WHO MERS-CoV Update - Saudi Arabia: Feb 29th

Credit WHO

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After a couple of slow months Saudi Arabia has seen an uptick in MERS cases this month, with 20 cases reported during February.  Today the World Health Organization updates us on the first 6 cases of the month, 3 of which were fatal.

Of these cases, two appear to have had camel contact, three have no known risk exposures, and one is a contact of a laboratory confirmed MERS case (#6 below).

Since the cut off date (Feb 16th) for this report we've seen 14 new cases, including three cases that appear to be linked from Riyadh.  We'll have to wait for the next WHO update to learn if any of those three are linked to the two cases (#4 & #6)  in today's report.

Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia

Disease outbreak news
 
29 February 2016 

Between 1 and 16 February 2016, the National IHR Focal Point for the Kingdom of Saudi Arabia notified WHO of 6 additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, including 3 deaths.

Details of the cases

1. An 80-year-old male from Alkharj city developed symptoms on 6 February and, on 13 February, was admitted to hospital. The patient, who had comorbidities, tested positive for MERS-CoV on 14 February. He passed away on 16 February. Investigation of history of exposure to the known risk factors in the 14 days prior to the onset of symptoms is ongoing.
2. A 75-year-old male from Alkharj city developed symptoms on 8 February and, on 10 February, was admitted to hospital. The patient, who had comorbidities, tested positive for MERS-CoV on 12 February and, on the same day, passed away. He had a history of frequent contact with camels and consumption of their raw milk. The patient had no history of exposure to other known risk factors in the 14 days prior to the onset of symptoms. The Ministry of Agriculture was notified and is now conducting investigations.
3. A 34-year-old male from Najran city developed symptoms on 1 February and, on 10 February, was admitted to hospital. The patient, who had no comorbidities, tested positive for MERS-CoV on 11 February and, on the same day, passed away. Investigations showed no clear history of exposure to the known risk factors in the 14 days prior to the onset of symptoms.
4. A 41-year-old male from Alkharj city developed symptoms on 3 February and, on 10 February, was admitted to hospital. The patient, who has no comorbidities, tested positive for MERS-CoV on 11 February. Currently, he is in stable condition in a negative pressure isolation room in a ward. The patient has a history of contact with a laboratory-confirmed MERS-CoV patient (see below – case no. 6). He has no history of exposure to other risk factors in the 14 days prior to the onset of symptoms.
5. A 78-year-old male from Taif city developed symptoms on 31 January and, on 2 February, was admitted to hospital. The patient, who has comorbidities, tested positive for MERS-CoV on 3 February. Currently, he is in stable condition in a negative pressure isolation room. The patient has a history of consumption of raw camel milk in the 14 days prior to the onset of symptoms. He has no history of exposure to other known risk factors in the 14 days prior to the onset of symptoms. The Ministry of Agriculture was notified and is now conducting investigations.
6. A 43-year-old, non-national male from Riyadh city developed symptoms on 21 January. On 31 January, he was admitted to hospital and, on the same day, tested positive for MERS-CoV . Currently, the patient, who has no comorbidities, is in stable condition in home isolation. Investigations showed no clear history of exposure to the known risk factors in the 14 days prior to the onset of symptoms.

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

Globally, since September 2012, WHO has been notified of 1,644 laboratory-confirmed cases of infection with MERS-CoV, including at least 590 related deaths.

WHO risk assessment

MERS-CoV causes severe human infections resulting in high mortality and has demonstrated the ability to transmit between humans. So far, the observed human-to-human transmission has occurred mainly in health care settings.
 
The notification of additional cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East, and that cases will continue to be exported to other countries by individuals who might acquire the infection after exposure to animals or animal products (for example, following contact with dromedaries) or human source (for example, in a health care setting). WHO continues to monitor the epidemiological situation and conducts risk assessment based on the latest available information.

Flu Near You Now Tracking Zika Symptoms

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Regular readers know that I participate in - and try to promote - Flu Near You, an interactive website where thousands of volunteers from around the nation quickly update whether they've experienced `flu-like' symptoms once a week.

Flu Near You is a partnership between HealthMap (healthmap.org),  Boston Children’s Hospital, and the Skoll Global Threats Fund.

Participation is easy. Once a week you receive an email with a link. Click on it, and you will be presented with a quick questionnaire (see above), where hopefully you'll only have to select to top item. 

The results are used to produce real-time maps of flu-like activity.

Today Flu Near You has added categories of Zika Symptoms to their weekly questionnaire.   Their email today advises:

Important note regarding Zika virus: In light of emerging health threats in the United States--including mosquito-borne diseases like the Zika virus--we are adding additional symptoms for our volunteers to report on. These symptoms include rash, eye pain, red eyes, joint pain, yellow skin / eyes, and dark urine and will allow researchers and public health authorities to identify potential outbreaks of disease like Zika, Chikungunya, and Dengue fever. Note, this change will only be reflected on our website and not our mobile apps, as we pilot these new features.

While I'm hoping that Zika (and CHKV and DENV) won't have enough of an impact on those living in the continental United States to show up on this kind of surveillance, this is an interesting idea and might produce some valuable results.

Flu Near You's primary function - tracking ILIs - is a worthwhile endeavor, only takes a few seconds each week, and I highly recommend people consider taking part.

Saudi MOH Announces 3 MERS Cases

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The uptick in Saudi MERS cases continues today with 3 new cases;  2 primary cases with camel contact and the second household contact in Riyadh to be announced in the last two days   

We've not seen a WHO GAR update in nearly a month, and these daily reports don't provide a lot of detail, but the index case of this cluster may be the 24 y.o. expat male reported on Feb. 17th who was simply listed as a `primary case'. 

`Primary cases’ are those that occur in the community when there is no known exposure to a health care facility or to a known human case.  Over the past 3 years, roughly 40% of Saudi cases are listed as either `primary’ or as from an undetermined origin.  

The Saudi MOH has announced 20 new MERS cases in the month of February, 7 of which are described as either direct or indirect contacts of camels. 

Not unexpected, as last November in EID Journal: Risk Factors For Primary MERS-CoV Infection, Saudi Arabia, we saw a small case-control study  that found 33% of their subjects reported camel contact in the 14 days prior to falling ill vs. 15% in the control group.


So far in 2016 we haven't seen any significant nosocomial outbreaks (only 1 asymptomatic HCW in Al Kharj), suggesting that so far at least, Saudi hospitals may be doing a better job identifying and isolating suspected cases than they have in the past (see MMWR: A Large Nosocomial Outbreak Of MERS In Riyadh - Summer 2015). 

Not Without Warning - The Return Of Mosquito Disease Threats

Global brief on vector-borne diseases
pdf, 4.45 Mb  WHO 2014


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Long before Zika arrived in the Americas (in 2014), before Chikungunya jumped to the Caribbean (in 2013), and even before Dengue re-emerged after 70 years in Key West (in 2009), researchers have been warning us that the Americas and Europe are not safe from emerging or re-emerging mosquito disease threats.  


The maps below show that diseases like Malaria and Yellow Fever once plagued much of the settled United States (with epidemics as far north as Boston and Michigan), until comprehensive mosquito control efforts during the early part the 20th century successfully beat them back. 

The last major Yellow Fever outbreak in the United States was in New Orleans in 1905, but it wasn't until 1949 that the U.S. was declared free of malaria as a significant public health problem (cite). 

While there are societal factors (mosquito control, window screens, air conditioning, etc.) that will presumably help limit any outbreak's impact, we have both the climate and the right mosquito vectors to support a variety of mosquito borne illnesses, including Yellow Fever, Dengue, Malaria, Chikungunya and Zika.

And we need look only to the arrival of West Nile Virus in 1999 - a mosquito-borne illness that prior to the mid-1990s was considered mostly mild, but which has since proved to cause significant neuroinvasive disease in a minority of cases (sound familiar?) - to see how quickly a new threat can spread.


From West Nile Virus: An Historical Overview by James J. Sejvar, MD we get a description of an apparent change in virulence of WNV infection once it arrived in an urban environment.

West Nile virus (WNV) has quickly established itself in North America since its recognition in New York City in 1999. Historically, WNV has been associated with temporally dispersed outbreaks of mild febrile illness. In recent years, the epidemiology and clinical features of the virus appear to have changed, with more frequent outbreaks associated with more severe illness being noted. The 2002 outbreak in North America was unprecedented in terms of the number of cases and geographic spread of the virus. Historical patterns of WNV provide few indications as to the future behavior of WNV in North America.

(SNIP)

WEST NILE VIRUS SINCE 1996

Beginning around 1996, the epidemiology and clinical spectrum of WNV appeared to change. A large outbreak of WNV occurred in the area around Bucharest, Romania, and was notable for a number of reasons (14, 15). It was the first WNV outbreak to be centered in a predominantly urban area, and it was the first outbreak of the virus in which the preponderance of symptomatic cases involved CNS infection.

Since WNV arrived in NYC, it has spread to all 50 states, and causes tens of thousands of mild West Nile Fever cases every year, and anywhere from a few hundred to several thousand cases of severe neuroinvasive West Nile Virus.

In 2012, the CDC reported 2,873 severe neuroinvasive WNV cases and 286 deaths (see JAMA: The 2012 West Nile Encephalitis Epidemic in Dallas, Tx).

WNV has an advantage in that it has a sylvatic cycle (birds to mosquitoes). Human infection is basically a result of incidental collateral damage (see graphic below).  

Zika, Dengue, and Chikungunya - at least outside of Africa and Asia - have no known non-human animal reservoirs, which means they have a harder time becoming endemic. But when enough people become infected, these viruses are  able to sustain themselves in an Urban Cycle, where transmission is strictly human-to-mosquito-to human.

In the middle of the last decade we saw Chikungunya made a break from Africa, and jump to Reunion Island in the Indian Ocean where it reportedly infected about 1/3rd of that island’s population (266,000 case out of  pop.770,000) in a matter of a few months, before moving on to Southeast Asia.



About the same time, Dengue began to turn up again in the United States after decades of absence. In January of 2009, in Outnumbered By A Competent Vector, we looked at reports of Dengue's incursions into Texas and Queensland, Australia.


In 2009, Dengue Resurfaced In Key West  after a 70 year absence, but even months before that, we saw a cautionary report from the Natural Resources Defense Council (see NRDC Report: Climate Change and Health Threats) warning that Dengue and other vector borne diseases could one day reestablish themselves in the United States.

Meanwhile, this growing threat of mosquito-borne illnesses wasn't going unnoticed in Europe, and in 2010 the ECDC's journal Eurosurveillance devoted a special edition to the threat to the EU from  Vector-borne diseases - December 2010.

In 2012 the ECDC released a cautionary report on the Status & Importance Of Invasive Mosquito Breeds In Europe and in 2014 they announced a new joint ECDC-EFSA project called  “VectorNet”.  A network for sharing data on the geographic distribution of arthropod vectors capable of  transmitting human and animal diseases.
 


Also in 2010, we saw an unusually severe Dengue outbreak in Puerto Rico, that before it was quashed, had infected more than 21,000 people, killing 31 (see MMWR: Dengue Epidemic In Puerto Rico).  Globally, Dengue has seen a 30-fold increase over the past 50 years (see chart below).

 

Credit WHO

In early 2012, in Preparing For An Unwanted Arrival we looked at a 160 page preparedness plan, released by PAHO and the CDC, anticipating the arrival of Chikungunya to the Americas. 

PAHO, CDC publish guide on preparing for chikungunya virus Introduction in the Americas

The Pan American Health Organization/World Health Organization (PAHO/WHO), in collaboration with the U.S. Centers for Disease Control and Prevention (CDC), has published new guidelines on chikungunya, a mosquito-transmitted virus transmitted that causes fever and severe joint pain.  The Guidelines for Preparedness and Response for Chikungunya Virus Introduction in the Americas aims to help countries throughout the Americas improve their ability to detect the virus and be prepared to monitor, prevent, and control the disease, should it appear.


(Continue . . . )

To download the guide, Preparedness and Response for Chikungunya Virus Introduction in the Americas select this link.

Not quite two years later, the virus finally arrived in the Americas (see WHO: Chikungunya In Caribbean – French Part of St. Martins), and within a year was widespread in the Caribbean, South and Central America.

In May of 2014 we looked at how Florida was Preparing For Chikungunya, and only two months later Florida reported the 1st Locally Acquired Chikungunya Infection In United States. While the number of cases remains small, the risk returns every year.

In April of 2014, the WHO declared World Health Day 2014: Vector-Borne Diseases, with the theme Small Bite, Big Threat.

And with Dengue continuing to expand in South America, and joined by Chikungunya, the CDC held a Grand Rounds: Preventing Aedes Mosquito-Borne Diseases in May of 2015.

 Mosquito borne diseases sicken and kill millions of people each year, and we've had decades of warning that they could someday return to the United States (or Europe), but the threat has remained largely ignored by the public.

Regardless how Zika pans out, it isn't the only current threat (i.e. Dengue, CHKV, Malaria, etc.), nor is it likely to be the last obscure mosquito-borne virus that will emerge from the jungles and threaten global health.  Nature has a very deep bench.

And with reports that Insecticide resistance is already widespread, we'll need to find new and better ways to control these mosquito vectors, if we are to stay ahead of these growing 21st century threats.

Saudi MOH Announces 1 MERS Case In Riyadh

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Although the numbers aren't large, for the 4th day running the Saudi MOH has announced a new MERS case, this time a 30 y.o. male in critical condition, listed as a secondary household contact of an earlier case.

We've seen 3 other cases reported in Riyadh this month, with the most recent report from 11 days ago (see Saudi MOH Announces 2 Primary MERS Cases In Riyadh). Presumably this case is a contact of one of those. 

While stopping camel-to-human transmission is viewed as critical to controlling MERS, the vast majority of cases are infected through contact with other humans via household, nosocomial, or community transmission.

Often, however, we never know the route of infection for primary cases - those not linked to health care facilities or households with other cases (see The Community Transmission Mystery).

CDC: Transcript & Audio From Yesterday's Zika Briefing

Preparing an ELISA Test - Credit CDC PHIL

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The CDC has posted a preliminary transcript, and the audio file, from yesterday's Zika Briefing by the CDC's Director Dr. Thomas Frieden, who was joined by Dr. Denise J. Jamieson, Dr. Paul Mead. And Dr. Julie Villanueva of the CDC, and Dr. Luciana Borio of the FDA.


The audio recording runs just under 50 minutes, and may be accessed at the link below:

Audio recording[MP3, 8.5 MB]

You can read the transcript at the link below (note: The date is wrong in the header, this is from Feb 26th).

Transcript for CDC Telebriefing: Zika

Tuesday, February 5, 2016 at 1:30 pm E.T.
Please Note:This transcript is not edited and may contain errors.

One of the topics in this press briefing is the development of a new diagnostic test for Zika, called Zika IgM Antibody Capture Enzyme-Linked Immunosorbent Assay (Zika MAC-ELISA), which is designed to detect antibodies to the virus that develop a week or more after infection and persist for a few months. 

This test is new, and has some limitations (see below), but should help improve the ability to test people who may have recently been infected with the Zika virus. 

New CDC Laboratory Test for Zika Virus Authorized for Emergency Use by FDA

Emergency action expected to bolster US laboratory capacity for Zika testing

 

Media Statement

For Immediate Release: Friday, February 26, 2016 Contact: Media Relations,
(404) 639-3286

In response to a request from the Centers for Disease Control and Prevention, the U.S. Food and Drug Administration (FDA) today issued an Emergency Use Authorization (EUA) for a diagnostic tool for Zika virus that will be distributed to qualified laboratories and, in the United States, those that are certified to perform high-complexity tests.

The test, called the CDC Zika IgM Antibody Capture Enzyme-Linked Immunosorbent Assay (Zika MAC-ELISA), is intended for use in detecting antibodies that the body makes to fight a Zika virus infection.  These antibodies (in this case, immunoglobulin M, or IgM) appear in the blood of a person infected with Zika virus beginning 4 to 5 days after the start of illness and last for about 12 weeks.  The test is intended to be used on blood samples from people with a history of symptoms associated with Zika and/or people who have recently traveled to an area during a time of active Zika transmission. 

The FDA can use the EUA to permit use, based on scientific data, of certain medical products in certain circumstances, including when there is a determination, by the Secretary of Health and Human Services, that there is a significant potential for a public health emergency that has a significant potential to affect national security or the health and security of United States citizens.  As there are no commercially available diagnostic tests cleared or approved by the FDA for the detection of Zika virus infection, it was determined that an EUA is crucial to ensure timely access to a diagnostic tool. CDC’s Zika MAC-ELISA is the first diagnostic test authorized for use in the U.S. for the detection of Zika virus during this situation in which there has been a determination that there is a significant potential for a public health emergency that has a significant potential to affect national security or the health and security of United States citizens living abroad and that involves Zika virus. 

Results of Zika MAC-ELISA tests require careful interpretation. A positive test result indicates that a person was likely infected recently with the Zika virus. However, the test can give an incorrect positive.  These false-positive results can occur when someone has been infected with another closely related virus (such as dengue virus). When positive or inconclusive results occur, additional testing (plaque reduction neutralization test) to confirm the presence of antibodies to Zika virus will be performed by CDC or a CDC-authorized laboratory.

Moreover, a negative test result does not necessarily mean that a person has not been infected with Zika virus. If a sample is collected just after a person becomes ill, there may not be enough antibodies for the test to measure, resulting in a false negative.  Similarly, if the sample was collected more than 12 weeks after illness, it is possible that the body has successfully fought the virus and antibody levels have dropped below the detectable limit.

As with any test, it is important that health care providers consult with their patients about test results and the best approach to monitoring their health.

CDC will begin distributing the test during the next two weeks to qualified laboratories in the Laboratory Response Network, an integrated network of domestic and international laboratories that can respond to public health emergencies. The test will not be available in U.S. hospitals or other primary care settings. Public health officials anticipate that distribution of the tests will improve laboratory testing capacity for Zika virus in the United States.

Saudi MOH: 1 Fatal Primary MERS Case (Camel Contact)

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Saudi Arabia's uptick in MERS cases continues with their 7th case reported in a week, this time a 50 y.o. male with camel contact who has already died.

Although we see posthumous reporting of cases from time to time, it isn't clear whether these cases were diagnosed late into their illness, or whether the  MOH simply delayed reporting them.  

A late diagnosis has the potential for putting more people (particularly HCWs and hospital patients) at risk of exposure, and in the past has led to large nosocomial outbreaks. 

Hopefully we'll get a better sense of the timeline of this case when the WHO publishes an update.

CDC Issues Travel Advice For The 2016 Summer Olympics In Rio

2016 Olympic Venues - Credit Wikipedia

     








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Last night the CDC issued a Zika related travel advisory for the 2016 Summer Olympics and Paralympic Games (held in August & September) that strongly urges pregnant women not to attend the Olympics, and advises others to exercise caution.


This advice differs greatly in content and tone from the messaging we've seen very recently from the World Health Organization. 

Just a week ago, in Audio: WHO Press Conference On Zika Virus, Microcephaly & GBS - Feb 19th, Dr Bruce Aylward, the WHO's Executive Director for Outbreaks and Health Emergencies, went out of his way to downplay the risks of attending the 2016 Summer Olympics.  

He pointed out that it will be winter in Rio, and the mosquito population will be `way down'. He also suggested the venue was relatively confined, making it easier for authorities to control the mosquito threat, and by then, acquired community immunity might be great enough to help mitigate the threat.

According to Aylward:

"Brazil is going to have a fantastic Olympics and it's going to be a successful Olympics and the world is going to go there. I just wish I was going there, but there's not going to be a lot of problems there by then, so I'll be somewhere else."  (cite)

The CDC's take on the risk is considerably less sanguine. First the CDC's statement, then I'll have a bit more.

CDC issues advice for travel to the 2016 Summer Olympic Games

Media Statement

For Immediate Release: Friday, February 26, 2016
Contact: Media Relations,
(404) 639-3286

Today, CDC issued advice for people planning travel to the 2016 Summer Olympic Games in Rio de Janeiro, Brazil, from August 5 to August 21, 2016, and to the 2016 Paralympic Games scheduled for September 7 to September 18, 2016. These recommendations provide information to travelers to help them take steps to stay safe and healthy during their trips. CDC’s travel guidance for the Olympics covers a variety of health and safety topics, including information about the Zika virus outbreak currently occurring in Brazil.

Because of the Zika outbreak, CDC recommends that pregnant women consider not traveling to the Olympics.

The Zika outbreak in Brazil is dynamic. CDC will continue to monitor the situation and will adjust these recommendations as needed. Current recommendations, based on CDC’s guidance for any area with active Zika transmission, include these:

• Women who are pregnant
  • Consider not going to the Olympics.
  • If you must go to the Olympics, talk to your doctor healthcare provider first; if you travel, you should strictly follow steps to prevent mosquito bites during your trip.
  • If you have a male partner who goes to the Olympics, you may be at risk for sexual transmission of Zika. Either use condoms the right way, every time, or do not have sex during your pregnancy.
• Women who are trying to become pregnant
  • Before you travel, talk to your  health care provider about your plans to become pregnant and the risk of Zika virus infection during your trip.
  • You and your male partner should strictly follow steps to prevent mosquito bites.

People considering travel should also refer to CDC’s travel notice “Zika Virus in South America” for additional information:  http://wwwnc.cdc.gov/travel/notices/alert/zika-virus-south-america.

While we won't know until September which one of these positions will turn out to be the most appropriate, the fact that the CDC has taken this stance this far in advance speaks to the level of concern they have over this outbreak.

Both agencies have gone out on a limb here. 

The WHO risks being perceived as bowing to political pressures from member states whose tourist economies are suffering, while the CDC risks being seen as throwing their faltering economies under the bus before all the facts are in.

It's not an enviable position to have to make this call, and I'm sure it hasn't been taken lightly by either agency. 

The paramedic in me says `Primum non nocere' - first do no harm, and based on the potentially devastating impact of having a microcephalic child, the CDC had little choice but to issue a warning that was consistent with its other travel advisories to the region.

Admittedly, Zika could still fizzle.

We could find out there are other factors (or perhaps, co-factors) responsible for the microcephaly outbreak, or that those numbers are over-inflated. We have far less information than we'd like, and a lot can change in five months.


But unlike what we saw with the 2009 H1N1 pandemic virus, the more we learn, the greater this viral threat appears. So unless and until that trend reverses, an abundance of caution on the part of CDC seems warranted.

MMWR: Zika Among Pregnant Travelers - Zika and Sexual Transmission

Credit PAHO

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The CDC continues to roll out an impressive amount of guidance and research information on the Zika epidemic, and this afternoon has released the following two new MMWRs.

Follow the links to read them in their entirety. 

• Zika Virus Infection Among U.S. Pregnant Travelers — August 2015–February 2016 FEBRUARY 26, 2016
   
  On January 19, 2016, CDC released interim guidelines recommending pregnant women who had traveled to areas with ongoing local transmission of Zika virus and who had symptoms consistent with Zika virus disease be tested for Zika virus infection. These guidelines were updated and expanded on February 5 to offer Zika virus testing to all pregnant women with Zika virus exposure, regardless of presence of symptoms. As of February 17, 2016, nine pregnant travelers with Zika virus infection from the United States had been identified. No Zika virus–related hospitalizations or deaths were reported among pregnant women. Pregnancy outcomes among the nine confirmed cases included two early pregnancy losses, two elective terminations, and three live births (two apparently healthy infants and one infant with severe microcephaly); two pregnancies (18 weeks’ and 34 weeks’ gestation) are continuing without known complications.
  

  Summary

  What is already known about this topic?Because of the risk for Zika virus infection and its possible association with adverse pregnancy outcomes, CDC issued a travel alert on January 15, 2016, advising pregnant women to consider postponing travel to areas with ongoing local transmission of Zika virus. CDC also released guidelines for Zika virus testing for pregnant women with a history of travel while pregnant to areas with ongoing Zika virus transmission.

  What is added by this report?

  This report provides preliminary information on testing for Zika virus infection of U.S. pregnant women who had traveled to areas with Zika virus transmission. As of February 17, 2016, nine U.S. pregnant travelers with Zika virus infection had been identified. No Zika virus–related hospitalizations or deaths were reported among pregnant women. Pregnancy outcomes included two early pregnancy losses, two elective terminations, and three live births (two apparently healthy infants and one infant with severe microcephaly); two pregnancies (18 weeks’ and 34 weeks’ gestation) are continuing without known complications.

  What are the implications for public health practice?In this small case series, Zika virus infection during pregnancy was associated with a range of outcomes, including early pregnancy losses, congenital microcephaly, and apparently healthy infants. Additional information will be available in the future from a newly established CDC registry for U.S. pregnant women with confirmed Zika virus infection and their infants.

  
  
  
• Transmission of Zika Virus Through Sexual Contact with Travelers to Areas of Ongoing Transmission — Continental United States, 2016 FEBRUARY 26, 2016
   
  CDC released interim guidance for prevention of sexual transmission of Zika virus on February 5, 2016, and updated guidelines on February 26, 2016. This report provides information on six confirmed and probable cases of sexual transmission of Zika virus from male travelers to female nontravelers.
  

  Summary

  What is already known about this topic?Zika virus is spread primarily by Aedes species mosquitoes, though recent reports have described two instances of sexual transmission of Zika virus, and replicative virus has been isolated from semen of one man with hematospermia. CDC released interim guidance for prevention of sexual transmission of Zika virus on February 5, 2016.

  What is added by this report?This report provides information on six confirmed and probable cases of sexual transmission of Zika virus from male travelers to female nontravelers. This suggests that sexual transmission of Zika virus might be more common than previously reported.

  What are the implications for public health practice?Men who reside in or have traveled to an area of ongoing Zika virus transmission who have a pregnant partner should abstain from sexual activity or consistently and correctly use condoms during sex (i.e., vaginal intercourse, anal intercourse, or fellatio) with their pregnant partner for the duration of the pregnancy.

Oregon Health Authority : Oregon's First Case Of Sexually Transmitted Zika Virus

Credit Wikipedia

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Just as with imported travel-related Zika cases, at some point in time reports of sexually transmitted Zika will become less blog worthy. But for now, while we are still trying to figure out the dynamics of Zika transmission, they give us insight into just how common this may be.

In addition they provide important reminders to those who may have been exposed to take precautions (see CDC Updated Guidelines For Preventing Sexual Transmission Of Zika).

This from the Oregon Health Authority. 

2/26/2016

Oregon has first case of sexually transmitted Zika virus

CDC offers prevention guidance

EDITORS: Richard Leman, MD, will be available to the media  from 10:45 to 11:15 a.m. TODAY in Room 1-E (lobby level) of the Portland State Office Building, 800 NE Oregon St.

Sexual transmission of Zika virus might happen more often than first thought.

Oregon Health Authority reported the state’s first case of sexually transmitted Zika infection. The illness was spread from a man who had traveled in a Zika-affected country to his female sex partner, who had not traveled. Both people later tested positive for Zika.

Zika seldom causes serious illness. Four out of five people who get Zika have no symptoms. When symptoms occur, they are generally mild and include fever, rash, joint pain and redness of the eyes.

The disease is concerning, however, because of its potential link to serious birth defects in babies born to women infected during pregnancy.

“Though mosquito bites appear to be the most common way Zika is spread, there is increasing evidence for sexual transmission as well,” says Richard Leman, MD, an OHA public health physician. “People who have been in Zika-affected areas in the previous two weeks and develop symptoms suggesting Zika should see their health care provider. CDC advises men with pregnant sex partners to use condoms or abstain from sex for the duration of pregnancy.”

The CDC is investigating more than a dozen possible cases of sexual transmission of Zika in the U.S., and has issued interim guidance:

Recommendations for pregnant women and men with pregnant sex partners who live in or have traveled to Zika-affected areas:

• Pregnant women and their male sex partners should discuss the male partner’s potential exposures and history of Zika-like illness with the pregnant woman’s health care provider. CDC has a list of Zika symptoms on its website. Providers should consult CDC’s guidelines for evaluation and testing of pregnant women, available on the CDC website.

• Men with a pregnant sex partner who live in or have traveled to an area of active Zika virus transmission should abstain from sex or use condoms during sex (vaginal, anal, or oral) for the duration of the pregnancy. Using latex condoms every time reduces the risk of sexual transmission of many infections, including those caused by other viruses.

• Pregnant women should consider postponing travel to Zika-affected regions. If they choose to go, they should take steps to avoid any contact with mosquitoes.

Recommendations for non-pregnant women, and men with non-pregnant sex partners who live in or have traveled to Zika-affected areas:

• It is still unclear whether Zika infection during pregnancy is responsible for recently reported birth defects involving brain development. Public health investigators are continuing their efforts to answer this question. In Oregon, public health officials are following these investigations closely and will continue to update their guidance to the public as they learn more.

• In the meantime, couples in which a man has recently spent time in an area with Zika virus transmission might wish to weigh this potential risk in their decisions about whether to use condoms during sexual activity.

Zika also may increase the risk of Guillan-Barré Syndrome, a problem marked by muscle weakness and sometimes paralysis. Public health investigators are working hard to determine whether Zika actually causes this condition.

For more Zika information and resources, visit the OHA Zika website at healthoregon.org/zika.

For some related posts, you may wish to revisit:

Eurosurveillance: `Possible' Sexual Transmission Of Zika, Italy - 2014

CDC HAN Advisory On Prevention Of Sexual Transmission Of Zika Virus

CDC : Sexual Transmission Of Zika May Be More Common Than Previously Believed

 

WHO Zika SitRep - Feb 26th

Credit Zika SitRep

 

 

 

 

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The World Health Organization has published their weekly Zika SitRep (12 page PDF) for February 26th.  While a causal link between Zika and microcephaly and GBS has not been firmly established, the WHO states:

Evidence that neurological disorders, including microcephaly and GBS, are linked to Zika virus infection remains circumstantial, but a growing body of clinical and epidemiological data points towards a causal role for Zika virus.

 

 I've reproduced the summary below, but follow the link to download the full report.

  

Zika situation report

26 February 2016

Zika virus, Microcephaly and Guillain-Barré syndrome

• Read the full situation report

Summary

• Between 1 January 2007 and 25 February 2016, a total of 52 countries and territories have reported autochthonous (local) transmission of Zika virus, including those where the outbreak is now over and countries and territories that provided indirect evidence of local transmission. Among the 52 countries and territories, Marshall Islands, Saint Vincent and the Grenadines, and Trinidad and Tobago are the latest to report autochthonous transmission of Zika virus.
• The geographical distribution of Zika virus has steadily widened since the virus was first detected in the Americas in 2015. Autochthonous Zika virus transmission has been reported in 31 countries and territories of this region. Zika virus is likely to be transmitted and detected in other countries within the geographical range of competent mosquito vectors, especially Aedes aegypti.
• So far an increase in microcephaly cases and other neonatal malformations have only been reported in Brazil and French Polynesia, although two cases linked to a stay in Brazil were detected in two other countries.
• During 2015 and 2016, eight countries and territories have reported an increased incidence of Guillain-Barré syndrome (GBS) and/or laboratory confirmation of a Zika virus infection among GBS cases.
• Evidence that neurological disorders, including microcephaly and GBS, are linked to Zika virus infection remains circumstantial, but a growing body of clinical and epidemiological data points towards a causal role for Zika virus.
• The global prevention and control strategy launched by WHO as a Strategic Response Framework encompasses surveillance, response activities and research, and this situation report is organized under those headings. Following consultation with partners and taking changes in caseload into account, the framework will be updated at the end of March 2016 to reflect epidemiological evidence coming to light and the evolving division of roles and responsibilities for tackling this emergency.

Audio: WHO Briefing On Guillain-Barré Syndrome In The Context Of Zika Virus

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Yesterday we saw the release of WHO Interim Guidance on Microcephaly, GBS & Breastfeeding With Zika. 

Today the World Health Organization held a press briefing with Dr. Tarun Dua, WHO Expert on Neurological Disorders, to discuss GBS and its potential link to the Zika virus. 

The audio file, including Q&A, runs just over 30 minutes and can be listened to by clicking the link below:

Click To Go To Audio File

Server: http://terrance.who.int/mediacentre/presser

File: WHO-RUSH_Zika_and_Guillaine-Barre_syndrome_presser_26FEB2016.mp3
32 minutes /30 Mb mp3

WHO H7N9 Update - Hong Kong (Imported)

Credit WHO

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The World Health Organization published the following update late yesterday on Hong Kong's recently imported H7N9 case (see HK CHP Updates On Imported H7N9 Case).

Human infection with avian influenza A(H7N9) virus – China

Disease outbreak news
25 February 2016

On 23 February 2016, the Department of Health (DH), Hong Kong Special Administrative Region (SAR) notified WHO of an additional laboratory-confirmed case of human infection with avian influenza A (H7N9) virus.

The patient, a resident of Hong Kong SAR, China, is a 60-year-old man with previously good health condition. On February 8, he developed symptoms and, on 11 February, consulted a private doctor. The patient was then admitted to hospital. His nasopharyngeal aspirate collected on 12 February initially tested negative for influenza A virus. On 15 February, the patient was discharged. On 23 February, re-testing of the sample taken on 12 February tested positive for influenza A (H7N9). He was re-admitted to hospital for isolation and is currently in stable condition.

Preliminary epidemiological investigations revealed that the patient worked in Suzhou, Jiangsu Province, China. He returned to Hong Kong SAR, China on 5 February. During his stay in Suzhou, the patient visited a wet market but denied having any direct contact with poultry during the incubation period. The DH is communicating with the National Health and Family Planning Commission of China to investigate the source of his infection.

According to available information, this case is likely to have been infected in Jiangsu Province. The DH is tracing close contacts of the patient and Tamiflu chemoprophylaxis will be prescribed to those contacts. On February 22, the patient's afebrile son developed sore throat and, on February 23, he was admitted to hospital for observation. The patient’s wife remains asymptomatic. Investigations are ongoing.

WHO risk assessment

WHO is assessing the epidemiological situation and conducting further risk assessment based on the latest information. Based on the information received thus far, the overall public health risk from avian influenza A(H7N9) viruses has not changed.

If the pattern of human cases follows the trends seen in previous years, the number of human cases may rise over the coming months. Further sporadic cases of human infection with avian influenza A(H7N9) virus are expected in affected and possibly in the neighboring areas. Should human cases from affected areas travel internationally, their infection may be detected in another country during travels or after arrival. If this were to occur, community level spread is considered unlikely as the virus has not demonstrated the ability to transmit easily among humans.

Saudi MOH Announces 2 More Primary MERS Cases

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The recent uptick in MERS cases continues, with 2 more cases announced today, both elderly males listed as primary cases, with one stable and the other in critical condition.

`Primary cases’ are those that occur in the community when there is no known exposure to a health care facility or to a known human case.

While some may have had zoonotic (i.e. camel) exposure - for many the source of infection is unknown . Over the past 3 years, roughly 40% of all Saudi cases are listed as either `primary’ or as from an undetermined origin.


As mild and/or asymptomatic carriage of the MERS virus has been frequently observed, limited unrecognized community spread of this virus is considered a possibility (see The Community Transmission Mystery and WHO Guidance On The Management Of Asymptomatic MERS Cases).

Sandman & Lanard On Zika Rumors : It’s The Outrage, Not The Hazard

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Last night NBC's inimitable Maggie Fox wrote a very smart piece - using input from a variety of experts including Peter Sandman & Jody Lanard - on how to effectively deal with the inevitable slew of rumors that have emerged surrounding the Zika virus.


If you haven't read it yet, I would urge you to do so.

Is It Really GMOs or Insecticides? What's Behind the Bogus Zika Rumors

by Maggie Fox

Rumors - some wildly implausible, and others possible but without evidence - are nothing new on the Internet, and as a blogger I struggle every day with how to deal with them in this space. 

My goal is to keep an open mind, but not so open my brains fall out. But like most `hard science' writers, I suffer from rumor fatigue.

The attack of the anti-vaxers during and after the 2009 H1N1 pandemic (see The Monsters Are Due On Vaccine Street) forced me to stop printing (and incessantly responding to) readers comments, the majority of which denounced the evils of `big pharma', Tamiflu, and vaccination or promoted `alternative' treatments like homeopathy.

I try not to ignore rumors outright, particularly when they have the potential of being right - or worse - causing harm, but I try not to let this blog become an echo chamber for them (see Brazil: The MOH Addresses The Larvacide Debate).

And I also try to apply the same standards to government propaganda, biased or uninformed media reports, and `forward looking' press releases from universities and research companies. 

But it is not easy. And like everyone else, I have my own biases.  And I'm sure that affects what I decide is `credible' or not.  


Luckily for me, and the rest of us, risk communications experts Dr. Peter Sandman & Dr. Jody Lanard have given a great deal of thought on why rumors are so well entrenched in our culture, and how best to deal with them.


Last night they published a longer version of their comments to Maggie Fox, and as always, they provide us with a lot to think about. While I'd love to print some excerpts, there is simply too much good stuff here to pick and choose from.  

So follow the link to read: 

Zika Rumors

by Peter M. Sandman and Jody Lanard 

(a February 22, 2016 email in response to a query from Maggie Fox of NBC)
Maggie Fox’s February 25 article drew from this email.

Eurosurveillance: `Possible' Sexual Transmission Of Zika, Italy - 2014

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Now that better testing is available for Zika virus infection it is possible to go back and re-analyse older samples stored from previously undiagnosed patients that exhibited Zika-like symptoms.

Today, the Journal Eurosurveillance looks at just such an occurrence from 2014, where a man returned to Italy from Thailand, developed a fever and rash - and was hospitalized.

Based on suggestive but inconclusive lab results, clinical signs, and travel history - he was initially diagnosed with Dengue. Nineteen days after his return, his girl friend developed similar symptoms, despite not having left the country. 

Test results on her were inconclusive as well.  

Stored serum samples from both patients were re-analysed in 2016 using newly developed Plaque reduction neutralisation tests (PRNTs), and both showed positive results for ZIKV neutralising antibodies.

Eurosurveillance, Volume 21, Issue 8, 25 February 2016

Rapid communication

An autochthonous case of Zika due to possible sexual transmission, Florence, Italy, 2014

G Venturi ¹ , L Zammarchi ^{2 3} , C Fortuna ¹ , ME Remoli ¹ , E Benedetti ¹ , C Fiorentini ¹ , M Trotta ³ , C Rizzo ⁴ , A Mantella ² , G Rezza ¹ , A Bartoloni ^{2 3}

---

Received:16 February 2016; Accepted:25 February 2016

---

We report a case of Zika virus infection imported in Florence, Italy ex-Thailand, leading to a secondary autochthonous case, probably through sexual transmission. The two cases occurred in May 2014 but were retrospectively diagnosed in 2016 on the basis of serological tests (plaque reduction neutralisation) performed on stored serum samples. Our report provides further evidence that sexual transmission of Zika virus is possible. 

(SNIP)

Because patient 2 had not travelled to tropical areas during the previous year and had unprotected sexual intercourse with patient 1 during a 20 day period between his return to Italy and her own onset of symptoms, transmission by semen was suggested. Exact dates of sexual intercourse could not be recalled by the patients, who reported several sexual contact events before patient 2’s symptom onset. Other transmission modalities (i.e. direct contact with other bodily fluids) are unlikely to play a role but may not be completely ruled out.

Transmission through local potentially competent vectors, Ae. albopictus, can likely be excluded considering that patient 1 came back to Italy outside the usual period of vector activity and vector control measures were implemented within eight days after his arrival to Italy, possibly before the estimated extrinsic incubation period could be completed [1,24].          

(Continue . . .)

Although we don't know how common sexual transmission of Zika really is, in recent days we've seen reports that the CDC is investigating more than a dozen suspected cases in the United States (see CDC : Sexual Transmission Of Zika May Be More Common Than Previously Believed).


While mosquito transmission is undoubtedly the biggest threat, evidence now suggests that sexual transmission is more than just a theoretical concern, and so public health agencies are aggressively producing guidance on the subject, including:

WHO: Interim Guidance On Prevention of Potential Sexual Transmission Of Zika Virus

CDC Issues Updated Guidelines For Preventing Sexual Transmission Of Zika

UK PHE Warns On Potential Sexual Transmission Of Zika