Some Signs Of Life In the Tropics

#11,596


After a quick start in May and June, the tropical Atlantic quieted down for July, and is just now starting to show some life.  While neither of the two disturbances shown in the map above have a closed circulation, both have some potential to develop. 

This morning's NOAA tropical forecast gives invest 97L - about to enter the Eastern Caribbean - a 70% chance of becoming a tropical cyclone over the next 5 days.

TROPICAL WEATHER OUTLOOK
NWS NATIONAL HURRICANE CENTER MIAMI FL
200 AM EDT SUN JUL 31 2016

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

1. A fast-moving tropical wave is nearing the Lesser Antilles. Although showers and thunderstorms are fairly well-organized, there are currently no signs a closed surface circulation.  However, this system has the potential for some slow development during the next couple of days, but the best chance for tropical cyclone formation is likely to be by the early to middle part of next week when the wave reaches the western Caribbean Sea.  This system is expected to bring locally heavy rains and gusty winds to portions of the Lesser Antilles, Virgin Islands, and Puerto Rico today. Shower and thunderstorm activity should spread westward across the eastern Caribbean Sea and Hispaniola by tonight and on Monday. Interests in these areas should monitor the progress of this disturbance.
* Formation chance through 48 hours...medium...40 percent
* Formation chance through 5 days...high...70 percent

2. Shower and thunderstorm activity associated with a tropical wave and a low pressure system centered about 650 miles west-southwest of the Cabo Verde islands has changed little in organization. This system is moving westward at 10 to 15 mph, and development, if any, should be slow to occur due to unfavorable upper-level winds.
* Formation chance through 48 hours...low...10 percent
* Formation chance through 5 days...low...10 percent

Long range models (which are always subject to change) take first  system into the Western Caribbean, and possibly into the Gulf of Mexico, by the middle of next week.


We'll take a closer look at August's tropical climatology later in the week, but suffice to say that August, September, and early October mark the busiest part of the hurricane season.

While it isn't at all clear yet whether either of these budding systems will pose a threat to the U.S. mainland, this is the time of year to get, and stay, prepared. 

So, if you haven’t already downloaded the updated Tropical Cyclone Preparedness Guide, now would be an excellent time to do so. You'll find additional preparedness information in my Hurricane Preparedness 2016 post from last May.

When it comes to getting the latest information on hurricanes, your first stop should always be the National Hurricane Center in Miami, Florida. These are the real experts, and the only ones you should rely on to track and forecast the storm.
 

And if you are on Twitter, you'll want to follow @FEMA, @CraigatFEMA, @NHC_Atlantic, @NHC_Pacific and @ReadyGov.

And a reminder, throughout the entire month of September FEMA, READY.GOV, state and local Emergency agencies, and grassroots coalition members will be promoting National Preparedness Month through community events, drills, and exercises and blogs like mine to encourage Americans to become better prepared to deal with all types of threats.

Cell Rpts: Zika Viruses Belong To One Serotype

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With two distinct lineages (African & Asian), and reportedly Growing Genetic Diversity Of Zika Viruses In Latin America, one of the concerns has been whether this diverse constellation of Zika strains would hamper the development of an effective vaccine.

Yesterday Cell Reports published an NIH funded study that provides potentially good news on that front, as researchers have found that despite its diversity, all of the Zika viruses tested to date belong to the same serotype.

First a link to the study, and the abstract, followed by excerpts from the press release.

Broadly Neutralizing Activity of Zika Virus-Immune Sera Identifies a Single Viral Serotype

Kimberly A. Dowd, Christina R. DeMaso, Rebecca S. Pelc, Scott D. Speer, Alexander R.Y. Smith, Leslie Goo, Derek J. Platt, John R. Mascola, Barney S. Graham, Mark J. Mulligan, Michael S. Diamond, Julie E. Ledgerwood, Theodore C. Pierson

Open Access
DOI: http://dx.doi.org/10.1016/j.celrep.2016.07.049
Highlights

    •Neutralization studies with convalescent ZIKV-immune sera identify a single serotype
    •Infection with a single ZIKV strain elicits broadly neutralizing antibodies
    •Strain selection may not be a critical parameter for ZIKV vaccine development

Summary

Recent epidemics of Zika virus (ZIKV) have been associated with congenital malformation during pregnancy and Guillain-Barré syndrome. There are two ZIKV lineages (African and Asian) that share >95% amino acid identity. Little is known regarding the ability of neutralizing antibodies elicited against one lineage to protect against the other. 

We investigated the breadth of the neutralizing antibody response following ZIKV infection by measuring the sensitivity of six ZIKV strains to neutralization by ZIKV-confirmed convalescent human serum or plasma samples. Contemporary Asian and early African ZIKV strains were similarly sensitive to neutralization regardless of the cellular source of virus. 

Furthermore, mouse immune serum generated after infection with African or Asian ZIKV strains was capable of neutralizing homologous and heterologous ZIKV strains equivalently. Because our study only defines a single ZIKV serotype, vaccine candidates eliciting robust neutralizing antibody responses should inhibit infection of both ZIKV lineages, including strains circulating in the Americas.

While this finding makes the development of a vaccine less complicated than if multiple serotypes were involved, there is still a long road  (and potentially bumpy) road ahead before we have a safe, effective, and commercially available Zika vaccine.

This press release on the above study from NIAID.

Public Release: 29-Jul-2016

Zika infection is caused by one virus serotype, NIH study finds

Finding may have implications for vaccine development

NIH/National Institute of Allergy and Infectious Diseases

WHAT:

Vaccination against a single strain of Zika virus should be sufficient to protect against genetically diverse strains of the virus, according to a study conducted by investigators from the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH); Washington University in St. Louis; and Emory University in Atlanta.

Zika virus strains are grouped into two distinct genetic lineages: African and Asian. The Zika virus strain circulating in the current outbreak affecting Central and South America and the Caribbean is of the Asian lineage. When individuals are infected with Zika virus, their immune systems produce neutralizing antibodies to fight the infection. These antibodies may offer immunity against future infections by strains of the same Zika virus lineage. Until now, it was unclear whether the antibodies could also protect against infection with strains of the other Zika virus lineage. Results from laboratory experiments and tests in mice now show this may be possible. Such protection indicates that, despite being genetically distinct, all strains of Zika virus have identical surface antigens and therefore are the same serotype. The closely-related Dengue virus has four serotypes, which is why people can be infected with dengue as many as four times, once with each serotype.

In this study, scientists took serum samples from people infected by Zika virus strains circulating in South America and mixed them with multiple strains of the virus in the laboratory to see how well the serum antibodies neutralized the virus. Results showed that antibodies elicited after infection with Zika virus strains of the Asian lineage were able to potently inhibit both Asian lineage and African lineage strains. The researchers conducted similar experiments using serum samples from mice and found that sera from mice infected with either Asian or African Zika virus strains were equally effective in neutralizing virus strains from either lineage.

The findings are important to the ongoing effort to rapidly develop a preventive Zika vaccine, according to the authors. Because there is only one Zika virus serotype, antibodies elicited by any Zika virus strain in a vaccine could conceivably confer protection against all Zika virus strains, the researchers conclude.

Thailand Reports `Probable' Imported MERS Case

Updated: Monday 8/1/16

There are new reports that the suspected case has tested negative and awaits a second test before being declared `cleared of MERS'.  

Whether that means he was never infected, or has simply cleared the virus, is uncertain at this time.  Hopefully follow up serological testing will be done to confirm or rule out a MERS infection.

#11,594


For the third time in just over a year Thailand is reporting an imported MERS case, who is now in isolation (along with his family and a Taxi driver) at Bamrasnaradul hospital.

According to press reports (there's nothing yet on the MOH website), the patient is an 18 year old Kuwaiti male who entered the country on Monday with two older relatives.   

He developed flu-like symptoms on Tuesday and tested positive for MERS on Wednesday.  His condition has improved, and he (and his contacts) will remain in isolation for 14 days. 

According to the Bangkok Post report (below) this case is considered `probable' because one lab returned a positive lab result, while several others were inconclusive. 

Other than being identified as Kuwaiti, we aren't provided with any information about this patient's recent travel history, or possible exposures.  Kuwait, which has only reported 4 cases in the past 4 years, last reported a MERS case in September of 2015.

New probable Mers case found

 30 Jul 2016 at 16:06 


A Kuwaiti man has been identified as a probable Mers case in Thailand although testing has not been conclusive, according to the Public Health Ministry.

The 18-year-old man entered the country on Monday with his father and grandmother and all of them are now hospitalised, said Ammuay Gajeena, director general of the Disease Control Department said at a news briefing on Saturday afternoon.

The purpose of their visit was to have the grandmother treated for knee-related complications.

When the man started to show flu symptoms a day later, the private hospital treating his grandmother took a sample of his body fluid to be tested for Middle East Respiratory Syndrome (Mers) at the facility's laboratory.

The test came positive on Wednesday and the hospital informed the ministry which immediately admitted him to the state-owned Bamrasnaradura Infectious Disease Institute.

(Continue . . . .)

For details on Thailand's two earlier imported MERS cases, you may wish to revisit:

WHO SEARO Statement On Thailand's Imported MERS Case

Thailand Discharges Their First (and Only) MERS Case

Thailand, which is a major medical tourism destination and gets many patients from the Middle East, has managed to quickly identify and contain three MERS cases.

But as we saw last year in Eurosurveillance: Estimating The Odds Of Secondary/Tertiary Cases From An Imported MERS Case - while most imported cases won't result in extended outbreaks - the odds of seeing at least 8 cases as the result of a single imported case was estimated at non-trivial 10.9%.

A reminder that on any given day, in any given hospital, a MERS, Ebola, or Avian flu patient can walk in the door.  For more on how hospitals can prepare, you may wish to revisit  TFAH Issue Brief: Preparing The United States For MERS-CoV & Other Emerging Infections.

CDC Statements On Zika In Florida and Puerto Rico

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The CDC will be holding a press conference at 1:30 EDT today to update us on Zika, but in the meantime we have a pair of press releases that likely telegraph some of what we'll hear later this afternoon.

The first is on the investigation into Florida's locally acquired Zika cases, which we saw announced this morning (see Florida DOH: `High Likelihood' Zika Locally Acquired In South Florida).

Florida investigation links four recent Zika cases to local mosquito-borne virus transmission

Press Release

For immediate release: Friday, July 29, 2016
Contact: Media Relations
(404) 639-3286

The Centers for Disease Control and Prevention (CDC) has been informed by the State of Florida that Zika virus infections in four people were likely caused by bites of local Aedes aegypti mosquitoes.  The cases are likely the first known occurrence of local mosquito-borne Zika virus transmission in the continental United States.  CDC is closely coordinating with Florida officials who are leading the ongoing investigations, and at the state’s request, sent a CDC medical epidemiologist to provide additional assistance.

State officials have responded rapidly with mosquito control measures and a community-wide search for additional Zika cases.  Under the current situation, there are no plans for limiting travel to the area.

“All the evidence we have seen indicates that this is mosquito-borne transmission that occurred several weeks ago in several blocks in Miami,” said Tom Frieden, M.D., M.P.H., director of the CDC. “We continue to recommend that everyone in areas where Aedes aegypti mosquitoes are present—and especially pregnant women—take steps to avoid mosquito bites. We will continue to support Florida’s efforts to investigate and respond to Zika and will reassess the situation and our recommendations on a daily basis.”

Zika virus spreads to people primarily through the bite of an infected Aedes species mosquito (Ae. aegypti and Ae. albopictus), but can also be spread during sex by a person infected with Zika to their partner.  Most people infected with Zika won’t have symptoms, but for those who do, the illness is usually mild.  However, Zika infection during pregnancy can cause a serious birth defect of the brain called microcephaly and other severe fetal birth defects.

“We have been working with state and local governments to prepare for the likelihood of local mosquito-borne Zika virus transmission in the continental United States and Hawaii,” said Lyle Petersen, M.D., M.P.H., incident manager for CDC’s Zika virus response. “We anticipate that there may be additional cases of ‘homegrown’ Zika in the coming weeks.  Our top priority is to protect pregnant women from the potentially devastating harm caused by Zika.”

CDC has been working with state, local, and territorial health officials to prepare for locally transmitted Zika infection in the United States.  Officials from Florida participated in all these activities, and their experience in responding to mosquito-borne diseases similar to Zika, including dengue and chikungunya, has helped guide their current investigations. To date, CDC has provided Florida more than $8 million in Zika-specific funding and about $27 million in emergency preparedness funding that can be used for Zika response efforts.  

Because we are in mosquito season, CDC continues to encourage everyone, especially pregnant women and women planning to become pregnant, to protect themselves from mosquito bites.  Remember to use an  insect repellent  registered by the Environmental Protection Agency (EPA), wear long-sleeved shirts and long pants, use or repair screens on windows and doors, use air conditioning when available, and remove standing water where mosquitoes can lay eggs.

We continue to learn about Zika virus, and we are working hard to find out more about these cases. Here is what we do know:

• Zika is spread to people primarily through the bite of an infected Aedes species mosquito (Ae. aegypti and Ae. albopictus).
•  A pregnant woman can pass Zika virus to her fetus during pregnancy or during birth.
•  Zika virus infection can cause microcephaly and other severe fetal brain defects, and is associated with other adverse pregnancy outcomes.
•  A person who is infected with Zika virus can pass it to sex partners.
•  Many people infected with Zika virus won’t have symptoms or will only have mild symptoms.
•  No vaccines or treatments are currently available to treat or prevent Zika infections.                                                                                                                            

As of July 27, 2016, 1,658 cases of Zika have been reported to CDC in the continental United States and Hawaii; none of these were the result of local spread by mosquitoes. These cases include 15 believed to be the result of sexual transmission and one that was the result of a laboratory exposure.  This number does not include the four Florida cases likely caused by local transmission.

For more information about Zika: http://www.cdc.gov/zika/ 

The 2nd press release complements and summarizes an MMWR report published today (see Update: Ongoing Zika Virus Transmission — Puerto Rico, November 1, 2015–July 7, 2016).

Zika infections increasing rapidly in Puerto Rico

Widespread Zika infections warrant urgent action to protect pregnant women
 
Press Release

 As of July 7, Zika has been diagnosed in 5,582* people, including 672 pregnant women, in Puerto Rico according to a new report published today in the Morbidity and Mortality Weekly Report (MMWR). Positive tests for people with suspected Zika virus infection have increased from 14 percent in February to 64 percent in June. Positive tests through blood supply screening also increased, reaching 1.8 percent during the latest week of reporting starting July 3.                                                                    

“Puerto Rico is in the midst of a Zika epidemic. The virus is silently and rapidly spreading in Puerto Rico,” said Lyle R. Peterson, M.D., M.P.H, Incident Manager for CDC’s Zika Response and Director, Division of Vector-Borne Diseases. “This could lead to hundreds of infants being born with microcephaly or other birth defects in the coming year. We must do all we can to protect pregnant women from Zika and to prepare to care for infants born with microcephaly.”

Many of the 5,582 people who tested positive for Zika virus infections were tested because they had symptoms of Zika. Because Zika infection during pregnancy can harm the developing fetus, pregnant women in Puerto Rico and other areas where Zika is spreading should be routinely tested during prenatal care whether or not they got sick. Of the 672 pregnant women, 441 (66 percent) experienced symptoms of Zika and 231 (34 percent) had no symptoms. Because approximately 80 percent of people infected with Zika do not have symptoms, the 672 pregnant women with evidence of Zika infection likely represent only a fraction of those who may be infected to date. 

In addition, 21 people with confirmed or suspected Guillain-Barré syndrome in Puerto Rico had evidence of Zika virus infection or recent unspecified flavivirus infection, and one person died after developing severe thrombocytopenia (low blood platelet count).

(Continue . . . )

Florida DOH: `High Likelihood' Zika Locally Acquired In South Florida

Area of Zika Transmission - Credit FL DOH

#11,592


It is not exactly surprising, but after investigating 4 recent Zika cases in Miami-Dade and Broward counties without travel history to Zika endemic regions, the Florida Department of Health has concluded they were likely locally acquired via mosquito vectors.


This from the DOH:

Department of Health Responds to Local Zika Cases

By Florida Department of Health, Office of Communications

July 29, 2016

Press Release

Contact:
Communications Office
NewsMedia@flhealth.gov
(850) 245-4111

Tallahassee, Fla.—The Florida Department of Health has gathered enough information as part of its ongoing investigation into non-travel related cases of Zika in Miami-Dade and Broward counties to conclude that a high likelihood exists that four cases are the result of local transmission. At this time, the department believes that active transmission of the Zika virus are occurring in one small area in Miami-Dade County, just north of downtown. The exact location is within the boundaries of the following area: NW 5th Avenue to the west, US 1 to the east, NW/NE 38th Street to the north and NW/NE 20th Street to the south. This area is about 1 square mile and a map is below to detail the area.  While no mosquitoes trapped tested positive for the Zika virus, the department believes these cases were likely transmitted through infected mosquitoes in this area.

The department is actively conducting door-to-door outreach and urine sample collection in the impacted area and will share more details as they become available. The results from these efforts will help department determine the number of people affected. These local cases were identified by clinicians who brought them to the attention of the department. In addition, blood banks in the area are currently excluding donations from impacted areas until screening protocols are in place.

In an effort to keep Florida residents and visitors safe and aware about the status of the Zika virus, the department will continue to issue a Zika virus update each week day at 2 p.m. Updates will include a CDC-confirmed Zika case count by county and information to better keep Floridians prepared.

There are three new travel-related cases today in Miami-Dade County. According to CDC, symptoms associated with the Zika virus last between seven to 10 days.

CDC recommends that women who are pregnant or thinking of becoming pregnant postpone travel to areas with widespread Zika infection. Florida’s small case cluster is not considered widespread transmission. According to CDC guidance, providers should consider testing all pregnant women with a history of travel to a Zika affected area for the virus. CDC recommends that a pregnant woman with a history of Zika virus and her provider should consider additional ultrasounds.

Florida has been monitoring pregnant women with evidence of Zika regardless of symptoms since January. The total number of pregnant women who have been monitored is 55, with 18 having met the previous CDC case definition.

The Council of State and Territorial Epidemiologists and CDC released a new case definition for Zika that now includes reporting both asymptomatic and symptomatic cases of Zika. Prior to this change, states reported only symptomatic non-pregnant cases and pregnant cases regardless of symptoms. This change comes as a result of increased availability for testing in commercial laboratories.

      (Continue . . . )

EID Journal: MERS-CoV Viral RNA In Blood Indicator Of Severity & Prognosis

Credit WHO

#11,591


MERS-CoV generally presents as a respiratory illness, and its severity may range from asymptomatic or mild to severe pneumonia.  As such, the preferred methods of testing are on sputum, bronchoalveolar lavage (BAL), or other respiratory fluids.

Unlike with most respiratory viruses, viral RNA from MERS-CoV has occasionally been detected in blood, urine, and stool.   For an excellent primer on this, you may wish to revisit Dr. Ian Mackay's MERS-CoV in the blood.... from 2014. 

This `extrapulmonary' detection of MERS-CoV RNA isn't consistent across the board, although it occurs often enough to pique the interest of researchers looking to better understand the pathology of the virus in the human host.


Which brings us to a new EID Journal Dispatch that looks at viral RNA findings in a subset (33%) of patients tested during Korea's MERS outbreak in the summer of 2015. 

While MERS-CoV viremia isn't common enough to make it a satisfactory screening test, researchers did determine that detectable MERS-CoV RNA in the bloodstream was an indicator of more severe disease and a poorer outcome. 

I've only posted some excerpts, so follow the link below the read the dispatch in its entirety. 

Volume 22, Number 10—October 2016
Dispatch

Viral RNA in Blood as Indicator of Severe Outcome in Middle East Respiratory Syndrome Coronavirus Infection


So Yeon Kim, Sun Jae Park, Sook Young Cho, Ran-hui Cha, Hyeon-Gun Jee, Gayeon Kim, Hyoung-Shik Shin, Yeonjae Kim, Yu Mi Jung, Jeong-Sun Yang, Sung Soon Kim, Sung Im Cho, Man Jin Kim, Jee-Soo Lee, Seung Jun Lee, Soo Hyun Seo, Sung Sup Park, and Moon-Woo SeongComments to Author


Abstract

We evaluated the diagnostic and clinical usefulness of blood specimens to detect Middle East respiratory syndrome coronavirus infection in 21 patients from the 2015 outbreak in South Korea. Viral RNA was detected in blood from 33% of patients at initial diagnosis, and the detection preceded a worse clinical course.

Middle East respiratory syndrome coronavirus (MERS-CoV) is a zoonotic, betacoronavirus lineage C RNA virus that was first identified in Saudi Arabia in 2012 (1). MERS-CoV causes respiratory and renal illness in humans, and infection often progresses to severe pneumonia, acute respiratory distress syndrome, renal failure, or death in a subset of patients (2). Risk factors, including patient age, preexisting health conditions, and high viral load in upper respiratory specimens, have been suggested to be related to disease severity and death (3,4). However, pathogenesis and clinical characteristics promoting recovery from infection or progression to serious organ failure have not been well elucidated.

Respiratory specimens are preferred for viral RNA detection and confirmatory diagnosis of MERS-CoV infection in humans (5). MERS-CoV has broad tissue tropism, including the kidney, intestinal tract, liver, histiocytes, macrophages, and T lymphocytes, but viral RNA has been found inconsistently in blood, urine, and fecal specimens (6–10). Reports have described small numbers of cases with extrapulmonary virus; therefore, it remains unclear whether extrapulmonary specimens have any diagnostic usefulness in determining infection or whether extrapulmonary viral detection has clinical implications in disease management.

A large MERS-CoV outbreak occurred in 2015 in South Korea. This outbreak comprised the first imported case and subsequent infection of 185 patients (11). Our study aimed to evaluate the diagnostic utility of blood specimens for MERS-CoV infection by using large numbers of patients with a single viral origin and to determine the relationship between blood viral detection and clinical characteristics.

(SNIP)

Conclusions

Our data showed a detection rate of 33% for viral RNA in blood at initial diagnosis, which was insufficient for initial confirmatory diagnosis. Blood viral RNA at the early phase was related to a worse clinical course in infected patients and might be a good prognostic indicator of severe outcome. Measuring blood viral RNA at hospital admission might be useful.

Dr. Kim is a medical doctor at the Department of Laboratory Medicine of National Medical Center in South Korea. Her research interests include molecular diagnostics and infectious diseases.

(Continue . . . . )

Saudi MOH Announces 1 Primary (Indirect Camel Contact) MERS Case

#11,591

After going six days without a new reported MERS case the Saudi MOH announced the hospitalization of a 58 year-old man from Jobail this morning.

The patient is listed in stable condition and as being a `primary case' with `indirect' contact with camels.

Last November's EID Journal: Risk Factors For Primary MERS-CoV Infection, defined indirect camel exposure as: Having visited settings where animals were kept but without having direct contact; or exposure to household members who themselves had direct animal exposure.

With July nearly over, the Saudi's have reported only 12 cases this month, compared with 45 cases in the month of June.  The primary difference being a large nosocomial outbreak in June at the King Khalid University Hospital.

OIE Notification On Denmark LPAI H7N7 Outbreak

Credit DVFA

 



#11,590

We've the OIE announcement on yesterday's report from  Denmark: Ducks Infected With LPAI H7 Avian Influenza that identifies the strain as LPAI H7N7 and confirms information provided by one of my readers (see yesterday's comments) that these ducks were being raised for release into the wild for hunting purposes.

First some excerpts from the OIE report, then I'll return with a bit more on H7N7.

Source of the outbreak(s) or origin of infection    

    Unknown or inconclusive

Epidemiological comments    


On 27 July 2016, LPAI H7N7 was detected in mallard ducklings collected in connection with the Danish surveillance programme for avian influenza. The diagnosis was confirmed and the virus was typed by sequencing. The killing of the mallards at the infected holding will be conducted on 28 July 2016. The Danish Veterinary and Food Administration has established a restricted zone of 1 km around the holding and are implementing the necessary measures in accordance with Council Directive 2005/94/EC

Control measures

Measures applied    

    Movement control inside the country
    Zoning
    Vaccination prohibited
    No treatment of affected animals

Measures to be applied    

    Disinfection / Disinfestation
    Stamping out

While a small number of human infections with (LPAI or HPAI) H7N7 viruses have been recorded, they have mostly been mild, often producing little more than conjunctivitis.
 


Last year, after an outbreak of LPAI H7N7 in the UK, the ECDC produced a Rapid Risk Assessment On LPAI H7N7, where they wrote:

Outbreaks in poultry holdings caused by low pathogenic or high pathogenic avian influenza A(H7N7) viruses have been reported previously in Europe, as well as human infections with low pathogenic avian influenza virus  A(H7N7). Such infections generally cause mild disease with influenza-like symptoms or conjunctivitis.

The group at risk for infection includes people with occupational exposure to poultry. This group should be made aware of the clinical features of infection, and advised to alert authorities and healthcare providers about  any relevant exposure if they develop influenza-like illness or other symptoms.

There is a low risk of zoonotic transmission to people who are directly exposed to infected birds during the culling and destruction process when there are outbreaks in poultry farms. The risk can be minimised if the exercise is performed under the safety measures recommended in Directive 2005/94/EC. Persons with direct contact to infected poultry before or during culling and disposal should be monitored for symptoms, and postexposure antiviral prophylaxis should be considered.

The risk for zoonotic transmission to the general public in EU/EEA countries is considered to be extremely low.

The caveat being (as always) that influenza viruses are constantly changing and evolving, and what we believe to be true about a particular subtype or strain can change over time.

Brazil Weekly Microcephaly Report - July 21st

#11,589

Brazil has released their weekly Microcephaly report card and it shows the number of suspected cases under investigation has increased by 132 in the last reporting period, while the total number of confirmed microcephaly cases has risen by 40.  

Upon further investigation, another 212 have been discarded as not meeting the criteria for microcephaly, so the number still under investigation decreases to 3062.

The (translated) weekly report follows:

Registration Date: 27/07/2016 18:07:27 the amended 07/27/2016 18:07:27 the REPORT CARD

Microcephaly: 1,749 confirmed cases in Brazil 

The weekly report gathers information submitted by state health departments until 23 July. Other 3,062 cases remain under investigation

New bulletin of the Ministry of Health, released on Wednesday (27), points out that, until July 23, were confirmed 1,749 cases of microcephaly and other nervous system disorders, suggestive of congenital infection. They remain under investigation by the Ministry of Health and the states 3,062 suspected cases of microcephaly across the country.

Since the beginning of the investigation, in October last year, 8,703 cases were reported to the Ministry of Health. Of these, 3,892 were discarded because of normal tests, or because they have microcephaly or malformations confirmed because noninfectious. They were also discarded by do not meet the case definition.

Of the total confirmed cases (1,749), 272 were confirmed by specific laboratory criteria for Zika virus. The Ministry of Health, however, points out that this figure does not represent adequately the total number of cases related to the virus. The folder considers that there was infection Zika most of the mothers who had babies with a final diagnosis of microcephaly.  

The 1,749 confirmed cases in Brazil occurred in 609 municipalities located in all Brazilian states and the Federal District.

In the same period, there were 371 suspected deaths of microcephaly and / or alteration of the central nervous system after birth or during pregnancy (miscarriage or stillbirth) in the country. This represents 4.3% of the total reported cases. Of these, 106 were confirmed to microcephaly and / or alteration of the central nervous system. Another 200 are still under investigation and 65 were discarded.

The Ministry of Health says it is investigating all cases of microcephaly and other disorders of the central nervous system informed by the states, as well as possible relationship with the Zika virus and other congenital infections. Microcephaly can be caused by various infectious agents beyond Zika as Syphilis, Toxoplasmosis, Other Infectious Agents, Rubella, Cytomegalovirus and Herpes Viral.

The folder guides pregnant women adopt measures to reduce the presence of Aedes aegypti, with the elimination of breeding sites, and protect themselves from mosquito exposure, keeping doors and closed or screened windows, wear pants and long sleeved shirts and use allowed repellents for pregnant women.

Denmark: Ducks Infected With LPAI H7 Avian Influenza

Funen - Credit Wikipedia

#11,588


From the DVFA (The Danish Veterinary and Food Administration) we are informed of an LPAI H7 outbreak in a flock of ducks on the island of Funen.

Although LPAI H5 and H7 viruses are common in birds - and pose little threat to poultry or to humans - they are taken seriously due to their ability to mutate into HPAI strains (see You Say You Want An Evolution?)

 
Two reports from the DVFA.

Avian flu in Funen gråandebesætning

A herd of mallard ducks on Funen in Brenderup affected by the less severe avian flu H7N7. The crew consists of 3,000 ducklings. To prevent infection and to prevent the virus evolves, the infected ducklings be killed. DVFA create a 1km restricted zone around the farm.

Press release , Published: July 27, 2016

The movement of birds within and to and from the restricted zone are done with DVFA permission. Backyard poultry within the zone must be registered with the Food Authority. See restricted zone here . The killing is carried out in collaboration between the Food Authority and the Emergency Management Agency. There will be a thorough cleaning and disinfection of the property.

Discovered by routine surveillance samples Smitten crew members are discovered during routine surveillance samples are being taken as part of the Danish action plan against bird flu. - 

We consider always low pathogenic bird flu seriously because it can evolve into a highly pathogenic type. I can reassure that the low-pathogenic avian flu is not contagious to humans. Killing and security is done to prevent further problems, says deputy head of the Food Administration, veterinarian Stig Mellergaard.

Backyard poultry within 1km zone must be registered owners of hobby poultry flocks in the restricted zone must let their herd register with the Food Agency to the Board by the crews, located in zone. the registration of the name, address, poultry type and number must be registered with the Food Authority's customer advice on 7227 6900 or via mail

Note: Although machine translators don't handle the term gråandebesætning very well, it roughly translates to  `mallard herd'. 

A second report from the DVFA follows:

Bird flu outbreak in Denmark

On July 27, 2016: Low pathogenic avian influenza in routine samples taken in Funen gråandebesætning

A fynsk gråandebesætning affected by low pathogenic avian influenza type H7N7, which is a less severe type. There implemented the necessary control measures on detection of low pathogenic avian influenza H7N7 including culling of the infected herd. Furthermore creates DVFA one 1 km restricted zone around the farm. The movement of birds within and to and from the restricted zone are done with DVFA permission. The infection in the herd is discovered during routine surveillance samples are being taken as part of the Danish action plan against bird flu. It is important that poultry owners comply with the restrictions within the restricted zone.

In the restricted zone are not allowed to:

• Moving poultry, other captive birds lay poultry, day-old chicks and eggs within, into and from the restricted zone,
• Hold fairs, exhibitions, markets, auctions, kapflyvninger or any other collection of poultry or other birds in the restricted zone
• Expose feathered to reconstruction of wildlife in the restricted zone
• Remove or spreading used litter, manure or slurry within the restricted zone.

The ban on movement of poultry, other captive birds lay poultry, day-old chicks and eggs do not apply for direct transit through the restricted zone on road or rail.
Authorize the movement can be given of Veterinary Unit under special conditions.

Have you backyard poultry within the zone?
Owners of backyard poultry within the restricted zone must let their poultry register with the Food & Drug Administration to help the Agency to gain knowledge of the crews that are in the zone.

DEFRA: Update On HPAI Outbreaks In France

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Although posted today, this UK DEFRA (Department for Environment, Food & Rural Affairs) report is current through the 22nd of July, and therefore does not include the 80th outbreak I reported on yesterday. 

Department for Environment, Food and Rural Affairs
Animal & Plant Health Agency
Veterinary & Science Policy Advice Team - International Disease Monitoring

Updated Outbreak Assessment

Avian Influenza of high pathogenicity (H5N1 & H5N2)in poultry in France

22 July 2016
Ref: VITT/1200 HPAI in France

Disease Report

Since the last update on the 18 th February, several new outbreaks in poultry have been reported as a result of increased surveillance in South West France (see map – only recent outbreaks shown).

To date there are 79 outbreaks of HPAI H5 (N1, N2 and N9) and sixteen outbreaks of LPAI H5 (N2 and N3) which have been reported to the EU Animal Disease Notification System. The most recent outbreaks have been reported this week, one in the Dordogne and one in Aveyron (OIE, 2016).

In Dordogne, a broiler flock was exhibiting increased mortality over a period of two days, and has tested positive for H5N1 HPAI. In Aveyron, a flock of fattening, free range ducks tested positive for H5N2 HPAI in the framework of national surveillance.

Disease control measures have been put in place around each infected premises including culling all  poultry present. The restriction zone (under an amendment to Implementing Decision 2015/2460/EU) has remained in place and not changed as a result of these outbreaks. The French eradication plan which was put in place earlier in the year has finished and farms are being restocked, so these new cases suggest that disease is still circulating or that viral contamination is still present in certain areas. The exports and trade of live poultry, hatching eggs and day-old chicks are carefully controlled from the restriction zone.

Situation Assessment

The eradication plan put in place by the French Authorities two months ago was designed to allow production of poultry (particularly fattening ducks and geese) to continue under strict control until the point of slaughter and then for restocking to take place after a period of the premises lying fallow and following a programme of C&D, particularly for those farms with free range birds. The monitoring programme on the repopulated farms has been carried out on 100 farms and 99 have tested negative, with just the one positive
result in Aveyron.

It will be of interest to understand whether the HPAI viruses in these recent outbreaks are closely related to those found in 2015 or if they are new introductions, which seems unlikely, but should not be dismissed until the sequences are known.

Conclusion

These recent outbreaks are a setback for the poultry industry in this region, but the French Ministry has confirmed that these results justify the strict biosecurity measures they have put in place in the last eight months because of the high infection pressure present.

The risk to the UK has not increased as a result of the new outbreaks reported. We will continue to monitor the situation closely. We would like to remind all poultry keepers to maintain high standards of biosecurity, remain vigilant and report any suspect clinical signs promptly and in addition using the testing to exclude scheme for avian notifiable disease where appropriate for early safeguard.

For more information, please see
www.defra.gov.uk/ahvla-en/disease-control/nad

The risk level for the UK remains at low, but heightened.

Saudi MOH: KKUH Hospital Outbreak As A `Superspreading' Event

Credit Saudi CCC

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For much of the month of June we followed the outbreak at  Riyadh's KKUH (King Khalid University Hospital) which spiraled to more than 2 dozen cases (see Saudi MOH On KKUH MERS Outbreak & Increased Asymptomatic Detections).

Of the 28 cases from the KKUH outbreak, 21 were listed as being either very mild or asymptomatic.  An unusually high ratio by any standard.

Today the Saudi National Command & Control Center (CCC) is back with another review of that outbreak, this time focusing on what they describe as a `super-spreading' event.

We've seen other large hospital outbreaks attributed to `super spreading' events (see The Lancet: Mapping The Korean MERS-CoV Superspreading Event).  

While some infected patients do shed more virus than others (see Influenza Transmission, PPEs & `Super Emitters’), it generally takes more than a highly infectious patient to spark an event.  According to Stein’s excellent 2011 review Super-spreaders in infectious diseases:

Super-spreading events are shaped by host, pathogen, and environmental factors. Often, more than one factor may be implicated in the same outbreak.

Although today's Weekly Monitor Report from the Saudis places the KKUH outbreak in the `superspreading' category, it provides relatively few details. Hopefully a more detailed epidemiological report is in the works.

Weekly Monitor

MERS-CoV

Volume 2 Issue 29 Tuesday 26 July 2016
Current Event

MERS Super-Spreading events

The recent outbreak of MERS reported from a university hospital raised the possibility of having a super-spreading events resulting in a larger outbreak.

Super-spreading events were strongly suspected considered in some MERS outbreaks. Certain MERS infected individual may transmits an infection disproportionately to more susceptible contacts, possibly because of increased viral load, heavy respiratory secretions, than the average infected individual.

Super-spreading events constitute the presence of those “highly infectious” individuals in crowded areas like emergency rooms in contact with other patients, healthcare workers and environment. Such events can cause large outbreaks similar to the outbreak in South Korea last year.

During the outbreak of Korea, majority of MERS transmission were linked to super-spreading events. Similarly, the recent nosocomial MERS outbreak in Riyadh (2016) was probably related to a super-spreading event (Figure 1). 

This was also observed in the outbreak of 2013 in Al-Ahsa. Mis-diagnosis or late diagnosis due to co-infection with another pathogen and/or immunosuppression are one of the facets in super-spreading incidents along with individual variation in infectivity and the number of contacts.

It is self-evident, however, that other factors played a role in these incidents. Super-spreading events tied to nosocomial outbreaks of MERS have been attributed in part to suboptimal infection prevention and control (IPC) measures, overcrowded emergency departments (ED), limited isolation rooms in EDs and inadequate ventilation, delayed hospital admission, interhospital transfers, and/or poor communication between healthcare facilities (HCFs).

Super-spreader events are key to amplify nosocomial transmission of MERS and support the Region adoption of IPC precautions particularly in treatment rooms.

It is important to identify such highly infectious individuals and super spreading events through full investigation of the transmission pathways from a single index case to secondary cases in HCFs. 

Rapid case detection and strict adherence to IPC Eastern Region measures, which can rapidly reduce the risk of super-spreading events and therefore the size of the nosocomial outbreaks.

Predicting and identifying super-spreaders open significant medical and public health challenges, and represent important aspects of infectious disease management and emergency preparedness plans. 

Generally, the key to prevent large outbreaks of emerging infectious diseases is through complete preparedness in HCFs and proper collaboration between health and other governmental agencies.

Super spreading events aren’t limited to SARS and MERS, as they have also been documented with measles, HIV, TB, S. aureus, Ebola, and various STDs . . .among others (cite).

While the host and the pathogen are important parts to the equation, the lesson in South Korea is environment and opportunity play huge roles in exacerbating these super spreader events.  

Beyond exposure to a highly infectious host, just last April the Saudi MOH identified a number of other factors behind many of these large hospital outbreaks.

Many of MERS outbreaks originated in the Emergency Department (ED). Almost all MERS outbreaks in HCFs stemmed from one or more of the following factors:

• Inadequate awareness of physicians to the case definition of MERS; 
• insufficient adherence to Infection Prevention and Control (IPC) practices and procedures especially during Aerosol Generating Procedures (AGP), by not wearing proper Personal Protective Equipment (PPE), or performing AGP in rooms with no negative pressure; inadequate implementation of respiratory triaging of cases;
• discharge against medical advice and inadequate communication of such incidents;
• gaps and flaws in the referral mechanism of MERS cases;
•  overcrowded ED and irregular control of entrances;
•  and inadequate control of visitation.

A reminder that - while we can't control the infectivity of patients walking into the emergency room - we can reduce a hospital's ability to spread the virus once they arrive.


For more on what that may take, you may wish to revisit TFAH Issue Brief: Preparing The United States For MERS-CoV & Other Emerging Infections.

 

Two Out-Of-Season H7N9 Cases - Beijing & Henan Province

 Credit WHO

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Over its 4 year history, mid-summer (epi weeks 24-36) has been a dead zone for H7N9 reports coming out of China, with just 5 cases falling within that time span since 2013. Most years, the H7N9 season ends on or around week 20 (mid May).

Although the numbers remain low, the summer of 2016 is proving to be a bit different, as we've continued to see reports of H7N9 activity throughout June and now into late July.

This unseasonable H7N9 activity - including outbreaks in Hong Kong and Macao Live Bird Markets -  last month prompted Hong Kong's CHP to publicly warn:

"In view of additional human cases reported in the Mainland with detections of human cases in previously unaffected areas in warmer months, as well as the recent local positive sample of faecal droppings of live poultry, the public should remain vigilant."

Today we've reports of two recent H7N9 cases, both very much out of season, and one in a province (Henan) that hasn't reported a case since the first wave (April of 2013).



In an epidemiology report for the month of June, they reveal a new case, with an apparent onset on June 9th.  This report is dated July 20th.

June 2016 before the outbreak of notifiable infectious diseases in Henan Province
 
Published: 2016-07-20 

2016 Nian . 6 months (2016 Nian . 6 Yue 1 RiMidnight to. 6 Yue 30 Ri24 ), the province reported a total of notifiable infectious diseases 49366 cases of death 131 cases. 

(SNIP)
 

On June 9, the second people's hospital reported the province, Fuyang city people infected H7N9 avian influenza 1, Zhang, female, 54 years old, farmer, xincai, and as confirmed cases.

In response, today Taiwan's CDC issued the following statement:

City, Henan province, China announced first H7N9 flu cases this year in the province, tourism outbreaks suggest that upgrading to warning (Alert)

County, Henan province, health and family planning Committee in the province first H7N9 flu cases this year, based on local environmental exposure risk, CDC Department announced that promote tourism in the province outbreak Taipei proposed to the second-level alert (Alert), and has notified the Mainland Affairs Council. Frequent cross-strait exchanges and falls during the summer, calls on travel plans to the region and local Taiwanese, be sure to pay attention to personal hygiene and diet, and avoiding contact with poultry and live bird markets in order to reduce the risk of infection.

CDC says the case for 54 years old female farmer, xincai, poultry or live poultry market exposure is not known. China city since to (2015) years autumn yilai cumulative at least 116 cases H7N9 flu cases, this popular quarter outbreak obviously below Qian three quarter, only June announced cases number more Shang quarter slightly increased, and in past no outbreak of provinces found cases; existing evidence displayed H7N9 flu still is limitations people descendants, case more for 50 age above, and with poultry class or live poultry market exposed history.

(Continue . . . )

Hospitalized in Beijing (h/t Sharon Sanders for the Beijing CDC link), we have a new case that has been making headlines in the Chinese media for the past couple of hours.

The city has found a case of human infection with the H7N9 avian influenza

Published: 2016-07-27

July 26, 2016, the city found a case of human infection with H7N9 avian influenza. Accounting for some patients, male, 36 years old, current address Langfang City, Hebei Province Yanjiao a district. In the provinces before the onset of suspicious live poultry exposure history. July 26, the Beijing Municipal Center for Disease Control reviewed detected as H7N9 avian influenza virus nucleic acid positive. Currently, patients are being treated in isolation in a hospital in Beijing, a critical condition.

Up to now, the city has reported 2016 3 H7N9 bird flu cases confirmed cases of human infection. This case is only sporadic cases in the city causing widespread risk of transmission is very low. Although our country there have been cases of avian influenza reported, but now that people are not susceptible to avian influenza virus. Poultry, sale, slaughter, Wildfowl and other people exposed to the virus because the probability of a large increase in the risk of infection.

Currently, etiology characterized H7N9 avian influenza virus transmission and propagation mode currently did not change significantly, China's urban and rural areas live poultry market transactions ubiquitous phenomenon backyard poultry in the short term it is difficult to eliminate. Therefore, it is expected there will still be human infection of H7N9 bird flu epidemic still on distributing state, there will be a small number of clusters of disease.

The city remains the illegal small-scale trading of live poultry and live birds enter the presence of other provinces the situation. Therefore, do not rule out the possibility the city residents infected with H7N9 avian influenza virus. In addition, many medical institutions in the city, a large number of foreign patients to seek treatment for the city, does not exclude foreign imported cases to the city medical institution may be diagnosed.

       (continue . . . )


Hong Kong's CHP hasn't taken notice of either of these cases yet, although I suspect when they do they will reiterate their warning about this uptick in warm weather H7N9 reports.

PNAS: The Enigma Of Disappearing HPAI H5 In North American Migratory Waterfowl

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One of the great unresolved avian flu mysteries is why - after the largest epizootic outbreak in U.S. history over the winter-spring of 2015 - did the virus fail to return the following fall?

The virus arrived in the Pacific Northwest via migratory birds in November of 2014, and ultimately spread to poultry in 15 states, resulting in billions of dollars in losses. 

The expectation was it would appear again last fall with the return of migratory birds, but that didn't happen.  And wild bird detections of HPAI since last summer have been practically nil.


To try explain this unexpected turn of events, we've a study appearing in PNAS (alas, behind a pay wall) - with Robert G. Webster of St. Jude Children's Research Hospital as the corresponding author - that concludes that migratory waterfowl are not a reservoir for highly pathogenic avian flu viruses. 
  

This has significance beyond just further defining the ecology of HPAI, as it validates the choice to employ traditional eradication methods - quarantine, culling and disinfection - rather than rushing to use a poultry vaccine. 

As we've discussed often over the years (see PLoS Bio: Imperfect Poultry Vaccines, Unintended Results & The HPAI Poultry Vaccine Dilemma), despite more than a decade of heavy use, poultry AI vaccines have not proven to be a panacea for avian flu around the world. 

The problem being that poultry vaccines aren’t always 100% effective; sometimes they only mask the symptoms of infection.

That can allow viruses to spread silently among flocks, to continue to reassort and evolve, and potentially lead to new subtypes of avian flu to emerge (see Subclinical Highly Pathogenic Avian Influenza Virus Infection among Vaccinated Chickens, China).


First the link and the abstract from of the study, then some snippets from a press release from St. Jude Children's Research Hospital to fill in the blanks.

The enigma of the apparent disappearance of Eurasian highly pathogenic H5 clade 2.3.4.4 influenza A viruses in North American waterfowl

Scott Kraussa, David E. Stallknechtb, Richard D. Slemonsc, Andrew S. Bowmanc, Rebecca L. Poulsonb, Jacqueline M. Noltingc, James P. Knowlesa, and Robert G. Webstera,1
   
Abstract

One of the major unresolved questions in influenza A virus (IAV) ecology is exemplified by the apparent disappearance of highly pathogenic (HP) H5N1, H5N2, and H5N8 (H5Nx) viruses containing the Eurasian hemagglutinin 2.3.4.4 clade from wild bird populations in North America. 

The introduction of Eurasian lineage HP H5 clade 2.3.4.4 H5N8 IAV and subsequent reassortment with low-pathogenic H?N2 and H?N1 North American wild bird-origin IAVs in late 2014 resulted in widespread HP H5Nx IAV infections and outbreaks in poultry and wild birds across two-thirds of North America starting in November 2014 and continuing through June 2015.

Although the stamping out strategies adopted by the poultry industry and animal health authorities in Canada and the United States—which included culling, quarantining, increased biosecurity, and abstention from vaccine use—were successful in eradicating the HP H5Nx viruses from poultry, these activities do not explain the apparent disappearance of these viruses from migratory waterfowl. 

Here we examine current and historical aquatic bird IAV surveillance and outbreaks of HP H5Nx in poultry in the United States and Canada, providing additional evidence of unresolved mechanisms that restrict the emergence and perpetuation of HP avian influenza viruses in these natural reservoirs.

Public Release: 25-Jul-2016

Evidence suggests migratory birds are not a reservoir for highly pathogenic flu viruses

St. Jude Children's Research Hospital
 

The H5 avian influenza A virus that devastated North American poultry farms in 2014-15 was initially spread by migratory waterfowl, but evidence suggests such highly pathogenic flu viruses do not persist in wild birds. St. Jude Children's Research Hospital led the research, which appears online this week in the Proceedings of the National Academy of Sciences.

While wild ducks and other aquatic birds are known to be natural hosts for low pathogenic flu viruses associated with milder symptoms, the results of this study indicate that is not the case with the highly pathogenic flu viruses that are associated with more severe illness. The research suggests that wild ducks and other aquatic birds are not an ongoing source of highly pathogenic flu infection in domestic poultry.

"The findings provide a scientific basis for the decision by officials to use culling and quarantines to stop the 2014-15 outbreak in domestic poultry," said corresponding author Robert Webster, Ph.D., an emeritus member of the St. Jude Department of Infectious Diseases. "Now, research is needed to identify the mechanism that has evolved in these wild birds to disrupt the perpetuation of highly pathogenic influenza."

In this study, researchers analyzed throat swabs and other biological samples taken from 22,892 wild ducks and other aquatic birds collected before, during and after a 2014-15 H5 flu outbreak in poultry. The outbreak has been linked to a highly pathogenic H5N8 influenza A virus spread from Asia to North America by migratory waterfowl. The H5N8 virus reasserted, or mixed genes, with other influenza viruses in North American waterfowl and went on to trigger 248 flu outbreaks in commercial and backyard turkey and chicken farms in the U.S. and Canada at a cost of nearly $5 billion.

Officials worked to end the outbreaks by quarantining and eliminating infected poultry. The last confirmed case occurred in June 2015. Officials worried that the highly pathogenic virus would be re-introduced into poultry farms by migratory aquatic birds carrying the virus. But none of the migratory birds included in this analysis were infected with a highly pathogenic flu virus. The sampling was conducted in Canada, the Mississippi flyway and along the U.S. Atlantic coast by David Stallknecht and Rebecca Poulson of The University of Georgia and Richard Slemons, Andrew Bowman and Jacqueline Nolting from the The Ohio State University in conjunction with Scott Krauss and James Knowles of St. Jude. The sampling was done as part of the federally funded Centers of Excellence for Influenza Research and Surveillance.

Such viruses have not been identified in any of the more than 100,000 wild birds tested since the flu surveillance sampling began 43 years ago, Webster said. "Existing immunity in wild birds is one of the possible explanations that may explain why highly pathogenic influenza A viruses do not become established in wild bird populations," he said. "But a more complete understanding of the mechanisms at work would aid efforts to prevent, control and eradicate these dangerous viruses in poultry in other areas of the world."

Webster added that while there were no reported human cases of influenza caused by the highly pathogenic flu viruses involved in this outbreak, other related H5 viruses have spread to humans with deadly results.