Texas DSHS Announces 1st Locally Acquired Chikungunya Case

Cameron County - Credit Wikipedia

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While we wait to see when we get the first locally acquired vector transmitted Zika infection in the continental United States, two other mosquito borne viruses are also on our radar:

Dengue and Chikungunya.

Dengue Resurfaced In Key West in 2009 after a 70 year absence, and has periodically shown up in Texas since the early 2000's.  The handful of outbreaks reported in Florida and Texas  in recent years have been small, localized and short lived.

Chikungunya was introduced to the Caribbean by viremic travelers in 2013, who inadvertently `seeded’ the virus into the local mosquito population. Since then millions have been infected across the Americas, although Florida is the only state to have reported (a small number) of locally acquired cases.

That is, until today. 

Although we are just learning about it this afternoon, it appears Texas had a locally acquired case of CHKV back in November of last year, which was contracted in the southernmost county in the state.

Brownsville is the largest city, and county seat of Cameron County, which lies on the border with Mexico, where last November the CDC issued Updated Travel Notices: Chikungunya In Mexico & Central America.

Exactly why this case wasn't reported to health authorities until very recently isn't clear, but the DSHS reminds labs and doctors of the need to report cases promptly in today's announcement.

DSHS Announces First Texas-Acquired Chikungunya Case  

Recently reported case contracted in 2015

The Texas Department of State Health Services has confirmed the first locally acquired case of chikungunya, a mosquito borne illness. A Cameron County resident got sick with the illness in November 2015 and was diagnosed with a lab test in January 2016. The case, however, was not reported to the local health department until last month. The investigation performed by the Cameron County Department of Health and Human Services determined the patient had not traveled, and the case was confirmed last week by testing at the US Centers for Disease Control and Prevention.

Chikungunya disease is a viral illness spread by mosquitoes and was first detected in travelers returning to Texas from areas with local transmission in 2014. All previous Texas residents who contracted the illness were infected while traveling abroad. Because this case was contracted more than six months ago and mosquito surveillance has not found chikungunya in local mosquitoes, the primary risk of infection remains related to travel. DSHS encourages people to protect themselves from mosquito bites at home and while traveling to stop the spread of chikungunya, Zika and West Nile virus.

Chikungunya and most other viruses transmitted by mosquitoes are required to be reported to the local health department or DSHS regional office within one week. DSHS reminds laboratories and health care providers to report cases promptly so health officials will have the information they need to make decisions that will protect public health.

Chikungunya illness is rarely fatal but can cause severe joint pain, high fever, head and muscle aches, joint swelling and rash. Most people feel better within a week, though some may develop longer-term joint pain.

CDC Statement On 1st MCR-1 Colistin Resistant Infection in U.S.

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Last Thursday, in MHRP: 1st Detection Of Colistin Resistant E. coli in U.S. Resident, we looked at a media release from the Military HIV Research Program and a link to a study in Antimicrobial Agents and Chemotherapy, both announcing the first discovery of an mcr-1 Resistant E. coli infection in a human on United States soil.

Today the CDC has released a statement on the finding, their ongoing epidemiological study to try to determine the origin of this patient's infection and possible spread, and the plan to bolster lab capacity around the country to test for this emerging resistance gene. 

First the statement, then I'll have a bit more.

Discovery of first mcr-1 gene in E. coli bacteria found in a human in United States

MCR-1 causes resistance to colistin, a last-resort drug for treating resistant infections

 

Media Statement

For Immediate Release: Tuesday, May 31, 2016 Contact: Media Relations,
(404) 639-3286

The Centers for Disease Control and Prevention is part of a coordinated public health response after the Department of Defense (DoD) announced the discovery of the first mcr-1 gene found in bacteria in a human in the United States. CDC is working with DoD, the Pennsylvania Department of Health, local health departments, and others to identify people who have had contact with the patient and take action to prevent local spread.

E. coli bacteria carrying the MRC-1 gene was found in a urine sample from a Pennsylvania woman with no recent travel outside of the U.S. The mcr-1 gene makes bacteria resistant to the antibiotic colistin, which is used as a last-resort drug to treat patients with multi-drug-resistant infections, including carbapenem-resistant Enterobacteriaceae (CRE).

The mcr-1 gene exists on a plasmid, a small piece of DNA that is capable of moving from one bacterium to another, spreading antibiotic resistance among bacterial species.  The CDC and federal partners have been hunting for this gene in the U.S. ever since its emergence in China in 2015. 

Despite some media reports, the Pennsylvania State Health Department investigation has determined that the woman did not have CRE and the bacteria identified is not resistant to all antibiotics (referred to as a pan-resistant infection). The presence of the mcr-1 gene, however, and its ability to share its colistin resistance with other bacteria such as CRE raise the risk that pan-resistant bacteria could develop. 

The investigation is currently focused on identifying close contacts, including household and healthcare contacts, of the Pennsylvania patient to determine whether any of them may have been at risk for transmission of the bacteria containing the mcr-1 gene.

Beginning in fall 2016, CDC’s Antibiotic Resistance Lab Network will provide the infrastructure and lab capacity for seven to eight regional labs, and labs in all states and seven major cities/territories, to detect and respond to resistant organisms recovered from human samples . State labs will be able to detect new forms of antibiotic resistance—including mutations that allow bacteria to survive the effects of the last-resort drugs like colistin—and report these findings to CDC. 

 With this comprehensive lab capacity, state health labs and regional labs that are part of the network will be able to investigate emerging resistance faster and more effectively, generating better data for stronger infection control among patients to prevent and combat future resistance threats. CDC will also provide new resources to state health departments to support their efforts to stop antibiotic-resistant outbreaks and prevent the spread of antibiotic-resistant pathogens across communities.  

Consistent with the National Action Plan for Combating Antibiotic-Resistant Bacteria, CDC and other government agencies will continue efforts to track, slow and respond to the emergence of antibiotic resistance.

For more information on the mcr-1 discovery, see http://www.hhs.gov/blog/2016/05/26/early-detection-new-antibiotic-resistance.html.

As stated in this release, this woman's infection was not Carbapenem resistant, and therefore still treatable.

But just two months ago The Lancet's Emergence of the mcr-1 colistin resistance gene in carbapenem-resistant Enterobacteriaceae, reported on two K pneumoniae isolates from China that carried both the MCR-1 gene and the gene for NDM-5 (Carbapenem-resistance), providing it near pan-drug resistance.


While still exceedingly rare, this is the kind of nightmare resistance combination that could someday propel us into a post-antibiotic era, one where even minor infections are no longer treatable.

Lest anyone think this hyperbole, that is the exact phrase used by WHO Director General Chan more than 4 years ago (see Chan: World Faces A `Post-Antibiotic Era’).

For more on this newest antimicrobial threat - MCR-1 - you may wish to revisit:

Eurosurveillance Editorial: Plasmid-Mediated Colistin Resistance (MCR-1 gene):The Story Unfolds

The Lancet: Dissemination Of The MCR-1 Colistin Resistance Gene 

MCR-1: The Return Of The Plasmids

WHO: Updated Interim Guidelines On The Prevention of Sexual Transmission of Zika Virus

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Six months ago sexual transmission of Zika was considered a rarity, and viewed as unlikely to constitute much of a public health risk. But as time has gone on, evidence has accrued that sexual transmission is much more common than previously believed.

On Friday, Lisa Schnirring of CIDRAP News wrote Zika data point to sexual transmission in women on research that found women in the sexually active age-group (15-65) far more likely to be infected than men.

 

We've also seen studies on the persistence of Zika Virus (and Zika RNA) in semen, urine, and even saliva (see Fiocruz: Revisting Zika Virus Detection In Saliva & Urine), which have raised (as yet, unanswered) questions over the full range of sexual transmission of the virus. 

 

Today the WHO has released new, interim guidance, which doubles the length of time (from 4 week to 8 weeks) they recommend couples follow safe sex practices or abstain from sex after returning from Zika endemic regions. 

They also recommend if the male partner was symptomatic, the waiting period should be extended to six months.  

While there isn't sufficient evidence to support non-intercourse sexual transmission of the virus, they do acknowledge the findings of the Zika virus in both saliva and urine, writing:

 3. Presence of Zika virus in other body fluids

Publications on the presence of Zika virus in other body
fluids that may be involved in sexual transmission have also been considered. Studies have reported the presence of Zika virus by RT-PCR in saliva 17, 18 and urine 14, 15, 18-25 .

The persistent shedding of Zika virus ribonucleic acid
(RNA) in both fluids has been found up to 29 days after
the onset of infection. Culture of Zika virus in urine 14, 18, 20,26 and saliva 18 has also been reported, with the virus cultured at day six after symptom onset for both fluids.

Follow the link below to download the full 4-page PDF guidance document.

Publication details

Number of pages: 5 Publication date: Updated 30 May 2016 Languages: English WHO reference number: WHO/ZIKV/MOC/16.1 Rev.1

Downloads

• Prevention of sexual transmission of Zika virus

Overview

The primary transmission route of Zika virus is via the Aedes mosquito. However, mounting evidence has shown that sexual transmission of Zika virus is possible and more common than previously assumed. This is of concern due to an association between Zika virus infection and adverse pregnancy and fetal outcomes, including microcephaly, neurological complications and Guillain-Barré syndrome. 

The current evidence base on Zika virus remains limited. This guidance will be reviewed and the recommendations updated as new evidence emerges.

ECDC Updated Risk Assessment On Africa's Yellow Fever Epidemic

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Parts of Africa are seeing their worst Yellow Fever outbreak in decades, and we've seen a small number of exported cases turning up in places like China, raising concerns of international spread.


Two months ago the ECDC issued a rapid risk assessment on the Angola outbreak (see Yellow Fever In Angola & The Risk Of International Spread - ECDC), which warned:

As yellow fever and dengue fever share the same mosquito vector, Aedes aegypti, any area where dengue has been transmitted could be suitable for establishment of local transmission of yellow fever if the virus is introduced by a viraemic traveller.

Theoretically, this shouldn't be much of a problem, as countries with competent vectors (Aedes mosquitoes) are supposed to require a yellow fever vaccination for travelers going to or returning from areas were the virus is endemic. 

But in actual practice, some countries have been less than diligent in enforcing this requirement, and fake Yellow Fever vaccination certificates are reportedly pretty common. 

Today the ECDC has published a new, updated risk assessment, which finds `the risk of exporting the virus to other countries is high'.

Rapid risk assessment: Outbreaks of yellow fever in Angola, Democratic Republic of Congo and Uganda, first update

30 May 2016

Available as PDF in English

Abstract

​The current epidemic of yellow fever, an acute viral haemorrhagic vector-borne disease, which has seen outbreaks in Angola, Democratic Republic of Congo and Uganda, highlights the risk of infection for unvaccinated travellers. There is also a risk of further international spread through introduction of the virus into areas with a competent vector and susceptible populations.

Given that outbreaks of yellow fever in urban settings have the potential for rapid spread and that significant yellow fever epidemics are ongoing in Angola, DRC and Uganda, this risk assessment evaluates the risk of yellow fever infection being introduced into Europe and sets out a range of options for response.
 

Hunan Province Reports A New H5N6 Infection

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Although case reports remain widely scattered and sporadic, we continue to see new cases of H5N6 crop up infection in China.  During its 1st 18 months of circulation (April 2014-Nov 2015), it was only diagnosed in 4 people.

But over the past six months (Dec 2015-May 2016), China has reported 11 new cases spread across 4 provinces.

In April Hunan Province reported their first case (see China Reports 2nd H5N6 Case in A Week), that of an 11 year-old girl from Lusong district, Zhuzhou city, who was said to be recovering after a serious bout of pneumonia.

Today Hunan Province reports their 2nd case, in a brief statement offered by their provincial CDC.

Hunan Diagnose H5N6 cases

Update Time: 2016-5-30

May 28, 2016, Hunan Diagnose H5N6 cases. Patients Tian Moumou, male, 50 years old, Xiangxi Autonomous Prefecture Guzhang County. When the disease in Jishou city workers, currently in critical condition, the hospital for treatment.

H5N6 avian-derived influenza virus is a virus, limited its ability to infect humans, there is no evidence of sustained human-to-human transmission.    

Over the past couple of months we've looked at the continuing evolution of H5N6 viruses (see Novel Reassortant H5N6 Viruses In Humans, Guangdong China and J. Virology: H5N6 Receptor Cell Binding & Transmission In Ferrets).


A little over a week ago the WHO released an assessment which noted not only the increase in human infections, but the ongoing evolution of the virus as well.

Avian influenza A(H5) viruses

       (Excerpt)

According to the animal health authorities in China 3,4 , influenza A(H5N6) viruses have been detected in poultry in recent months in many provinces in the country, including those reporting human cases. Recent publications indicate ongoing evolution of avian influenza A(H5N6) viruses through reassortment with other avian influenza viruses resulting in viruses with different internal genes. 5,6

To date, no changes in transmissibility in humans have been detected as a result of these reassortant 1viruses. Surveillance is continuing in both human and animal populations to monitor for further virus evolution. All recent avian influenza A(H5N6) viruses that have been tested remain susceptible to the neuraminidase inhibitor class of antiviral drugs.

While the overall case counts remain low, and we've seen no indication of human-to-human spread, this upward trend in cases is of concern, as are the detections of H5N6 in poultry in Vietnam and Laos, and the virus showing up in migratory birds in Hong Kong.


For more background on this emerging avian flu threat, you may wish to revisit some of these blogs from last year:

H5N6: The Other HPAI H5 Threat

H5N6 Rising: Infecting Birds, Humans, & Even Cats

EID Journal: Influenza A(H5N6) Virus Reassortant, Southern China, 2014

Detection Of Airborne H9 Nucleic Acid In Chinese Live Poultry Market

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In China the link between live poultry markets (LPMs) and the spread (and reassortment of) avian flu strains is already well established, and it is easy to understand why.

Large quantities of birds of varying species (chickens, ducks, geese, quail, and others) are brought in from different farms, housed together in cramped quarters, and then slaughtered (and often de-feathered) in open air booths as thousands of people walk by. 

Not only does this expose humans to avian viruses, it facilitates the sharing of different avian flu subtypes (H5, H7, H9) among the birds, promoting continual reassortment and the creation of new clades, or subtypes.


In 2014, a year after the H7N9 virus emerged in China, in CDC: Risk Factors Involved With H7N9 Infection, we looked at a case-control study that pretty much nailed LPMs as the prime  risk factor for infection.

While even casual exposure to poultry in live bird markets was cited as the primary risk factor, people who owned, raised, or slaughtered birds at home, on farms, or in the wild were not found to be at any increased risk.

Last December, a Who's Who of avian flu experts, writing in The Lancet: Interventions To Reduce Zoonotic & Pandemic Risks From Avian Flu In Asia listed immediate actions that should be taken by LPMs to curb the evolution and spread of avian flu in Asia.


The detection of viral RNA (or sometimes live virus) in LPMs isn't new (see Macao Detects H7 In Poultry Market - Live Sales Halted 3 Days), and some studies (see H5N1: Hiding In Plain Sight) have shown these viruses may survive for days or even weeks under the right conditions.

But these detections have generally been on fomites (inanimate objects like knives, table tops, cages, etc.) or in environmental contamination from chicken manure, feathers, entrails, or dust.  

Less well defined is the airborne spread of avian viruses in these markets, although it may explain how a few people just walking past a live market have reportedly been infected.


Three years ago, in How to Aerosolize A Chicken, we looked at one plausible way this can happen, through the use of mechanical de-feathering machines used in some chicken stalls.

And there is some evidence that avian viruses can be spread from farm to farm - at least over short distances - by prevailing winds (see Bird Flu’s Airborne `Division).

Adding more weight to this idea, a year ago, in CIDRAP: H5N2 Roundup & Detection In Environmental Air Samples, we looked at air sampling conducted by the University of Minnesota around infected poultry farms that found evidence of airborne virus particles.

But until now, little has been published on the search for airborne avian flu viruses in and around live poultry markets in China.  

Which brings us to a study, published last week in the Chinese Medical Journal, which describes two years of environmental and air testing from one of the hundreds of LPMs in Nanning, China (Guangxi province).

They collected Aerosol samples from one (of 12) random stalls (including chickens, geese, and ducks) every week.  At the same time they collected floor sewage and feathers, and swabbed poultry cages and chopping blocks.

Samples were cataloged and tested for influenza A viral RNA and positive samples were then analyzed to determine their (H5/H7/H9) subtype.

RT-PCR testing is very sensitive, and the detection of viral RNA is a much lower bar than isolating live virus, and doesn't tell us about the viability of the viruses they detected.

The (open access) study found ample environmental evidence of viral contamination, and reports the first positive detection of Airborne H9 (presumably H9N2) in a Chinese LPM. 

Although not a huge threat to human health, H9N2 is increasingly on our radar because the number of human infections appear to be increasing, we've seen signs of increasing mammalian adaptations, and because it has contributed its internal genes to a number of reassorted avian flu viruses.

Guangxi Province has only reported 3 cases of H7N9, and so it isn't terribly surprising that H7 viruses were not detected, and while H5 viruses were found in roughly 20% of environmental samples, no airborne H5 was detected.

The full report can be read at the link below, I've included some excerpts from the discussion:

First Positive Detection of H9 Subtype of Avian Influenza Virus Nucleic Acid in Aerosol Samples from Live Poultry Markets in Guangxi, South of China.

Kang N¹, Chen M¹, Bi FY¹, Chen MM¹, Tan Y¹.

  

Discussion

Overall,  the present results suggest that AIV  nucleic  acid exist in aerosol and other environmental samples from LPMs of  Guangxi.  Aerosol  transmission  might  be  an  important  mode of human infected by AIV after visiting LPMs; thus, it is needed to monitor virus distribution in aerosol sample from LPMs.

Previous studies have shown that LPMs were closely linked to H9N2, H5N1, and H7N9 infection in human in 2003,[4]  2006, and 2013,[5] respectively.

LPMs promote the transmission of AIV from avian to human. It is still needed to confirm the transmitted mechanism through exposure  or  visiting  LPMs.  Chickens  were  successfully  infected  with  AIV  H5N1and  H9N2  by  aerosol  and  caused  higher titers of virus. [6,7]

Avian influenza H9 has been isolated animals  from  LPMs[8‑11]  and  from  air  in  chicken  houses  in  China. Our results first reported H9 subtype of AIV nucleic acid existing in aerosol sample from LPM of Guangxi, China, providing support for aerosol transmission of AIV in LPM.

H5 subtype of AIV nucleic acid was not detected positive in  aerosol  while  it  was  positive  in  other  four  styles  of  environmental samples. H9 subtype was positive in aerosol and other four styles of environmental samples in 2014.

It is still needed further study to investigate whether there are differences in viral viability between H5 and H9 subtypes in aerosol and other environmental samples. As  LPMs  play  an  important  role  in  the  dissemination  of  AIVs, active surveillance to monitor AIV in LPMs should be carried out as an early warning system for AIV outbreaks.

WHO Zika Virus Outbreak Global Response (Interim Report)

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The World Health Organization has published a 14-page report outlining the WHO-led global response to the Zika Virus, and the emerging funding (or lack thereof) that they've received to date.


The report begins with brief sections on Zika's background and on last February's Strategic Response Framework and Operations Plan, which is summarized in the graphic below.

It then provides an agency by agency list of funding requests, the funding actually received, and the resultant gap.  At this point these funding gaps run (depending on which agency) from about 80% to 99%.




The full report is available HERE.

Avoiding Naegleria

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Each summer we see a handful of tragic deaths – mostly of children – due to a nearly always fatal condition called PAM (Primary amebic meningoencephalitis), caused by a brain infection from an amoebic parasite called Naegleria fowleri.

Dubbed the `brain eating amoeba' by the press, this parasite enters the brain through the nasal passages, usually due to the forceful aspiration of water (containing the amoeba) into the nose. 

Until a few years ago, nearly all of the Naegleria infections reported in the United States were linked to swimming in warm, stagnant freshwater ponds and lakes (see Naegleria: Rare, 99% Fatal & Preventable), making this pretty much a summer time threat.

In 2011, however,  we saw two cases reported in Neti pot users from Louisiana, prompting the Louisiana Health Department to recommend that people `use distilled, sterile or previously boiled water to make up the irrigation solution’ (see Neti Pots & Naegleria Fowleri).

While extraordinarily rare in the United States, every year Pakistan reports a dozen or more infections from this `killer amoeba’, as chlorination of their water supplies is often inadequate, and for many, nasal ablutions are part of their daily ritual. 

 
Unusually, in 2013 we saw a 4 year-old  infected through contact with a municipal water supply while visiting St. Bernard Parish, Louisiana.  Since then testing has revealed Naegleria in a number of municipal water supplies across the state of Louisiana (see Louisiana: 2nd Public Water System Reports Naegleria).


And just last month we looked at an MMWR: Epidemiological Investigation Into A Case Of Primary Amebic Meningoencephalitis  in California which suggested a poorly chlorinated spring-fed swimming pool was the likely source of infection and death of a 21 year old woman.  

This was also an unusual finding, and furthers the recent pattern of seeing PAM cases arise from atypical settings (Northern states, via neti pots and municipal water supplies, etc.) in the United States.

Up until a recently, infection with Naegleria fowleri was universally fatal, but in 2013 an investigational drug called miltefosine was used successfully for the first time to treat the infection.  Early diagnosis, and administration of this drug, are crucial however.

Even with this new drug, prevention is the key to saving lives, and leading the charge in educating the public is http://amoeba-season.com/, a USF Philip T. Gompf Memorial Fund project, which was set up by a pair of Florida doctors who tragically lost their 10 year-old son to this parasite in 2009.  

Their twitter account -  @AmoebaSeason - is promoting Healthy and Safe Swimming Week 2016  all this week, which will culminate with with a twitter `Thunderclap' on May 31 at 4:00PM EDT urging the CDC to make brain amoeba infection reportable.

I'm hoping some of my readers will join in. 

In the meantime, their website offers a wealth of information on the amoeba, and some important safety advice to avoid this waterborne threat.

 

For some of my earlier blogs on Naegleria you may wish to revisit:

A Reminder About Naegleria

Reminder: COCA Call Today On Naegleria Fowleri & Cryptosporidium

MMWR: CDC Imports Investigational Drug For Amoebic Infections

NOAA: `Near Normal' Atlantic Hurricane Season Expected

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With the caveat that it just takes one major land falling storm in a populated region to make for an epic hurricane season, today NOAA announced their prediction for this year’s Atlantic hurricane season.  


First their statement, after which I’ll have a bit more.

Near-normal Atlantic hurricane season is most likely this year 

70 percent likelihood of 10 to 16 named storms

May 27, 2016 NOAA’s Climate Prediction Center says the 2016 Atlantic hurricane season, which runs from June 1 through November 30, will most likely be near-normal, but forecast uncertainty in the climate signals that influence the formation of Atlantic storms make predicting this season particularly difficult. 

 

NOAA predicts a 70 percent likelihood of 10 to 16 named storms (winds of 39 mph or higher), of which 4 to 8 could become hurricanes (winds of 74 mph or higher), including 1 to 4 major hurricanes (Category 3, 4 or 5; winds of 111 mph or higher). While a near-normal season is most likely with a 45 percent chance, there is also a 30 percent chance of an above-normal season and a 25 percent chance of a below-normal season. Included in today’s outlook is Hurricane Alex, a pre-season storm that formed over the far eastern Atlantic in January. 

“This is a more challenging hurricane season outlook than most because it’s difficult to determine whether there will be reinforcing or competing climate influences on tropical storm development,” said Gerry Bell, Ph.D., lead seasonal hurricane forecaster with NOAA’s Climate Prediction Center. "However, a near-normal prediction for this season suggests we could see more hurricane activity than we’ve seen in the last three years, which were below normal.”

Bell explained there is uncertainty about whether the high activity era of Atlantic hurricanes, which began in 1995, has ended. This high-activity era has been associated with an ocean temperature pattern called the warm phase of the Atlantic Multi-Decadal Oscillation or AMO, marked by warmer Atlantic Ocean temperatures and a stronger West African monsoon. 

However, during the last three years weaker hurricane seasons have been accompanied by a shift toward the cool AMO phase, marked by cooler Atlantic Ocean temperatures and a weaker West African monsoon. If this shift proves to be more than short-lived, it could usher in a low-activity era for Atlantic hurricanes, and this period may already have begun. High- and low-activity eras typically last 25 to 40 years.

In addition, El Niño is dissipating and NOAA’s Climate Prediction Center is forecasting a 70 percent chance that La Niña — which favors more hurricane activity — will be present during the peak months of hurricane season, August through October. However, current model predictions show uncertainty as to how strong La Niña and its impacts will be.

(Continue . . .)

While these outlooks can give us an idea of what kind of season to expect, long-range forecasting is still fairly crude, and the number of storms matters less than where the storms that do form end up going.


Below average hurricane years - such as we've seen for the past three seasons - are always welcome, but they don't necessarily turn out uneventful.

The outlook in 1992 was for a `below average' year, and with only 4 hurricanes and 3 tropical storms, it certainly met that mark. 

And were it not for the first hurricane of that year - a CAT 5 monster named Andrew that devastated a large swath of South Florida - there would be little reason to remember it.

Andrew was the last land falling CAT 5 storm to hit the US mainland. Before that, you'd have to go back to Camille, which struck the Gulf coast in 1969.


It's been more than 10 years since the last major (CAT 3+) storm has hit the United States (Wilma in 2005), and hopefully we'll avoid that again this year.

But the smart money is on preparing as if we won't get that lucky. 

Last Sunday, in Hurricane Preparedness 2016,we looked at many of the steps you and your family need to do to prepare for this year's hurricane season.

 
And lastly, when  it comes to getting the latest information on hurricanes, your first stop should always be the National Hurricane Center in Miami, Florida. Those on Twitter should also follow @FEMA, @ReadyGov. @CraigatFEMA, and @NHC_Atlantic  or  @NHC_Pacific.

Virulence Of A Novel Reassortant Canine H3N2 In Ferret, Dog and Mouse Models

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For the past few years we've been following research into the emergence and evolution of an emerging avian-origin canine H3N2 virus, which first appeared in Korea nearly a decade ago, moved into China, and appeared in the United States in the spring of 2015.

Unlike the canine influenza virus (CIV) that emerged in North America in 2004 (H3N8) which jumped from equines, the HA and NA genes from A/canine/Korea/01/2007 (H3N2) are closely related to those identified in 2003 in chickens and doves in South Korea.

Over the next few years CIV H3N2 spread into China, and in 2011 a study that appeared in the Journal of General Virology, showed that it had begun to infect cats as well (see  Korea: Interspecies Transmission of Canine H3N2).


The plot thickened again when we saw evidence of reverse zoonosis, resulting in a  Canine H3N2 Reassortant With pH1N1 Matrix Gene, producing a novel hybrid between the 2009 H1N1 virus and CIV. 

When this H1N1 M gene turned up in reassorted swine variant viruses (H1N1v, H3N2v, H1N2v), The CDC speculated that `This M gene may confer increased transmissibility to and among humans, compared to other variant influenza viruses.’ – CDC HAN 2012

 
And just last April, in A Canine H3N2 Virus With PA Gene From Avian H9N2 - Korea, we saw yet another example of CIV reassortment, this time with an avian virus. 

The Canine H3N2 virus is very much a work in progress, as it continues to evolve, to expand both its geographic and host range, and to reassort with other viruses. 

All of which serves as prelude to a study, recently published in the Archives of Virology, which finds `significantly enhanced virulence' in mice infected with one of these H3N2/H1N1pdm reassortant viruses.

Virulence of a novel reassortant canine H3N2 influenza virus in ferret, dog and mouse models

Kwang-Soo Lyoo, Woonsung Na , Minjoo Yeom, Dae-Gwin Jeong, Chang-Ung Kim, Jeong-Ki Kim, Daesub Song 

Abstract

An outbreak of a canine influenza virus (CIV) H3N2 reassortant derived from pandemic (pdm) H1N1 and CIV H3N2 in companion animals has underscored the urgent need to monitor CIV infections for potential zoonotic transmission of influenza viruses to humans. 

In this study, we assessed the virulence of a novel CIV H3N2 reassortant, VC378, which was obtained from a dog that was coinfected with pdm H1N1 and CIV H3N2, in ferrets, dogs, and mice. 

Significantly enhanced virulence of VC378 was demonstrated in mice, although the transmissibility and pathogenicity of VC378 were similar to those of classical H3N2 in ferrets and dogs. This is notable because mice inoculated with an equivalent dose of classical CIV H3N2 showed no clinical signs and no lethality. 

We found that the PA and NS gene segments of VC378 were introduced from pdmH1N1, and these genes included the amino acid substitutions PA-P224S and NS-I123V, which were previously found to be associated with increased virulence in mice. 

Thus, we speculate that the natural reassortment between pdm H1N1 and CIV H3N2 can confer virulence and that continuous surveillance is needed to monitor the evolution of CIV in companion animals.

As companion animals, dogs and cats are continually exposed to human flu strains and are increasingly viewed as potential `mixing vessels’ for influenza reassortment (see Study: Dogs As Potential `Mixing Vessels’ For Influenza).


None of this is to suggest that canine influenza is on the verge of becoming a human health threat, but as the CDC notes in their Canine Flu FAQ, there are good reasons to watch viruses like these very closely. 

Can canine influenza viruses infect humans?

To date, there is no evidence of transmission of canine influenza viruses from dogs to people and there has not been a single reported case of human infection with a canine influenza virus.

However, influenza viruses are constantly changing and it is possible for a virus to change so that it could infect humans and spread easily between humans. Human infections with new influenza viruses (against which the human population has little immunity) are concerning when they occur. Such viruses could present pandemic influenza threats. For this reason, CDC and its partners are monitoring the canine influenza H3N8 and H3N2 viruses (as well as other animal influenza viruses) closely. In general, canine influenza viruses are considered to pose a low threat to humans.

MHRP: 1st Detection Of Colistin Resistant E. coli in U.S. Resident

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It has only been a little over six months since The Lancet published the first study on a newly discovered plasmid-mediated MCR-1 gene (see Return of the Plasmids) that conveys resistance to a 50-year-old (polymixin) antibiotic called colistin.

This is important since - despite its age and reputation for causing nephrotoxic side effects - colistin is the antibiotic of last resort for some types of resistant gram negative bacteria like E. coli and Klebsiella.  

And like the better known NDM-1 Carbepenum resistance gene - which came to prominence just over 5 years ago (see NDM-1: A New Acronym To Memorize) - this MCR-1 gene is carried by plasmids - which are snippets of DNA that can  transfer the gene to other types of bacteria (see Study: Adaptation Of Plasmids To New Bacterial Species).

In short order other detections of MRC-1 started to come in from around the globe (see The Lancet: Dissemination Of The MCR-1 Colistin Resistance Gene) and EID Journal: Possible Transmission Of MCR-1 Harboring E. coli Between Companion Animals & Humans).

These findings have led to increased surveillance for this MCR-1 gene, particularly testing isolates that have shown signs of resistance to other antibiotics.


Which brings us to a press release this afternoon from the Military HIV Research Program: MHRP and a link to a study in Antimicrobial Agents and Chemotherapy, both announcing the first detection of an MCR-1 Resistant E. coli infection in a human on United States soil.

First discovery in United States of colistin resistance in a human E. coli infection 

The U.S. Military HIV Research Program (MHRP)

SILVER SPRING, MD. - The Multidrug Resistant Organism Repository and Surveillance Network (MRSN) at the Walter Reed Army Institute of Research (WRAIR) characterized a transferrable gene for colistin resistance in the United States that may herald the emergence of truly pan-drug resistant bacteria.

Colistin is the last agent used to combat bacteria that are resistant to the strongest antibiotics. Colistin has remained the best tool available to treat multidrug resistant bacteria because bacteria were not exchanging genes for its resistance. This latest discovery shows that colistin may be losing its effectiveness in antimicrobial therapy. Now, bacteria may be exchanging resistance genes for colistin.

Alarms sounded in the microbiology community in late 2015 when the first transferrable gene for colistin-resistance was identified in China. Since the report, the global health community has monitored and searched for the occurrence of this gene in the food supply and in humans. This colistin-resistance gene has been reported in Europe and Canada and, as of now, is reported in the U.S.

A clinical sample from a urinary tract infection was collected from a patient in a military treatment facility in Pennsylvania. The sample was sent to the Walter Reed National Military Medical Center (WRNMMC) where colistin susceptibility was tested. The results showed that no safe dosage of colistin would be effective to treat such a bacterial infection. WRNMMC recognized colistin-resistance and sent a sample to WRAIR's MRSN for sequencing, which identified the colistin-resistant gene, mcr-1.

"Colistin is one of the last efficacious antibiotics for the treatment of highly resistant bacteria. The emergence of a transferable gene that confers resistance to this vital antibiotic is extremely disturbing. The discovery of this gene in the U.S. is equally concerning, and continued surveillance to identify reservoirs of this gene within the military healthcare community and beyond is critical to prevent its spread," reported Dr. Patrick McGann, MRSN, WRAIR.

Through intergovernmental communication, it was learned the CDC and USDA are also reporting a swine intestinal infection with a single mcr-1 positive E. coli strain. While there is no evidence that links these recent findings, the evidence of the strain in the U.S. is a public health concern. The gene is transferrable to other bacteria, which could worsen the current global crisis of antimicrobial resistance.

An urgent public health response is underway to contain and prevent potential spread of mcr-1. Active surveillance of multidrug resistant organisms (MDROs), such as mcr-1, allows for earlier and more accurate identification of originating sources. The collection and storage of isolates and samples in the MRSN's growing repository helps researchers identify trends in resistance and prevalence of MDROs and provide best practices for medical providers. The repository also enables them to compare isolates from previous occurrences to better respond to future findings. Recognized as a model program by the White House, the MRSN is a key component of the National Action Plan for Combating Antibiotic Resistant Bacteria (CARB).

With the MRSN's archive, this isolate will be archived for future studies to identify new countermeasures. "Through our surveillance system, we have the unique ability to coordinate source information with susceptibility and sequencing data, and if need be, go back to understand changes in infecting organisms to best treat infection and track emerging multidrug resistant organisms," COL Emil Lesho, Director of the MRSN, WRAIR.

This finding has been published by Antimicrobial Agents and Chemotherapy (AAC) of the American Society for Microbiology (ASM).

In early 2012 World Health Director-General Margaret Chan issued a dire warning about our dwindling antibiotic arsenal (see Chan: World Faces A `Post-Antibiotic Era’) – a theme  echoed a year later by CDC Director Thomas Frieden during the release of a major US report on the threat (see McKenna On CDC Antibiotic Resistance Report).

A month scarcely goes by without our seeing more bad news the antibiotic resistance front, bringing the day when we may enter that post-antibiotic era ever closer.

If you haven’t already done so (or would like a refresher), I would highly recommend you watch  Maryn McKenna’s TED Talk - What do we do when antibiotics don’t work any more?.

A 70% Chance Our Bonnie Lies Over The Ocean

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Although the 2016 Atlantic tropical season doesn't officially kick off until next Wednesday (June 1st), we've already had one (very rare) tropical storm form last January, and the National Hurricane Center is watching an area off the Southeastern United States they give a 70% chance of becoming the second named storm of the year over the weekend.

ZCZC MIATWOAT ALL
TTAA00 KNHC DDHHMM
SPECIAL TROPICAL WEATHER OUTLOOK
NWS NATIONAL HURRICANE CENTER MIAMI FL
825 AM EDT THU MAY 26 2016

For the North Atlantic...Caribbean Sea and the Gulf of Mexico:

1. A low pressure area centered between Bermuda and the Bahamas is gradually becoming better defined while shower activity is increasing. Environmental conditions are expected to become more conducive for tropical or subtropical cyclone formation on Friday while the system moves west-northwestward or northwestward  toward the southeastern United States coast.

With the Memorial Day weekend approaching, all interests along the southeast coast from Georgia through North Carolina should monitor the progress of this low.

An Air Force reconnaissance plane will be scheduled to  investigate this low on Friday. The next Special Tropical Weather Outlook on this disturbance will be issued by 3 PM EDT today.  For additional information on this system, see High Seas Forecasts issued by the
National Weather Service.

* Formation chance through 48 hours...medium...50 percent
* Formation chance through 5 days...high...70 percent

With the end of El Nino in the Pacific, the odds for seeing more Atlantic tropical storms tends to increase.  While there are other factors at play (sea surface temps, the Saharan dust level, and wind shear, to name a few), a neutral or La Nina cycle can portend more risk.

If this low turns into a named storm, she will be named Bonnie.

While Bonnie is unlikely to turn into anything more than a tropical storm, now is an excellent time for all interests along the Atlantic or Gulf coast to review their hurricane and severe weather preparedness plans.


For details on how to go about that, you may wish to revisit Sunday's blog: Hurricane Preparedness 2016

NEJM: Zika Virus And The Risk Of Microcephaly

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While the link between maternal Zika virus infection and an increase in congenital defects - such as microcephaly - is pretty well accepted, unknown at this time is just how big a risk that really is.

We've only seen two studies on point, and they provided two very different results.

• In Association between Zika virus and microcephaly in French Polynesia, 2013–15: a retrospective study, researchers came up with about a 1% likelihood of microcephalic birth when the mother is infected in the first trimester. 
•  While in NEJM: Zika Virus Infection In Pregnant Women - Brazil (Preliminary Report), a small study suggested that 29% of women who tested positive for the Zika virus during pregnancy saw `. . . grave outcomes, including fetal death, placental insufficiency, fetal growth restriction, and CNS injury.' 

Today the NEJM carries a perspective - based on an analysis of Zika outbreaks in Bahia, Brazil -  that attempts to quantify the risks based on the limited information available. 

But based on what they know right now, these researchers found a `strong association between the risk of microcephaly and infection risk in the first trimester and a negligible association in the second and third trimesters'.

Then, depending upon which set of assumptions they used (to fill in the missing data gaps) - they came up with a range of risk that ran between .88% and 13.2% - of  1st trimester Zika infection resulting in a microcephalic birth.

Since there are still major gaps in the data, and microcephaly is but one possible `grave outcome', these results need to be taken in context. 

Follow the link to read the full report:

Perspective 

Zika and the Risk of Microcephaly 
 

Michael A. Johansson, Ph.D., Luis Mier-y-Teran-Romero, Ph.D., Jennita Reefhuis, Ph.D., Suzanne M. Gilboa, Ph.D., and Susan L. Hills, M.B., B.S.

May 25, 2016DOI: 10.1056/NEJMp1605367

Media Reporting Bird Flu Outbreak In Cameroon

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Although Cameroon hasn't reported a bird flu outbreak in nearly a decade - given its close proximity to hard hit Nigeria- it isn't all that surprising that they would find themselves once again dealing with an outbreak of H5N1.

This report by Lefigaro.fr with AFP.

 (Translated)

Cameroon: a bird flu outbreak detected

Update on 05/26/2016 at 10:47 

A home H5N1 avian influenza has been identified in a poultry farm in Yaounde, killing nearly 15,000 poultry in three days, reported today the Cameroonian state radio. The virus was detected Mvog Betsi poultry complex on the outskirts of Yaounde, following the finding of a "high mortality in poultry" in this firm, announced the radio, adding that "nearly 15,000" 33,000 poultry on account that the site died.  

The deaths were recorded in three days, between 20 and 23 May, according to an analysis report of the National Veterinary Laboratory (LANAVET) consulted by AFP. The dead birds were incinerated and the rest of the herd was slaughtered, while access to the infected area is now prohibited, according to the radio citing the government.  

(Continue . . . )

You can also read an English language report at Panic as bird flu outbreak kills 15,000 birds in Cameroon where the country's Minister of Livestock, Fisheries and Animal Industries is quoted as confirming H5N1.


As we've discussed previously, surveillance and reporting of all diseases (human and livestock) is weak across much of Africa, and the assumption is that outbreaks like these may occur but may only rarely be reported.


Last March, in Libya's Under Reported Burden Of H5N1 (FAO Workshop), we learned of an FAO report which cited `at least 4 deaths' due to H5N1 in Libya, and more than 100 suspected or confirmed poultry outbreaks.

Yet `officially',  Libya has never reported a human H5N1 infection to WHO. 

Last summer, in FAO: Concerns Rising Over Spread Of Avian Flu In Africa and again last October in WHO Scales Up Influenza Surveillance In Africa we looked at growing concerns over the recent spread of highly pathogenic avian flu in Africa and the very limited surveillance and reporting from the region.
 
This outbreak - on the outskirts of Yaounde - which is both the nation's capital and has a population of 2.5 million, almost certainly improves the odds of it being noticed, tested, and publically announced. 

Hopefully this discovery will lead to more intense surveillance in Cameroon's rural districts as well. 

HK CHP Notified Of 1 H7N9 Case In Guangdong Province

WHO Avian Flu Risk Assessment - May 2016

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If history is any guide (see WHO Chart above), we ought to be getting near the start of H7N9's summer hiatus.  The pattern has been - starting around epi week #20 and running through the heat of the summer - case reports drop off dramatically.

While this fourth winter wave has seen fewer cases reported than usual, we are still getting sporadic reports well towards the end of May.  

 
On Sunday we saw Hebei Province report only their second case since the virus emerged in 2013, and today we have another case reported from Guangdong province. 

There may be others we won't hear about until China releases their May infectious disease reports in mid-June.


This from Hong Kong's CHP.

CHP notified of additional human case of avian influenza A(H7N9) in Guangdong

     
The Centre for Health Protection (CHP) of the Department of Health (DH) today (May 26) received notification of an additional human case of avian influenza A(H7N9) from the Health and Family Planning Commission of Guangdong Province and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

The case involves a male patient aged 63 who lives in Meizhou, Guangdong.
 
From 2013 to date, 759 human cases of avian influenza A(H7N9) have been reported by the Mainland health authorities.

"We will remain vigilant and work closely with the World Health Organization and relevant health authorities to monitor the latest developments," a spokesman for the DH said.

The DH's Port Health Office conducts health surveillance measures at all boundary control points. Thermal imaging systems are in place for body temperature checks on inbound travellers. Suspected cases will be immediately referred to public hospitals for follow-up.

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