grande State, northern Brazil, and limited sequence analyses revealed that the virus was most closely related to a 2013 ZIKV from French Polynesia, within the Asian clade (6).

(SNIP)

As reported by Musso et al. (8), the phylogeny and movement of ZIKV and chikungunya virus are strikingly similar. Each virus is grouped into 3 genotypes of very similar geographic distribution: East Africa, West Africa, and Asia. For both viruses, it also seems that viruses from East Africa moved into Asia ≈50–100 years ago and evolved into a unique Asian genotype (9,10). In addition, the similarity with respect to the recent movement of these viruses from Asia into the Pacific Islands and then into the New World (9) is noteworthy. It seems that similar ecologic and/or human social factors might be responsible for the movement of chikungunya virus and ZIKV into the New World at approximately the same time. 

Further studies might elucidate the exact mechanism of this transcontinental movement, leading to effective prevention strategies.

Saturday, January 30, 2016

Pondering The Great Zika Unknowns

PAHO - Zika Spread Epi Week 4



















#10,948


It is practically an axiom of infectious disease blogging that the first details you get on any emerging disease outbreak are nearly always wrong, or at least misleading. Rarely are all of the pieces to the puzzle immediately available, and the media's narrative is often geared more to boosting circulation than presenting the facts.

As a result, I only sparingly use media accounts in this blog and try to use official releases of information where I can.   Of course, those are often wrong (or biased), as well.

I've called it the `fog of flu'  before - borne of situations where there are alarming but ambiguous reports of something `bad' breaking out - but very little real information.  We deal with it every winter, as we try to parse out the avian H5N1, H5N6 and H7N9 cases from the yearly cascade of seasonal flu and other respiratory outbreaks in places like Egypt and China.


Since November we've been aware of reports of elevated cases of microcephaly in Brazil which the local authorities have tentatively linked to the arrival of Zika last spring. The case numbers have been alarming, the stories of its impact tragic, and we've seen strong warnings issued by our own CDC regarding travel to the region by pregnant women.

But despite all of that, it is far from clear what is going on with Brazil's rates of microcephaly, or even if Zika is responsible.

Overnight both Crof and Dr. Ian Mackay have weighed in on this topic, and I encourage you to read both of their efforts.

First Crof, whose excellent analysis of the (admittedly sketchy) numbers to date (see Is microcephaly surging in Brazil, or just  efforts to find it?), was inspired by Declan Butler's Nature News & Comment article Report questions size of surge in Brazil's microcephaly cases.

Ian took a hard look at this week's  MMWR report Possible Association Between Zika Virus Infection and Microcephaly — Brazil, 2015, and finds it wanting in:

Microcephaly in Brazil: is it occurring in greater numbers than normal or not?

A paper came out yesterday (AEST) from Morbidity and Mortality Weekly Report (MMWR) with the heading...



Possible Association Between Zika Virus Infection and Microcephaly — Brazil, 2015

Reads as though some great data may finally show us a hint of an association between Zika virus (ZIKV) infection and microcephaly disease. Right? 

Nope. There are none. At least none that could approach satisfying that title which highlights that it is not just the popular media who can generate misleading titles (headlines in their case).
(Continue. . .)


This lack of evidence doesn't mean the evidence won't be found, or that a problem doesn't exist.  Only that there are an awful lot of questions yet to be answered.

CIDRAP Director Dr. Michael Osterholm, on the other hand, already finds the evidence compelling. He looks at the rise in mosquito-borne threats in the Americas - due in large part to the cutbacks in mosquito control efforts over the past couple of decades - in:

How Scared Should You Be About Zika?


Zika, or perhaps co-infection (or sequential infection) with Zika and other similar arboviruses (DENV, CHKV), may very well turn out to be responsible for increased rates of microcephaly, spikes in Guillain-Barré syndrome (GBS), or other serious outcomes.

Other viral infections have produced similar impacts, so it is certainly plausible.  But until we know for sure, it is important not ignore other possibilities.

While it may be overstated, I find it hard to believe Brazil's reported surge in microcephaly is due entirely to observational bias, even granting that the base line numbers are suspect and most of the cases are still only suspected.  Something certainly seems amiss.

But that's what epidemiological investigations are for . . . to find out

There are other issues, other unknowns, including determining exactly what species of mosquitoes can (and cannot) transmit the virus, that will need to be nailed down by scientists before we can accurately gauge the impact Zika will have on North America.

I certainly have no inside information or special insight into all of this - but considering the potential impacts to individuals, to families, and to society - it seems only prudent to regard Zika as the most likely culprit - at least until proven otherwise.

Which means, until we know different, the smart money will be on preparing to deal with an enhanced mosquito threat this summer, and likely for many years to come.


Because if it isn't Zika, there's always WNV, Dengue, CHKV, and EEE out there, and they can all ruin your entire day.

Friday, January 29, 2016

CDC Guidance For People Exposed To Birds Carrying Avian Flu Viruses

CREDIT CDC Avian Flu












#10,947



With so many new and emerging avian flu viruses popping up in poultry and wild birds, both in the United States and around the world, I suppose it was only a matter of time before a new term would appear describing them:

 Avian Influenza Viruses Of Public Health Concern.

The list, which started off with H5N1, and a couple of H7 viruses, has grown rapidly over the past several years, and now includes H5N1, H7N9, H10N8, H5N6, H7N8, H5N2, H5N8, H5N9, H7N7, H7N2, H7N3, H9N2 . . . among others.


Only a handful of these avian viruses are known to infect humans, and of those, all but a few (H5N1, H5N5, H7N9, H10N8) usually produce mild, self-limiting influenza-like symptoms.  

Unless you work with live poultry, purchase birds from a live market, or are involved in the culling of infected birds, your odds of exposure right now are pretty slim. But, in the words of the CDC:

Avian influenza virus infections in humans are of public health concern, not only because of the illness they may cause, but because of their pandemic potential.
Some avian influenza viruses have been associated with greater numbers of human infections and more serious illnesses in people and therefore may pose a greater known public health risk. Avian influenza viruses of particular public health concern include (1) those viruses which are known to have caused severe disease in humans, such as highly-pathogenic avian influenza (HPAI) A (H5N1) virus and low-pathogenic avian influenza (LPAI) A (H7N9) virus.
Also, (2) avian influenza viruses that are related to viruses known to cause severe disease in humans are of concern because of their perceived potential to cause severe disease in people. These include HPAI A (H5) and A (H7) viruses identified in birds in the United States during 2015 and 2016. Finally, (3) other avian influenza viruses may be deemed to be of public health concern based on specific circumstances.


This week the CDC has published guidance for those who may be exposed to birds that may be carrying avian flu. Again, this is primarily for those who work in the poultry industry who have been exposed to flocks determined to be infected with avian flu.



You are being given this information and these instructions because you were recently around poultry or wild birds found to be infected with avian influenza viruses (“bird flu”) of public health concern. Some avian influenza viruses have caused rare, sporadic infections in people, resulting in human illness ranging from mild to severe. These viruses are of public health concern because of their ability to cause human illness and also because of their potential to cause a pandemic.

Infected birds shed bird flu virus in their saliva, mucous and feces. Human infections with bird flu viruses are rare, but they can happen when enough virus gets into a person’s eyes, nose or mouth, or is inhaled. This can happen when virus is in the air (in droplets or possibly dust) and a person breathes it in, or when a person touches something that has virus on it and then touches their mouth, eyes or nose. Most often these infections have occurred after unprotected contact with infected birds or surfaces contaminated with avian influenza viruses. However, some infections have been identified where direct contact was not known to have occurred.

Because human infections with these viruses are possible, all people with exposure to birds infected with avian influenza viruses of public health concern and people with exposure to surfaces contaminated with these viruses should be monitored for illness for 10 days after their last exposure. State and local health departments are helping to monitor people’s health and you should contact your health department if you get any of the symptoms listed on this fact sheet during the 10 days after your last exposure. By following the instructions below, you can help ensure that you receive prompt medical evaluation, possible testing and appropriate treatment if you become ill with signs and symptoms that could be due to bird flu.

Please follow these instructions carefully:

1. Monitor your health for symptoms of avian influenza virus infection.
During and then immediately after your last exposure to infected birds or contaminated surfaces, monitor yourself daily for any of these signs and symptoms for 10 days:














You should observe your health daily even if you carefully followed all guidelines and instructions for properly putting on and taking off personal protective equipment (PPE) and maintaining biosecurity precautions.  

Re-start your 10-day monitoring period from Day 1 if you are around sick birds again.

2. Call your state/local health department immediately if you develop any illness signs or symptoms during the 10-day observation period.
Your health department will help you determine what to do next.

Remember: 

  • Most of the signs and symptoms of bird flu overlap with those of other respiratory illnesses (like seasonal flu).
  • If you develop any of the signs or symptoms listed on this fact sheet, immediately call the health department of the state you are in at the time. Your health department wants to hear from you, even if it turns out to be a ‘false alarm’.  
  • Your health department may contact you by phone, email or text while you are observing your health.
  • If you have symptoms, your health department may give you instructions and ask you to get tested for avian influenza virus infection.  
  • To test for avian influenza virus, a doctor or nurse will collect a sample from you by swabbing your nose and/or throat.
  • If you become sick while you are observing your health, a doctor may prescribe you an antiviral medication that is used for treatment of influenza.  It is important to follow the directions for taking the medication. (CDC recommends that clinicians prescribe antiviral medications for treatment of ill persons who had exposure to avian influenza viruses of public health concern.)

UK PHE Warns On Potential Sexual Transmission Of Zika













#10,946


There is a great deal we still don't know about the Zika virus, but given its suspected link to profound birth defects, public health agencies around the globe are faced with a difficult decision:

Do you wait for irrefutable proof of harm, or do you warn people based on the available (and often anecdotal) evidence, in hopes of preventing needless tragedies?

Given the devastating effects that microcephalic birth defects have on families and society, most health agencies would prefer to be proactive, even if it risks raising some degree of alarm. 

In this regard, this week the UK's PHE (Public Health England) has issued some specific advice to sexually active men who have recently returned from regions where Zika has been reported, based on limited reports that the virus may be sexually transmitted.

The notion that Zika might be transmitted direct contact first came to light in 2011 when the EID Journal carried a dispatch on the first Probable Non–Vector-borne Transmission of Zika Virus, Colorado, USA, involving two researchers infected in Africa, one of whom returned to the Untied States and passed the virus (presumably via sexual contact) on to his wife. 

This was the first instance where sexual transmission of an Arbovirus was suspected, the author’s writing:

Results also support ZIKV transmission from patient 1 to patient 3. Patient 3 had never traveled to Africa or Asia and had not left the United States since 2007. ZIKV has never been reported in the Western Hemisphere. Circumstantial evidence suggests direct person-to-person, possibly sexual, transmission of the virus.

A second clue came a year ago, when the CDC's EID journal carried a dispatch called:

Potential Sexual Transmission of Zika Virus


Didier MussoComments to Author , Claudine Roche, Emilie Robin, Tuxuan Nhan, Anita Teissier, and Van-Mai Cao-Lormeau

Abstract
In December 2013, during a Zika virus (ZIKV) outbreak in French Polynesia, a patient in Tahiti sought treatment for hematospermia, and ZIKV was isolated from his semen. ZIKV transmission by sexual intercourse has been previously suspected. This observation supports the possibility that ZIKV could be transmitted sexually.


Even if sexual transmission is possible, this would be a minor route of infection compared to the mosquito-vectored virus.  But as we've seen with Ebola in West Africa, some viruses can persist in the host long after they have physically recovered, and so this potential route of infection must be considered.


In addition to providing Zika virus: travel advice for pregnant women, this week the UK government updated their detailed guidance -  The characteristics, symptoms, diagnosis and epidemiology of Zika - with the following advice on sexual transmission of the virus.


Sexual transmission

Sexual transmission of Zika virus has been recorded in a limited number of cases, and the risk of sexual transmission of Zika virus is thought to be very low. However, if a female partner is at risk of getting pregnant, or is already pregnant, condom use is advised for a male traveller :
  • for 28 days after his return from a Zika transmission area if he had no symptoms of unexplained fever and rash
  • for 6 months following recovery if a clinical illness compatible with Zika virus infection or laboratory confirmed Zika virus infection was reported
This is a precaution and may be revised as more information becomes available. Individuals with further concerns regarding potential sexual transmission of Zika virus should contact their GP for advice.

The data is very limited, and the risks of sexual transmission are likely very low.  But there is still much we still don't know about how the Zika virus affects the human body, how it is shed, and the potential for non–vector-borne transmission of the virus.


For another look on how the Zika virus is shed from the human body, earlier today Dr. Ian Mackay looked at the detection of Zika virus in urine, in his VDU blog:

Zika virus disease samples...don't pass urine (by)..

CDC-NIAID Telebriefing: Zika 101 Transcript & HHS Blog

Mosquito Bite Prevention for the United States PDF













#10,945



Amid the whirlwind of Zika related public health announcements yesterday (see WHO To Convene IHR Emergency Committee Meeting On Zika WHO Zika Media Briefing Audio Recording) the CDC held telebriefing of their own called ZIKA 101, featuring NIAID Director Dr Tony Fauci and the CDC's Principal Deputy Director Anne Schuchat, M.D..

Dr. Schuchat was the `voice' of the CDC during much of the opening months of the 2009 H1N1 pandemic, and impressed mightily with her ability to convey rapidly changing and unscripted information – while acknowledging  the things about the virus that were still unknown – in almost daily briefings.

For those unable to attend the CDC's event, we have a transcript posted to the CDC's media site late yesterday:


Thursday, January 28, 2016.

Please Note:This transcript is not edited and may contain errors.
OPERATOR: Welcome, and thank you for standing by.  At this time, all participants are in listen only mode.  After the presentation, we'll conduct a question and answer session.  To ask a question, please press the star and 1 and please record your name.  Today’s conference is being recorded.  If you have any objections, you may disconnect at this time.
 
TOM SKINNER: We’ll be joined today by DR.  Anne Schuchat, the Principal Deputy Director of the CDC and DR. Tony Fauci, Director of the National Institutes for Allergy and Infectious Diseases, both providing opening remarks about the current outbreak of Zika virus infection.  We understand we are getting a lot of calls and a lot of interest in this story right now.  We want to try to provide you all with as much information as we can, and so we're having this telebriefing.  I’ll turn the call over now to Dr. Schuchat. 
(Continue .. .)



Dr. Schuchat also penned a blog on Zika yesterday for the HHS.GOV website, which goes over the basics of Zika.

 
Summary: 
 
The Zika virus is spread to people through the bite of infected mosquitos. About 1 in 5 people who get infected with Zika virus will show symptoms.
 
In the past several weeks, increased cases of Zika virus disease (Zika) have been reported in South and Central America, and to a limited degree in the Commonwealth of Puerto Rico, a US territory, and the US Virgin Islands.  Zika is a little known illness spread by a certain type of mosquito. Although most people who may be exposed to Zika virus will have only mild or no symptoms, there has been evidence linking Zika virus to negative effects on pregnancies in some cases, which has received widespread public attention. We understand that this news is concerning, especially to pregnant women and their families who may travel to or live in affected areas. Here are some answers to common questions about Zika.

(Continue . . .)

Thursday, January 28, 2016

WHO To Convene IHR Emergency Committee Meeting On Zika

















#10,944


Over the past several days the World Health Organization has come under intense pressure from a variety of sources to convene an Emergency Meeting of the IHR to discuss whether Zika constitutes a PHEIC (Public Health Emergency of International Concern).

An opinion piece appeared yesterday in JAMA (see JAMA Viewpoint: Emerging Zika pandemic requires more WHO action now) urging that a meeting be called.


Meanwhile Helen Branswell (see As Zika spreads, WHO facing calls to take more urgent measures ) and Maggie Fox (see Experts Urge Quicker Action on Zika) both carried reports on numerous calls for action from experts around the globe.

A short while ago the WHO emailed the following statement to journalists announcing an IHR Emergency Meeting will be held on Monday.




 WHO Media Statement on Zika virus

Geneva 28 January 2016--WHO Director-General, Margaret Chan, will convene an International Health Regulations Emergency Committee on Zika virus and observed increase in neurological disorders and neonatal malformations.

The Committee will meet on Monday 1 February in Geneva to ascertain whether the outbreak constitutes a Public Health Emergency of International Concern.

Decisions concerning the Committee’s membership and advice will be made public on WHO’s website.

Outbreak in the Americas

In May 2015, Brazil reported its first case of Zika virus disease. Since then, the disease has spread within Brazil and to 24 other countries in the region.

Arrival of the virus in some countries of the Americas, notably Brazil, has been associated with a steep increase in the birth of babies with abnormally small heads and in cases of Guillain-Barré syndrome, a poorly understood condition in which the immune system attacks the nervous system, sometimes resulting in paralysis.

A causal relationship between Zika virus infection and birth defects and neurological syndromes has not been established, but is strongly suspected.

WHO action

WHO’s Regional Office for the Americas (PAHO) has been working closely with affected countries since May 2015. PAHO has mobilized staff and members of the Global Outbreak and Response Network (GOARN) to assist ministries of health in strengthening their abilities to detect the arrival and circulation of Zika virus through laboratory testing and rapid reporting. The aim has been to ensure accurate clinical diagnosis and treatment for patients, to track the spread of the virus and the mosquito that carries it, and to promote prevention, especially through mosquito control.

The Organization is supporting the scaling up and strengthening of surveillance systems in countries that have reported cases of Zika and of microcephaly and other neurological conditions that may be associated with the virus. Surveillance is also being heightened in countries to which the virus may spread. In the coming weeks, the Organization will convene experts to address critical gaps in scientific knowledge about the virus and its potential effects on fetuses, children and adults.

WHO will also prioritize the development of vaccines and new tools to control mosquito populations, as well as improving diagnostic tests.

FIOCRUZ Researchers Investigate Other Possible Zika Mosquito Vectors











#10,943


The accepted wisdom today is that the Aedes Aegypti mosquito (and very likely the Aedes Albopictus) are the two primary mosquito vectors for Zika, Dengue and Chikungunya. Both are well distributed in Central and South America, and both make serious inroads into North America as well. 

But worldwide there are well over 3,500 species of mosquito, and at least 175 of those can be found in the United States.  Most do not transmit disease, but other non-Aedes species can and do carry diseases like  Malaria (Anopheles) and West Nile (Culex).

Reseachers at FIOCRUZ (FundaĂ§Ă£o Oswaldo Cruz), one of the oldest and most prestigious scientific research institutes in South America, are now investigating the possibility that other, non-Aedes mosquito species, might carry and spread Zika and Chikungunya.

The keyword is `possibility', as all of this is speculative and nothing has been proven yet.  But one never knows until one looks.


The concern is that the Culex mosquito - which is 20 times more prevalent than the Aedes variety in Brazil - might also play some role in the rapid spread of these viruses.  Researchers hope to have some answers in a few weeks.



Fiocruz investigating whether mosquito can also transmit zika


01.27.16 at 19:20 Folhapress


KLEBER NUNES RECIFE, PE (Folhapress) - Researchers at Fiocruz Pernambuco are investigating whether the mosquito Culex quinquefasciatus, also known as mosquito or muriçoca, can transmit the virus zika. The restlessness of experts came to realize that the French Micronesia in 2007, when the first outbreak was recorded, there was a tiny population of Aedes aegypti, the mosquito that is the vector of the disease in Brazil, and an alarming infestation of Culex. "In wild environments it was the zika virus found in other types of Aedes and Culex. Why in the urban area would be only one vector? Is that what we want to understand," said Constance Ayres, entomologist and research coordinator.

To verify the transmission of the virus zika, the researchers infected Culex mosquitoes 200. Everyone gets the salivary glands and the digestive tracts examined. "If found the zika these materials, particularly in the salivary gland, we have a strong indication that the Culex is also vector of the disease. Then one field research will need to confirm. Otherwise, we will consider how the insect gene that blocks the action of the virus [in Culex], "said Ayres. The conclusion of this research phase shall be disclosed until the end of February.

Depending on the outcome, actions to combat the spread of disease caused by zika virus can change completely. "Unlike the Aedes aegypti mosquito, Culex lays its eggs in dirty water, like drains and sewers. Then, you need to prioritize sanitation throughout the country," she said. The mosquito has different habits of Aedes, which, according to Ayres, increase the need for the population to redouble care not to be infected. "While the Aedes aegypti feeds on human blood during the day, Culex do so at the night," he said.


Conventional wisdom isn't what it used to be.  Only a few months ago Zika was considered a mild, self-limiting illness with minimal public health impact.  Today, the evidence suggests otherwise.


Which is why, even if this research doesn't end up implicating other mosquito vectors, it is worth doing.




H7N9 Case Reports From Guangdong & Zhejiang Province










# 10,942


H7N9 reports continue to dribble out of China with reports today from Hong Kong's CHP and from the Xinhua News agency alerting us to two cases, one from Guangdong Province and the other from Zhejiang.

As discussed many times before, many Chinese provinces only release information in EOM epidemiology reports, and so we often learn about their cases weeks after the fact. 

First from Hong Kong's CHP and announcement of two cases (the Hunan case I reported yesterday), but with a new case from Guangdong Province as well.

28 January 2016
 

CHP closely monitors two additional human cases of avian influenza A(H7N9) in Mainland 

The Centre for Health Protection (CHP) of the Department of Health (DH) is today (January 28) closely monitoring two additional human cases of avian influenza A(H7N9) in the Mainland, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

According to the Health and Family Planning Commission (HFPC) of Guangdong Province and the HFPC of Hunan Province, the 74-year-old male patient lived in Meizhou, Guangdong, while another 33-year-old male patient, with poultry contact history, lived in Yongzhou, Hunan. 


(Continue . . .)


The second case, reported by Xinhua News, contains a bit more detail.


New human H7N9 case reported in east China
 

Source: Xinhua   2016-01-28 17:31:12     [More]

HANGZHOU, Jan. 28 (Xinhua) -- Another human H7N9 avian flu case has been confirmed in east China's Zhejiang Province, several other provinces have also reported cases this winter.

The patient is a 59-year-old woman from Gaoxin District in Shaoxing City, she has been hospitalized, according to the Municipal Health and Family Planning Commission on Thursday.

The patient had purchased a hen from Dahutou Village and had killed it herself, according to the commission.

Sporadic human H7N9 cases have been reported in Shanghai, Hunan, Guangdong and Fujian. There have been two fatalities, one in Zhejiang and another in Guangdong.

H7N9 is a bird flu strain first reported to have infected humans in March 2013 in China. It is most likely to strike in winter and spring.

Wednesday, January 27, 2016

WHO Update - Lassa Fever In Nigeria





















#10,941

For most of January we've been following a Lassa Fever outbreak in Nigeria (see Nigeria: Lassa Fever Outbreak With 40 Fatalities), one which appears to have an unusually high mortality rate (at least based on the numbers provided).


Lassa is a Viral Hemorrhagic Fever (VHF), albeit not as deadly as Marburg or Ebola. The Lassa virus is commonly carried by multimammate rats, a local rodent that often likes to enter human dwellings. Exposure is typically through the urine or dried feces of infected rodents, and roughly 80% who are infected only experience mild symptoms

The overall mortality rate is believed to be in the 1%-2% range, although it runs much higher (15%-20%) among those sick enough to be hospitalized.

Like many other hemorrhagic fevers, person-to-person transmission may occur with exposure to the blood, tissue, secretions, or excretions of an individual, although the CDC reassures:

Casual contact (including skin-to-skin contact without exchange of body fluids) does not spread Lassa virus. Person-to-person transmission is common in health care settings (called nosocomial transmission) where proper personal protective equipment (PPE) is not available or not used. Lassa virus may be spread in contaminated medical equipment, such as reused needles.

Today's update from WHO lists 159 suspected cases of Lassa fever and 82 deaths, pushing the fatality rate to over 50%.  The Nigerian MOH's most recent status update  Daily Situation Report No. 16: 24th January 2016 lists:

  • Total cases reported (confirmed and suspected): 172; Total deaths (confirmed and suspect): 83 (CFR: 48%)
  • Total confirmed cases: 57; Deaths in confirmed cases: 34 (CFR: 60%)

By either measure, this is an unusually high fatality rate for Lassa Fever. 


The last major outbreak of Lassa in Nigeria was  reported in 2012.  Last year, Nigeria only reported 250 cases (likely a substantial under count) and 8 deaths.   By contrast - in 2012 - 117 deaths were recorded, but the fatality rate remained under 10%.




Lassa Fever – Nigeria

Disease outbreak news
27 January 2016

The National IHR Focal Point of Nigeria has notified WHO of different outbreaks of Lassa fever occurring in the country.

Details of the outbreaks

Between August 2015 and 23 January 2016, 159 suspected cases of Lassa fever, including 82 deaths, were reported across 19 states. Investigations are ongoing and a retrospective review of cases is currently being performed; therefore, these figures are subject to change.

The 4 most affected states are Bauchi, Edo, Oyo and Taraba, which account for 54% of the confirmed cases (n=54) and 52% of the reported deaths (n=34). The remaining 15 States have reported less than 5 confirmed cases.

Samples of 54 cases, including 34 deaths, were confirmed for Lassa fever by reverse transcription polymerase-chain reaction (RT-PCR). All samples tested negative for Ebola virus disease, Dengue and yellow fever.

To date, 4 health care workers were laboratory-confirmed for Lassa fever; of these 4 cases, 2 passed away. It is important to note that these cases are not considered as cases of hospital-acquired infection as no confirmed or suspected cases were reported in the 4 different health facilities where these health care workers were employed.

As of 21 January, 2,504 contacts had been listed and 1,942 are currently being monitored. A total of 562 contacts have completed follow up. So far, none of the contacts have tested positive for Lassa fever.

Public health response

The WHO country office is supporting the Federal Ministry of Health (MoH) in coordinating the response, especially regarding surveillance (including active surveillance and contract tracing), case management, infection prevention and control, and sensitization of community and health workers. WHO and MoH have identified a need to reinforce trainings for clinicians and community sensitization.

Background

Lassa fever is endemic in Nigeria and causes outbreaks almost every year in different parts of the country, with yearly peaks observed between December and February. The disease is an acute viral haemorrhagic illness caused by Lassa virus, a member of the arenavirus family of viruses. It is transmitted to humans from contacts with food or household items contaminated with rodent excreta. The disease is endemic in the rodent population in parts of West Africa. Person-to-person infections and laboratory transmission can also occur, particularly in the hospital environment in the absence of adequate infection control measures. Diagnosis and prompt treatment are essential.


An Update On The Russian Influenza Epi Report













#10,940


Thanks to a sharp eyed reader (@BVance) we have an update - posted today - from the WHO National Influenza Centre Of Russia that refutes recent Russian media claims (see A Russian Influenza Epidemiology Report To Ponder) of a `mutated, highly virulent H1N1 virus', but that does not back away from their own reports of recently identified antigenic changes.

As I pointed out this morning, there was nothing in Week 3 Russian Epi report to support the media's claim of increased `morbidity and mortality'  associated with these changes. 

This latest media release (in Russian) indicates that seasonal flu activity continues to rise across much of Russia, but denies the media's assertions of a hyper-virulent strain.  While the intent of this strongly worded statement is to reign in a hyperbolic press, they go on to state:

The genomes examined to date strains indeed several mutations have been identified, but they are not associated with high pathogenicity, and are probably the result of conventional genetic drift.

As previously stated, the importance of all of this is whether any of these genetic changes might impact the selection (next month) of the H1N1 strain to be included in next fall's flu vaccine. 


Press Release: Influenza epidemic situation on 01.27.2016

PRESS RELEASE

The epidemiological situation of influenza on 01/27/2016 

The rise of the incidence of influenza began with the 2nd week of 2016 in the Volga region (Volgograd, Rostov-on-Don, Stavropol) and has now exceeded the epidemic threshold fixed in 47 regions of the Russian Federation in all federal districts, except the Crimean Federal District.

At the present time (4 weeks. Years) the incidence of influenza and SARS on the population of the Russian Federation as a whole was 91.6 cases of flu and colds by 10 thousand. People., Which is higher than the baseline for Russia (69.5 cases) 31.8% and epidemiological week. threshold (61.8) 48.2%.

This week, compared with the previous week, the incidence observed in the cities of Russia continued to grow. The incidence of influenza and SARS on the European criteria relating to the mean intensity of the epidemic.

The geographical spread of the flu in Russia as a whole and in all districts widespread, except for Siberia, where the spread of influenza corresponds to the regional level.

The etiological structure of influenza overwhelming place is the virus that caused the pandemic of 2009 - A (H1N1) pdm09. A feature of the virus is higher pathogenicity for humans compared with other influenza viruses. However, the incidence rises caused by the influenza A (H1N1) pdm09 since 2009 are regular and are not something special or unforeseen.

The greatest danger is the flu for people with reduced immunity, the elderly and people with chronic diseases. It was found that among the dead from the flu and its complications are no persons vaccinated against influenza.

In this regard, appeared in the media with reference to the State Organization "Institute of Influenza" Russian Ministry of Health information about the high incidence of influenza in the current epidemic season is associated with mutations in the genome of circulating virus A (H1N1) pdm09, to inform you that this information does not correspond to reality.

According to a preliminary molecular genetic analysis of circulating influenza A (H1N1) pdm09 antigenic properties and nucleotide sequences correspond to the vaccine strain A / California / 7/09. The genomes examined to date strains indeed several mutations have been identified, but they are not associated with high pathogenicity, and are probably the result of conventional genetic drift.

The genome studied to date strains indeed found several mutations, but they are not associated with high pathogenicity, and are due to normal genetic drift, which is of interest only to specialists, virologists.

FGBI "Influenza Research Institute" Russian Ministry of Health reminds you of the need for timely treatment to the doctor in the case of the first symptoms of the disease.

Brazil MOH: Epi Week 3 Microcephaly Update








# 10,939


At first glance the numbers presented today by the Brazilian MOH are a bit confusing, as they highlight they are now investigating 3,448 Microcephaly cases, seemingly a reduction from last week's 3893 Suspected Microcephaly Cases Under Investigation. 

All becomes clear when you look at the chart above, which shows that 270 cases are now confirmed - and removed from that number - and 462 cases have been discarded. 

Today's report actually adds 287 suspected cases since last week's report, but after you deduct the discarded and confirmed cases, you end up with 3,448.  All totaled, the number of cases that have been investigated in 2015-16 is 4,120.


The MOH summary (the full Epi report has not yet been posted) follows:


Apart from the cases that remain under investigation, the ther 270 have had confirmation of the disease and 462 were classified as discarded

The Ministry of Health investigates 3,448 suspected cases of microcephaly across the country. The new report released on Wednesday (27) also points out that 270 cases have had microcephaly confirmation, and 6 with respect to the Zika virus. Other 462 reported cases have been discarded. In all, 4,180 suspected cases of microcephaly were recorded until 23 January.

"Regarding the report released on January 20, there appears a tendency to reduce the number of notifications. The increase identified in a week of reported cases was 7%. However, the amount of discarded cases grew 63%, from 282 to the current 462, "said Claudio Maierovitch, director of the Department of Surveillance of Communicable Diseases of the Ministry of Health.

In total, 68 deaths were reported due to congenital malformations after delivery (stillbirth) or during pregnancy (miscarriage). Of these, 12 were confirmed to the relationship with congenital infection, all in the Northeast, 10 in Rio Grande do Norte, one in CearĂ¡ and one in PiauĂ­. Continue research in 51 deaths and five have already been discarded.

It should be noted that the Ministry of Health is investigating all cases of microcephaly or defects reported by the states, and the possible relationship with the Zika virus and other congenital infections. The microcephaly can be caused by various infectious agents beyond Zika, such as syphilis, toxoplasmosis, Other Infectious Agents, Rubella, Cytomegalovirus and Herpes Viral.

According to the report, the 4,180 cases reported since the beginning of the investigation on 22 October last year - were recorded in 830 municipalities in 24 Brazilian states. The Northeast region has 86% of reported cases and Pernambuco continues with the highest number of cases that remain under investigation (1125), followed by the states of ParaĂ­ba (497), Bahia (471), CearĂ¡ (218), Sergipe (172 ), Alagoas (158), Rio Grande do Norte (133), Rio de Janeiro (122) and MaranhĂ£o (119).

So far, they are with indigenous circulation of Zika virus 22 units of the federation. They are: GoiĂ¡s, Minas Gerais, Federal District, Mato Grosso do Sul, Roraima, Amazonas, Para, Rondonia, Mato Grosso, Tocantins, Maranhao, Piaui, Ceara, Rio Grande do Norte, Paraiba, Pernambuco, Alagoas, Bahia, EspĂ­rito Santo , Rio de Janeiro, Sao Paulo and Parana.


A table showing Microcephalic cases under investigation by Regions and Federative Units is available at the above link.




Xinhua: Hunan Province Reports 1st H7N9 Case Of The Season






# 10,938


Hunan Province, which ranks 7th in the number of announced H7N9 cases (n=26) since 2013, reports their first H7N9 positive patient for the winter of 2015-16.


Source: Xinhua   2016-01-27 19:51:56

CHANGSHA, Jan. 27 (Xinhua) -- A new human H7N9 avian flu case was confirmed in central China's Hunan Province, with several coastal provinces reporting such cases this winter.

The patient is a 33-year-old man from Xintian County who is receiving treatment in a hospital, said the Hunan Provincial Health and Family Planning Commission on Wednesday.

Sporadic human H7N9 cases have been reported in Shanghai, Zhejiang, Guangdong and Fujian, including two fatalities, one in Zhejiang and another in Guangdong.

Three human H5N6 cases were also reported in Guangdong and one in Jiangxi. The H5N6 patient in Jiangxi, a 42-year-old male who lived in Guangdong, died in a hospital in Jiangxi in December. One H5N6 patient died in Guangdong in the same month. 
We've yet to see the kind of January surge in H7N9 cases that we've witnessed over the past couple of years in China.  Whether this reflects some change in the behavior or spread of the virus, or a change in surveillance and reporting, is unknown.

As I noted in yesterday's WHO: Influenza at the Human-Animal Interface - January 2016, since February of last year we've seen significantly reduced (or delayed) reporting on avian flu out of China, with many provinces preferring to release information in batches, often weeks after the fact.


While the reduction in reported infections may be a good sign, it may be several months before we see China's full accounting of avian flu cases.

Saudi MOH Reports 1 Primary MERS Case (Camel Contact)



# 10,937


The Saudi MOH has announced their 5th positive MERS case in a week, and following the trend we've seen all month, this case is linked to camel contact. 




A Russian Influenza Epidemiology Report To Ponder











UPDATED:  See An Update On The Russian Influenza Epi Report

# 10,936


Every winter since the end of the 2009 H1N1 pandemic we've seen frequent, vague, often hyperbolic reports of H1N1 outbreaks around the world carrying an unusually high mortality, often suggesting that a `mutation' was responsible.

In India and the Middle East, the (now) seasonal H1N1pdm virus is still regarded as a `swine flu' by the media, and is always good for a headline.  Doubly so if the `M' word can be incorporated.

Yet despite this yearly hype, over the seven years since it appeared A/H1N1pdm09 has remained remarkably stable. While the H3N2 vaccine strain has been changed repeatedly, nearly all circulating H1N1 viruses have remained antigenically similar to the H1N1 strain that appeared back in 2009.

We have seen some limited, sporadic mutations (see 2014's  EID Journal: Emergence of D225G Variant A/H1N1, 2013–14 Flu Season, Florida) linked to enhanced virulence, and recently the ECDC reported that a genetic subcluster of viruses within the 6B subgroup has emerged, defined by HA1 amino acid substitutions S162N and I216T (see  Influenza virus characterisation, Summary Europe, December 2015).

Despite these changes, the H1N1 viruses that have been examined have all reportedly been antigenically similar to the vaccine virus A/California/07/2009. 

Once again this winter we've been seeing numerous reports of large H1N1 outbreaks - mostly in the Middle East and Eastern Europe -  with supposedly high mortality rates. Over the past couple of weeks, there have been multiple reports coming out of Russia and the Ukraine.

This morning Sharon Sanders on FluTrackers posted the following (translated) report



In Russia, died from the flu 50 people, a high incidence is related to a mutation of the H1N1 virus Society January 26th, 16:19 UTC + 3, 24 people died this week, said Head of the Laboratory of Biotechnology and Research Institute of Influenza diagnostic preparations


PETERSBURG, January 26. / Correspondent. Natalia Mihalchenko TASS /. High morbidity and mortality from influenza in certain regions of Russia is associated with a mutation of the virus H1N1 (Swine Flu). This was reported by TASS Head of the Laboratory of Biotechnology and Research Institute of Influenza diagnostic preparations Anna Sominina.

Total of 50 Russians died of influenza, including 24 this week," - she said. "Among the isolated and studied in laboratories around 40% of viruses are changes in the genome that do not contain the vaccine. All in all today was able to identify three mutations" - added Sominina. According to the Institute of influenza in the country weekly epidemic threshold was exceeded by 48.8%, the baseline - 32%. Among the types of circulating influenza virus H1N1 predominant (96%). 
(Continue . . . )


Granted, Tass isn't always the most reliable source.   But Sharon also found and posted the following (week 3) Epidemiological report from the WHO National Influenza Centre Of Russia, which lends some credence to the above report.

Week 11.01.2016-17.01.2016
Influenza and ARI morbidity data

Epidemiological data show increase of influenza and other ARI activity in Russia in comparison with previous week. The nationwide ILI & ARI morbidity level (60.6 per 10 000 of population) was lower than the national baseline (69.5 per 10 000) by 12.8%.

ILI and ARI epidemic thresholds were exceeded in 9 of 59 cities collaborating with two WHO NICs in Russia.

Cumulative number of diagnosed influenza cases

Cumulative results of influenza laboratory diagnosis by different tests were submitted by 50 RBLs and two WHO NICs. According to these data as a result of 2580 patients investigation the overall proportion of respiratory samples positive for influenza virus was estimated as 25.3% including 615 (94.1%) influenza A(H1N1)pdm09 cases, 17 (2.6%) influenza A(H3N2) cases, 10 (1.5%) influenza A cases and 12 (1.8%) influenza B case.
Results of influenza diagnosis

Conclusion

Influenza and ARI morbidity data.  Increase of influenza and other ARI activity was registered during the week 03.2016 in traditional surveillance system in Russia. The nationwide ILI & ARI morbidity level (60.6 per 10 000 of population) was lower than the national baseline by 12.8%.

Etiology of ILI & ARI morbidity. The overall proportion of respiratory samples positive for influenza  was estimated as 25.3%. Percent of positive ARI cases of non-influenza etiology (PIV, adeno- and RSV) was estimated as 22.2% of investigated patients by IFA and 16.0% by PCR.

Antigenic characterization. Totally 45 influenza A(H1N1)pdm09 and 2 A(H3N2) viruses were characterizated antigenically in two NICs of Russia since the beginning of the season. 35 (76.6%) influenza A(H1N1)pdm09 strains were related closely to influenza A/California/07/09 virus, 10 (23.4%) influenza A(H1N1)pdm09 viruses had decreased up to 1/16 titers. Two A(H3N2) strains were similar to influenza A/Hong-Kong/4801/2014 virus but reacted with antiserum to influenza A/Switzerland/9715293/2013  vaccine strain up to 1/4 - 1/8 of homological titer only.

Genetic characterization.
Three influenza A(H1N1)pdm09 viruses were identical for 97.8% to A/California/07/09 virus and for 99.0% to influenza A/South Africa/3626/13  virus. All investigated strains had  substitutions S84N, S162N+ and I216T in HA.

In sentinel surveillance system clinical samples from 57 SARI and 50 ILI/ARI patients were investigated by rRT-PCR. 24 (35.6%) influenza SARI cases were detected including 21 influenza A(H1N1)pdm09, 1 influenza A(H3N2) and 2 influenza B cases. 5 (10.0%) influenza ILI/ARI cases were detected including 4 influenza A(H1N1)pdm09 and 1 influenza A(H3N2) cases.


 
Two of the amino acid substitutions mentioned in the above report (S162N+ & I216T) are associated with the new genetic subcluster within subgroup 6B mentioned by the ECDC, while the third change (S84N) has been linked to reduced antigenic reactivity (cite).

Going back through the Russian Epi Weekly reports, as of the last week of 2015, they reported 23 of the 23 viruses H1N1 viruses examined to be antigenically similar to the vaccine strain, meaning that these reduced titer samples have all appeared over the past three weeks.

It would not be a huge surprise to finally see some significant antigenic drift in the H1N1pdm09 virus.  It has remained stable far longer than anyone expected. But it remains to be seen whether these `reduced titer' viruses will spread beyond the region.



The reports of increased `morbidity and mortality' from these viruses  - while possible - appear to be anecdotal at this time, and are not reflected in the data provided by the Russian Epi report. 

Influenza viruses  - `mutated' or otherwise - are responsible for hundreds of thousands of deaths each year, and so these statements will require additional  data to substantiate. 

The timing here is important, as decisions on what vaccine strains to include in next fall's North American Influenza vaccine are normally made by the end of February.


So we'll keep an extra close eye on the Russian Influenza reports in the weeks to come.