Confirmation Of Najran MERS-CoV Cluster via ProMed Mail

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Although the Saudi MOH website hasn't been updated in more than two weeks, for the past 3 days FluTrackers and I been following unofficial reports of a cluster of MERS cases in the southern town of Najran, near the Yemen border (see Tuesday's More On The Silence Of The Saudis).

While the details have varied in these reports - citing anywhere from 6 to 12 cases - they all reportedly belonged to a single household.

Today we appear to have confirmation of at least 7 cases following the publication of an email from the Saudi Assistant Deputy Minister for Preventive Health - Abdullah Assiri - by ProMed Mail.

31 May 2018 MERS-CoV (19): Saudi Arabia (NJ) household cluster conf.

Date: 31 May 2018
From: Abdullah Assiri [edited]

MERS update, Kingdom of Saudi Arabia
------------------------
[1] 23 May 2018
New case ID: 18-1711
MERS in Najran city: 45-year-old male living in Najran city, Najran Region.
Date of onset: [17 May 2018]
Date of hospital admission: [20 May 2018]
Diagnosis: MERS pneumonia with ARDS [acute respiratory distress syndrome], critical
Contact tracing: 11 household contacts listed for follow-up
Contact with camels and consumption of raw milk.
Ministry of Agriculture has been informed, and investigation of camels is ongoing.
Case classification: community acquired/primary

[2] 27 May 2018
New case ID: 18-1712
MERS in Najran city: 39-year-old male living in Najran city, Najran Region.
Date of onset: [22 May 2018]
Date of hospital admission: [25 May 2018]
Diagnosis: MERS URTI [upper respiratory tract infection], stable
Case classification: community acquired/secondary (household to 18-1711)

[3] 28 May 2018
New case ID: 18-1713
MERS in Najran city: 46-year-old male living in Najran city, Najran Region.
Date of onset: [26 May 2018]
Date of hospital admission: [27 May 2018]
Diagnosis: MERS URTI, stable
Case classification: community acquired/secondary (household to 18-1711)

[4] 28 May 2018
New case ID: 18-1714
MERS in Najran city: 19-year-old male living in Najran city, Najran Region.
Date of onset: [26 May 2018]
Date of hospital admission: [27 May 2018]
Diagnosis: MERS URTI, stable
Case classification: community acquired/secondary (household to 18-1711)

[5] 29 May 2018
New case ID: 18-1715
MERS in Najran city: 28-year-old male living in Najran city, Najran Region.
Date of onset: [27 May 2018]
Date of hospital admission: [28 May 2018]
Diagnosis: MERS URTI, stable
Case classification: community acquired/secondary (household to 18-1711)

[6] 29 May 2018
New case ID: 18-1716
MERS in Najran city: 31-year-old male living in Najran city, Najran Region.
Date of onset: [27 May 2018]
Date of hospital admission: [28 May 2018]
Diagnosis: MERS URTI, stable
Case classification: community acquired/secondary (household to 18-1711)

[7] 30 May 2018
New case ID: 18-1717
MERS in Najran city: 52-year-old male living in Najran city, Najran Region.
Date of onset: [27 May 2018]
Date of hospital admission: [28 May 2018]
Diagnosis: MERS URTI, stable
Case classification: community acquired/secondary (household to 18-1711)

--
Abdullah Assiri
Assistant Deputy Minister for Preventive Health
Kingdom of Saudi Arabia


[ProMED-mail would like to thank Dr. Abdullah Assiri for clarifying the information from the media report we posted yesterday (30 May 2018) (see MERS-CoV (18): Saudi Arabia (NJ) susp. family cluster, RFI 20180530.5829389). According to the official records provided by Dr. Assiri, there is an ongoing household cluster of MERS-CoV infection in Najran involving a primary case (case No. 1 above), a 45-year-old male from Najran, currently in critical condition, with a history of direct contact with camels and raw camel products (milk) and 6 additional contacts in stable condition with symptoms of an acute upper respiratory tract infection out of 11 identified household contacts.

This cluster is occurring in Najran, the capital city of the Najran region, located in the southwest of Saudi Arabia. The region shares a border with Yemen.

Tapping Into Your Preps

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Yesterday Oregon Emergency Management officials issued the above advice after the local water supply was contaminated by a toxic algae bloom, making tap water unsafe to drink for children, the immunocompromised, and others.

Within hours, store shelves were stripped of bottled water and other supplies (see AP story & photo Cryptic emergency alert panics Oregon city's residents), as thousands of Oregonians found themselves caught without even the most basic of supplies; drinking water.

This crisis, and the public's reaction, are almost identical to what we've seen in the past  along the shores of Lake Erie (see Water, Water, Everywhere But Not A Drop To Drink).

Toxic algae - which is present in small quantities in most fresh water lakes - blooms during the summer (when temps are warm, sunlight is abundant, and winds are generally light)  – particularly when fed by nutrient rich fertilizer (or other pollutant) run offs. 

The advice to the public to use their `2 Weeks Ready water supplies' to help get through this crisis is, of course, of little help to those who failed to prepare in advance, but may spur them on to becoming better prepared for the next emergency.

The operative word being `may', because as I recounted last year during the approach of hurricane Irma to Florida - a state hit with some regularity by major storms - store shelves had been stripped of bottled water, flashlights, batteries, radios, and other hurricane supplies a full 5 days before the storm arrived.

Despite the strong likelihood of a hurricanes, and yearly preparedness campaigns, people - for reasons that baffle me - rarely prepare for an emergency - even in Hurricane Alley.

While Oregonians have nothing to fear from hurricanes, they all live in a seismically active region - one that could produce a much larger earthquake and tsunami than the San Andreas fault in California. 

It's a disaster scenario we've looked at several times in the past - including in 2011's  Just A Matter Of Time, and 2015's  OSU: Pragmatic Action - Not Fatalism - In Order To Survive The `Big One’ - and one that FEMA  and local Emergency Management take very seriously (see FEMA: Cascadia Rising 2016).

For this reason - and for lesser emergencies - the Oregon Office Of Emergency Management promotes a 2 Weeks Ready campaign.  Note, the goal is for citizens to be prepared to be on their own for a minimum of two weeks following a disaster.

2 Weeks Ready

A large earthquake and tsunami will demolish parts of western Oregon and leave much of the area's transportation routes destroyed. Oregonians will need to count on each other in the community, in the workplace, and at home in order to be safe until help can arrive. This is just one reason why OEM encourages people to be prepared to be on their own for a minimum of two weeks following a disaster. We've created a wide variety of two weeks ready resources, and recently launched a series of fun and friendly animated videos.

It doesn't take a mega-earthquake, Cat 5 hurricane, asteroid strike, or pandemic to ruin your entire day.  Infrastructures fail and floods, fires, even industrial accidents can disrupt your daily supply of goods and services.

If you aren't prepared in advance to handle a few days without potable (or any) tap water,  or to endure an extended power outage (summer or winter), you - and your loved ones - are unlikely to fare very well during a major disaster. 

While you may not live along the coastline, or in tornado alley, or in a seismically active region of the country, there is probably not a speck of ground where you can't be impacted by a disaster.  Some places are higher risk than others, but no place is immune.

While FEMA and other agencies urge at least 72 hours worth of preparedness, in truth, if you have less than 10 to 14 days worth of food, water and supplies, you and your family are in for a very rough time should a major disaster strike.

Salem Oregon's water crisis will likely be short-lived, and no one is apt to die for lack of water. But the next disaster there - or anyplace else on the planet - could come with little or no warning, and be both prolonged and deadly. 

You need to ask yourself . . . if a disaster struck your community today, do you already have?

• A battery operated NWS Emergency Radio to find out what was going on, and to get vital instructions from emergency officials
• A decent first-aid kit, so that you can treat injuries
• Enough non-perishable food and water on hand to feed and hydrate your family (including pets) for the duration
• A way to provide light when the grid is down.
• A way to cook safely without electricity
• A way to purify or filter water
• A way to stay cool (fans) or warm when the power is out.
• A small supply of cash to use in case credit/debit machines are not working 
• An emergency plan, including meeting places, emergency out-of-state contact numbers, a disaster buddy,  and in case you must evacuate, a bug-out bag and a predetermined place to go. 
• Spare supply of essential prescription medicines that you or your family may need
• A way to entertain yourself, or your kids, during a prolonged blackout

If your answer is `no’, you have some work to do.  A good place to get started is by visiting Ready.gov.

You may also wish to revisit some of my preparedness blogs:

When 72 Hours Isn’t Enough

In An Emergency, Who Has Your Back?

#NatlPrep: The Gift Of Preparedness 2017

NEJM: Gates On Innovation For Pandemics

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On this 100th anniversary of the worst pandemic in recorded history, and the 50th anniversary of the 1968 H3N2 pandemic, it is no surprise that we're hearing a lot of talk about the `next pandemic'. 

But it is more than just the calendar that has scientists worried.  There are other factors which make another - possibly severe - pandemic increasingly likely.

The first is how the world has changed over the past 10 decades.  We are now a highly mobile society, with literally millions of international travelers in the air on any given day. While a trip from England to New York City might have taken 5 days (via ocean liner) in 1918, today it can be done in just under 8 hours.

An infected, but pre-symptomatic, international traveler 100 years ago would likely have fallen ill before reaching their destination, while today that passenger would have a very good chance of carrying an incubating virus undetected to almost any corner of the earth. 

But it isn't just people being moved, it is farm animals as well. 

Unlike 50 years ago, pork is no longer a locally produced product of small family farms. Commercial pigs are often mass raised in one region, shipped off to a corn belt' area to be fattened, and often transported again someplace else to be slaughtered. 

Internationally, live hogs are often shipped for breeding purposes, to inject genetic diversity into local herds to improve the breed.

And hitching a ride are frequently H1, H2, and H3 swine flu viruses - which, while endemic in pigs around the globe - have significant genetic diversity across the world (see Trans. & Emerg. Dis.: Appearance Of Reassortant European Avian‐origin H1 influenza A viruses in Swine - Vietnam).

This move from small farms to large commercial operations has also helped to turn LPAI (low path avian influenza) viruses - which are ubiquitous and largely harmless in wild birds - into HPAI (highly pathogenic) avian flu strains in poultry.

Also, as we've discussed often in the past, we've seen a huge rise in the number of zoonotic emerging diseases, other than influenza.  SARS, MERS-CoV, Zika, Ebola, Marburg, SFTS, Nipah,  . . . .  the list goes on. 

For a deeper discussion on why this appears to be happening, you may wish to revisit 2016's  The Third Epidemiological Transition,which looks at the work of the late  anthropologist and researcher George Armelagos of Emory University.

The gist of  his theory, however, is that the world has entered into an age of newly emerging infectious diseases, re-emerging diseases and a rise in antimicrobial resistant pathogens.

So far, given the events of the past 40 years, it has been hard to argue against it. 

And as technology grows, the ability of `bad actors'  to create engineered pathogens becomes both easier and cheaper, and no longer requires the deep pockets, security apparatus and expertise of a nation state. 

We saw this ominously depicted earlier this month in the Johns Hopkins Clade X exercise, where a genetically altered Nipah virus (spliced onto a parainfluenza backbone) was the cause of their fictional pandemic. 

All of which brings us to a Perspective Article penned by Bill Gates and published today in NEJM, which looks at the unique pandemic challenges of this 21st century, and some of the innovations (both existing, and under development) which will be needed to combat the next global health crisis.

Follow the link below to read the full article.

Perspective 

Shattuck Lecture

Innovation for Pandemics

Bill Gates

UK Heatwave Plan & Excess Mortality Due To Elevated Ambient Temperatures

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While it likely comes as a surprise to many people, the biggest weather-related killer in the United States each year isn't hurricanes, tornadoes, lightening, floods or blizzards . . .  but rather heat waves.

Excessive heat has likely killed more Americans over the past 50 years than all of the tornadoes, floods, and hurricanes combined.

In 2002 Rupa Basu and Jonathan M. Samet wrote in the Journal Epidemiological Reviews (see Relation between Elevated Ambient Temperature and Mortality: A Review of the Epidemiologic Evidence): 

An average of 400 deaths annually are counted as directly related to heat in the United States, with the highest death rates occurring in persons aged 65 years or more (3). The actual magnitude of heat-related mortality may be notably greater than what has been reported, since we do not have widely accepted criteria for determining heat-related death (4, 5–7), and heat may not be listed on the death certificate as causing or contributing to death. 

This disparity between counted and estimated heat-related deaths can be illustrated by the reports from the infamous heat wave of 1980, which `officially’ claimed `more than 1250 lives’ (cite NOAA Heat Wave: A Major Summer Killer) but which unofficially may have killed as many as 10,000  (Tracking and Evaluating U.S. Billion Dollar Weather Disasters, 1980-2005 (Lott and Ross, 2006). 

Eight years later, a heat wave across the central and eastern part of the nation killed as many as 7,500 people (cite). More recently, in 1999, a prolonged heat wave along the Eastern seaboard is believed to have killed 500 (cite).

The situation in Europe, Asia, and elsewhere around the world can be equally dire - and between climate change, growing urban populations, and increasingly fragile infrastructure - the public health threat from prolonged heat waves is only expected to rise.

In 2015 the WMO (World Meteorology Organization) and the WHO (World Health Organization) issued new guidance on Heat Health Warning systems. From the press release:

WMO, WHO Issue Guidance on Heat Health Warning Systems

News
1 July 2015

Geneva 1 July 2015 (WMO) The World Meteorological Organization (WMO) and the World Health Organization (WHO) have issued new joint guidance on Heat–Health Warning Systems to address the health risks posed by heatwaves, which are becoming more frequent and more intense as a result of climate change.

“Heatwaves are a dangerous natural hazard, and one that requires increased attention,” said Maxx Dilley, Director of WMO’s Climate Prediction and Adaptation Branch, and Maria Neira, Director of WHO’s Department of Public Health, Environmental and Social Determinants of Health. “They lack the spectacular and sudden violence of other hazards, such as tropical cyclones or flash floods but the consequences can be severe.”

Over the past 50 years, hot days, hot nights and heatwaves have become more frequent. The length, frequency and intensity of heatwaves will likely increase over most land areas during this century, according to the Intergovernmental Panel on Climate Change. In addition to the health impact, heatwaves also place an increased strain on infrastructure such as power, water and transport.

       (Continue . . . )


The UK has updated their Heatwave Guidance plan (see excerpt below), and it is a good reminder as we go into the Northern Hemisphere's summer of the importance of preparing to deal with heat waves.

First a link and an excerpt, then I'll return with more.

Heatwave plan for England

Ref: Ref: PHE publications gateway number 2015049 PDF, 1.65MB, 43 pages

 
Executive summary

The Heatwave plan for England is a plan intended to protect the population from heat-related harm to health. It aims to prepare for, alert people to, and prevent, the major avoidable effects on health during periods of severe heat in England.

It recommends a series of steps to reduce the risks to health from prolonged exposure to severe heat for:

•     the NHS, local authorities, social care, and other public agencies
•     professionals working with people at risk
•     individuals, local communities and voluntary groups

The heatwave plan has been published annually since 2004, following the devastating pan- European heatwave in 2003. This year’s plan builds on many years of experience of developing and improving the ability of the health sector and its partners to deal with significant periods of hot weather.

(Continue . . . )

While rarely mentioned, modern building architecture and home design often contribute to heat related deaths. Many windows no longer open, ceilings are lower, overhangs shorter, and temperature control is nearly completely dependent upon high tech equipment and a steady supply of electricity.

Following Hurricane Irma last September in Florida, I - along with millions of other Floridians - were without electrical power for days.  According to press reports, at least a dozen people died due to heat-related complications at one Florida nursing home.   

How many others succumbed around the state is unknown.   

While less is known about the particulars, yesterday's NEJM carried a statistical analysis (Mortality in Puerto Rico after Hurricane Maria) suggesting that 4645 excess deaths occurred in the 3 months following the storm.

It is a pretty good bet that some number of those were heat related.

Living in Florida, included in my Hurricane/General Disaster preparedness plan are ways to cope with the heat when the power grid is down.

First and foremost, I have water.  Lots of water.  Enough stored to last a month for myself, and my cat.  If the power is out, water (and sewer) services are often not far behind.

But I also have several solar panels (see Rethinking Solar Power On A Budget), including several small ones suitable for a bug out bag.  An excerpt from that post-Irma blog:

I've just started my conversion over to 5 volt solar charging (and I'll keep my old system, since it still works), so I'm hardly an expert. The most basic system (see photo below) can be put together for about $40.

A 10,000 milliamp battery with (3 fold) solar panal, a USB fan, and USB LED light.

The beauty of this system is it will fit in a backpack, weighs about 2 lbs, and while the solar charging will be slow and you'll have to be judicious with their use, it should keep phones, lights, MP3 players, and fans going for a few days.  Longer if you don't need the fan.

For under $100 you can buy a couple of bigger power bricks, and a much larger solar panel (20 watts plus), which will increase your capabilities significantly. That will be my next step.

Lest anyone think these sorts of preps are only important for those of us who live along the coastline during Hurricane season, in the summer of 2012, a powerful Derecho swept across the Mid-Atlantic states (see Picking Up The Pieces), killing 15 and leaving nearly 4 million people without power, some for more than 2 weeks.

While 15 people died during the storm, at least 32 died of heat-related illnesses in the two weeks that followed (see 2013 MMWR Heat-Related Deaths After an Extreme Heat Event — Four States, 2012, and United States, 1999–2009).

During any disaster, the most likely large-scale impact with be prolonged power outages, and with that can come many challenges, not the least of which include  heat-related illnesses and deaths. 

Being prepared - in advance - to deal with these types of threats can mean the difference between days or weeks of misery and relative comfort, and sometimes the difference between life and death.

For more on general preparedness, you may wish to revisit:

When 72 Hours Isn’t Enough

In An Emergency, Who Has Your Back?

#NatlPrep: The Gift Of Preparedness 2017

More On The Silence Of The Saudis

Screen shot From Saudi MOH MERS Page

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For the past several hours I've been trying to track down - without success -  some kind of official response to multiple unconfirmed Arabic media (and social media) reports of a large household outbreak of MERS-CoV in the Southern KSA town of Najran. 

As we discussed yesterday , in WHO: UAE MERS-CoV Case & IHR Concerns, the Saudi MOH last updated their MERS Surveillance page on May 15th, and since then has removed all daily reports since February 23rd (see screenshot at the top of this blog).

While we haven't heard any reasons behind this recent halt in reporting or the removal of data from the MOH site, over the past few months daily reports on MERS activity from KSA have become increasingly erratic (see EMRO MERS-CoV Summary - April).

The Holy month of Ramadan, during which hundreds of thousands of religious pilgrims visit the Holy Cities of Saudi Arabia, began around the time their MOH website went silent (May 16th), and will run through mid-June.  It will be followed by the Hajj in the third week of August. 

Although press freedoms are sharply curtailed in Saudi Arabia (listed by Reporters Without Borders as 169th of 180 Countries), we do see some independent press reports get out.

It is also true that we've seen some less-than-reliable reporting in the past - and a good deal of `echo chambering' of unverified stories, particularly on social media - making it very difficult to assess the validity of many of these reports.

And that is the quandary we find ourselves in today. 

While we've no official word from the Saudi MOH website and nothing from the official Saudi Press Agency, we have multiple unconfirmed media reports of a large (the numbers vary from 6 to 12 people) household outbreak of MERS-CoV in Najran.

Typical of the twitter traffic this afternoon surrounding this story is the following tweet from Najran Today.

  A (translated) report this afternoon from Sabq.org  reads:

Health" for "already": 6 injured people from the same family as the "Corona" in Najran

Private sources for "already" wounded six people infected with "Corona" explained which was confirmed by the Ministry of Health represented by the General Administration of communication and relationships and awareness in response to an inquiry "above", where indicated that it was diagnosed in Najran emerged outcome positive, and was immediately transferred to Riyadh via dedicated to infectious diseases Air ambulance.

It's "already": The characters on the family home by Health Affairs in Najran region, represented by a specialized medical team from the Department of Public Health as soon as the result was the work of all necessary procedures from an epidemiological survey, and an inventory of all contacts and Mnazerthm and provide health education, and are followed and communicate with them on a daily basis, according to the approved protocol such cases.

She continued:

She added, has been shown to the Ministry of Health that the family has a farm in Najran, a number of camels heads, and had been reported to the Ministry of Environment and Water and Agriculture to take preventive measures.

There are other reports, going back nearly 24 hours, listing either 6, 8, or even 12 cases - although it isn't clear whether all of them were actually symptomatic, or whether some were simply household members or close contacts being tested.

Whether these reports are accurate, or are simply the result of the fact that the Internet abhors a news vacuum, is the $64 question.

But real or not, this is what happens whenever a government - any government - shuts down their reporting on disease outbreaks.  We've seen similar news blackouts in Egypt, China, and Indonesia - with similar results.

With the power an anonymity of the Internet - something resembling the truth, or sometimes just flat out rumors and lies - will always take their place. 

Either way, nothing is gained and a great deal is lost by officials not getting ahead of a story.  Unfortunately that is a lesson that many governments around the world still haven't managed to learn.

I've talked to Sharon Sanders at FluTrackers, and they are monitoring the situation as well.  Hopefully we'll get some clarification on these reports sooner than later.

WHO: UAE MERS-CoV Case & IHR Concerns

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Although I don't find any formal announcement on the UAE Health Authority website, today the World Health Organization is reporting (see below) on a single UAE MERS case with illness onset on May 4th, although that isn't the only news of note provided by this WHO update.

As we've discussed frequently over the past few months, reporting on MERS cases out of Saudi Arabia suddenly became more erratic last January, with `daily MOH updates' often posted belatedly, days skipped entirely, or posted with conflicting details.

Although we've had some WHO EMRO monthly summaries (see here, here, and here), we've not seen a WHO DON report (with case line listing) out of Saudi Arabia since late January, making this the longest reporting gap by the WHO since the virus emerged in 2012.

While an updated line listing of MERS cases is included in today's update, no new Saudi Cases have been added since the middle of January (see screenshot below). 

The total number of cases reported in today's update has increased by 64 since the January 26th report, which when you deduct the UAE and Oman cases, suggests an increase in Saudi Arabian of 62 MERS cases.

Details on those cases, however, remain curiously unavailable through the WHO DON reports.

First today's update, then I'll return with a bit more on the IHR and this dearth of data from KSA.

Middle East respiratory syndrome coronavirus (MERS-CoV) – United Arab Emirates

Disease outbreak news
28 May 2018

On 16 May 2018, the National IHR Focal Point of the United Arab Emirates (UAE) reported one (1) laboratory-confirmed case of Middle East Respiratory Syndrome (MERS-CoV) infection to WHO.

Details of the case

The case is a 78 year old, male national, residing in Gayathi, UAE. On 13 May 2018, the patient presented to a hospital in Abu Dhabi with fever, cough and shortness of breath, which began on 4 May 2018. A lower respiratory/nasopharyngeal sample was collected on 14 May 2018 and tested positive for MERS-CoV by reverse transcription polymerase chain reaction (RT-PCR) at the Sheikh Khalifa Medical Centre laboratory. He is currently in stable condition in hospital. The patient has hypertension and interstitial lung disease as underlying conditions. Investigation into the source of infection is ongoing. The patient reported recent travel to the Kingdom of Saudi Arabia and he owns a camel farm in UAE, which he visits on daily basis.

Globally, 2207 laboratory-confirmed cases of MERS-CoV, including 787 MERS associated deaths have occurred since September 2012. The global number reflects the total number of laboratory confirmed cases reported to WHO under IHR to date. The total number of deaths includes the deaths that WHO is aware of since 2012 through follow-up with affected member states. For more information, see link below.

    MERS-CoV case reported on 23 August 2017
    xls, 230kb

Public health response

Contacts of the confirmed patient have been identified and are being monitored for the appearance of symptoms for 14 days from the last exposure to the confirmed patient. The Communicable Disease Department in UAE is in coordination with the animal authorities to initiate camel testing at the patient’s farm in UAE.

(Continue . . . )

  
After three months of erratic reporting on the KSA Health Ministry website, the surveillance page - which appears to be under redesign - has become static, and all data after January 23rd 2018 is currently missing.


While the lack of daily MERS updates is disappointing, the Saudis are under no obligation to post them.  In recent years we've seen many other countries (China, Egypt, Indonesia, etc.) pull back from making detailed public announcements on infectious disease cases.

But under the terms of the 2005 IHR (International Health Regulations) - WHO member countries have agreed to develop mandated surveillance and testing systems, and to report certain disease outbreaks and public health events to WHO in a timely manner. 

Thirteen years after it was approved, fewer than half the countries of the world self-report having met the core requirements of the IHR. But even among those who have - timely reporting continues to be problematic for a variety of political, economic, and societal reasons.

 
While public chastisement is rare in diplomatic circles, in the past few years we've seen signs of growing frustration over the lack of progress on the IHR, including:

• In January of 2017, amid initial reports of a surge in H7N9 cases in China (see WHO DIrector-General Chan On H7N9 In China), the D-G once again urged that all countries promptly report cases under the IHR 2005 agreement.
• In 2015, the World Health Organization issued a particularly strong rebuke (without singling out the Saudis) on the reporting of MERS-CoV and the handling of asymptomatic cases in their WHO Statement On The 10th Meeting Of the IHR Emergency Committee On MERS.
• Also in 2015, in the wake of the slow international response to the West African Ebola Epidemic, we looked at proposals to add some `teeth' to the IHR (see Adding Accountability To The IHR).

Since the Saudis and the WHO have not publicly addressed the lack of reporting (publicly or through the IHR), we don't know what is behind this recent lack of case details in the WHO reports.  Hopefully those details will be released soon.

But the bigger picture is that the slow progress by many countries in reaching the core goals of the IHR, and the continued gaps in reporting, undermine our ability to detect and react to infectious disease threats around the world.

With the number of disease threats (natural and potentially man-made) facing the globe, this is not an enviable position to be in.

As the WHO IHR infographic above reminds us, `Until all sectors are on board with the IHR, no country is ready'.  

Influenza & Other Resp. Viruses.: Airborne & Fomite Detection of Avian H7N2 - NYC 2016

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Nearly 18 months ago (Dec 15th, 2016) the New York City Health Department issued an unusual Statement On Avian H7N2 In Cats at a Manhattan animal shelter.

While cats are known to be susceptible to some novel  flu strains (see Catch As Cats Can) this outbreak was remarkable due to its size (initially involving 45 cats), its location (NYC), and the virus involved - a relatively uncommon avian LPAI H7N2 virus not reported in the United States in over a decade. 

Over the holidays the story continued to escalate when the NYC DOH released a statement announcing a mild Human H7N2 Infection in a veterinarian who was treating sick cats.  Additionally, more than 400 cats - across multiple facilities - were said to have been infected. 

Although the risk to human health was believed low, the Health Department offered guidance to those who have had contact with cats in these shelters, and urged people to avoid `nuzzling and close facial contact' with sick cats.

Human infection with LPAI H7N2 has only rarely been reported, with only a couple of cases  on record in the United States (in 2002 and 2003), and 4 people who were presumed to have been infected in the UK in 2007 following local outbreaks in poultry.

In all cases, illness was described as mild and self limiting.

While only one human infection was reported, and the incident was declared over by late January, this was a bit of a wake up call on the potential spread of a zoonotic avian flu virus by a companion animal.

At the time, the CDC wrote:

Why is CDC concerned about H7N2?

As part of CDC’s mission to protect the public from emerging health threats, CDC monitors changes in flu viruses found in human and animal populations. Finding a bird flu virus in an unexpected animal, like a cat, is always concerning, because it means the virus has changed in a way that may pose a new health threat. Animal viruses that gain the ability to infect humans are especially concerning because most people will not have existing immune protection against such viruses.

Also, there is potential for a pandemic (a global outbreak of disease) to occur when a new animal virus gains the ability to infect humans and also has the ability to spread efficiently from person to person. For these reasons, these incidents must be carefully investigated and appropriate actions taken to ensure that there is no ongoing spread of the novel virus among people.

Since then, we've learned a good deal more about the H7N2 virus, including:

• Last May, in J. Virology: Virulence Of A Novel H7N2 Virus Isolated From Cats In NYC - Dec 2016,  we saw a follow up report on the NYC outbreak, which found the H7N2 virus will require additional adaptation before it poses a substantial human health threat.   
• Last November, in EID Journal: Avian H7N2 Virus in Human Exposed to Sick Cats,we saw another study that found the human H7N2 virus bound to both α2,6-linked (mammalian) and α2,3-linked (avian) sialic acids, an important trait for any species jumping avian flu virus to acquire, although virulence remained low.
• Followed by EID Journal: Characterization Of A Feline Influenza A(H7N2) Virus last December, which found:

Direct contact transmission of feline H7N2 subtype viruses was detected in ferrets and cats; in cats, exposed animals were also infected via respiratory droplet transmission. These results suggest that the feline H7N2 subtype viruses could spread among cats and also infect humans. Outbreaks of the feline H7N2 viruses could, therefore, pose a risk to public health.

All of which serves as prelude to a new study, published last week in the journal Influenza & Other Respiratory Viruses, which documents both the airborne and fomite detection of the avian H7N2 virus at the quarantine facility where roughly 500 infected cats were housed.

You'll want to read the full (open access) PDF, but I've excerpted the abstract below.  When you return, I'll have a postscript.

Detection of an Avian Lineage Influenza A(H7N2) Virus in Air and Surface Samples at a New York City Feline Quarantine Facility

Francoise M. Blachere,William G. Lindsley, Angela M. Weber,Donald H. Beezhold,Robert E. Thewlis,Kenneth R. Mead,John D. Noti

First published: 16 May 2018

Background

In December 2016, an outbreak of low pathogenicity avian influenza (LPAI) A(H7N2) occurred in cats at a New York City animal shelter and quickly spread to other shelters in New York and Pennsylvania. The A(H7N2) virus also spread to an attending veterinarian. In response, 500 cats were transferred from these shelters to a temporary quarantine facility for continued monitoring and treatment.

Objectives

The objectives of this study was to assess the occupational risk of A(H7N2) exposure among emergency response workers at the feline quarantine facility.

Methods

Aerosol and surface samples were collected from inside and outside the isolation zones of the quarantine facility. Samples were screened for A(H7N2) by quantitative RT‐PCR and analyzed in embryonated chicken eggs for infectious virus.

Results

H7N2 virus was detected by RT‐PCR in 28 of 29 aerosol samples collected in the high‐risk isolation (hot) zone with 70.9% on particles with aerodynamic diameters > 4 μm, 27.7% in 1‐4 μm, and 1.4% in < 1 μm. Seventeen of 22 surface samples from the high‐risk isolation zone were also H7N2‐positive with an average M1 copy number of 1.3 x 103. Passage of aerosol and surface samples in eggs confirmed that infectious virus was present throughout the high‐risk zones in the quarantine facility.

Conclusions

By measuring particle size, distribution, and infectivity, our study suggests that the A(H7N2) virus had the potential to spread by airborne transmission and/or direct contact with viral‐laden fomites. These results warranted continued A(H7N2) surveillance and transmission‐based precautions during the treatment and care of infected cats.

While the avian H7N2 virus - at least as a human health threat - doesn't appear particularly robust, this study found concentrations of airborne virus in the quarantine facility's `hot zone' roughly equivalent to what has been previously documented in several health care facilities during an H1N1 influenza season.

And roughly 25% were `respirable'; light enough to remain airborne for a extended period of time and small enough to be easily drawn deeply into the lungs when inhaled.

The authors wrote:

Thus, our results support both airborne and fomite-mediated A(H7N2) transmission as potential transmission routes amongst cats. Because the deposition site of any respiratory pathogen within the airway ultimately affects disease kinetics and pathogenesis, transmission-based precautions were pivotal to protecting quarantine staff and volunteers.

For more on the potential for companion animals to serve as an intermediate host for influenza viruses with pandemic potential, you may wish to revisit:

Emerg. Microbes & Inf.: Genetic & Evolutionary Analysis of Emerging Canine H3N2

Emerg. Microbes & Infect.: Virulence, Transmissibility & Evolution of Canine H3N2 Influenza Viruses

PLoS One: Evidence of Subtype H3N8 Influenza Virus Infection among Pet Dogs in China

Korean CDC Statement On H5N6 In Cats

NOAA 2018 Tropical Outlook: A Near or Above Normal Hurricane Season Expected

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With a disturbed area of weather over the Yucatan now given a 90% chance of developing into a tropical system over the weekend as it moves slowly north into the Gulf of Mexico, yesterday afternoon NOAA released their 2018 Atlantic Hurricane Season Outlook.

And while not a specific forecast, it is not what storm weary residents of Puerto Rico, Texas, and Florida wanted to hear.

Some excerpts from yesterday's press release, then I'll return with a bit more.

Forecasters predict a near- or above-normal 2018 Atlantic hurricane season

New satellite data and model upgrades to give forecasts a boost

May 24, 2018 NOAA’s Climate Prediction Center is forecasting a 75-percent chance that the 2018 Atlantic hurricane season will be near- or above-normal.

Forecasters predict a 35 percent chance of an above-normal season, a 40 percent chance of a near-normal season, and a 25 percent chance of a below-normal season for the upcoming hurricane season, which extends from June 1 to November 30.

“With the advances made in hardware and computing over the course of the last year, the ability of NOAA scientists to both predict the path of storms and warn Americans who may find themselves in harm’s way is unprecedented,” said Secretary of Commerce Wilbur Ross. “The devastating hurricane season of 2017 demonstrated the necessity for prompt and accurate hurricane forecasts.”

NOAA’s forecasters predict a 70-percent likelihood of 10 to 16 named storms (winds of 39 mph or higher), of which 5 to 9 could become hurricanes (winds of 74 mph or higher), including 1 to 4 major hurricanes (category 3, 4 or 5; with winds of 111 mph or higher). An average hurricane season produces 12 named storms, of which 6 become hurricanes, including 3 major hurricanes.

(SNIP)

In addition to the Atlantic hurricane season outlook, NOAA also issued seasonal hurricane outlooks for the eastern and central Pacific basins. An 80 percent chance of a near- or above-normal season is predicted for both the eastern and central Pacific regions. The eastern Pacific outlook calls for a 70-percent probability of 14 to 20 named storms, of which 7 to 12 are expected to become hurricanes, including 3 to 7 major hurricanes. The central Pacific outlook calls for a 70-percent probability of 3 to 6 tropical cyclones, which includes tropical depressions, tropical storms and hurricanes.

NOAA will update the 2018 Atlantic seasonal outlook in early August, just prior to the peak of the season.

        (Continue . . . )
 
 
While these tropical outlooks don't always pan out, as a native Floridian, I take the threat seriously.  Many hurricanes don't measure up to the hype, but the ones that do (think: Katrina, Andrew Camille, Donna . . . ), often exceed expectations.

And as they say, it only takes one hitting where you live or work, to have a major impact on your life.

Currently the National Hurricane Center is watching what could become the first tropical system of the season (see below), possibly impacting the Gulf coast later this weekend into the early part of next week.

While likely mostly a heavy rainmaker, it is possible this system could become a tropical storm or even a minimal hurricane. Residents along the Gulf coast should remain vigilant, and follow the NHC's and any local Emergency Management guidance.


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.

If you are on Twitter, you should also follow, @NHC_Atlantic, @NHC_Pacific,  @FEMA  and @ReadyGov

And if you haven't started your 2018 hurricane preparedness, I'd invite you to revisit Tuesday's blog and  Hurricane Preparedness Week 2018 (May 6th - May 12th).

HK CHP Urges Heightened Vigilance As EV71 Cases Rise

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Non-polio Enteroviruses (NPEV's) - of which there are dozens - typically spread in the summer and early fall, and generally produce mild or even asymptomatic infections, mostly in children under the age of 10.

Symptomatic cases can range from a mild fever or a runny nose - to HFMD (Hand Foot Mouth Disease) - a generally mild childhood disease characterized by blisters on the hand, feet, and mouth.

In North America HFMD is usually caused by the Coxsackie A16 virus, or less commonly, the Coxsackie A10 virus. In recent years, we’ve also seen the emergence of the Coxsackie A6 virus (see MMWR: Coxsackievirus A6 Notes From The Field) which has been associated with more severe illness.

For several decades - particularly in Asian and Western Pacific nations - we've monitored yearly NPEV epidemics of a much more serious nature, with the most severe illness linked to Human Enterovirus 71 (EV-71), which can cause a polio-like paralysis, and sometimes even death.

Other NPEV's, including EV-D68 and Coxsackievirus A6 are also linked to more severe disease.  But in terms of the number of severe cases, EV-71 is currently the biggest threat.

Yesterday Hong Kong's CHP released their latest EV Scan (Week 21, May 24, 2018), which shows a sharp uptick in the number of EV71 cases in the region during the month of May.
 

EVSCAN (Week 21)
As of May 24, 2018

EV SCAN is a weekly report produced by the Enteric and Vector-borne Disease Office of the Centre for Health Protection, Department of Health. It summarises the surveillance findings of local situation of hand, foot and mouth disease (HFMD) and enterovirus 71 (EV71) infection.

HIGHLIGHTS

• The activity of hand, foot and mouth disease (HFMD) is increasing in Hong Kong
• In Hong Kong, the usual peak season for HFMD and EV71 infection is from May to July. A smaller peak may also occur from October to December.
• HFMD is a common disease in children usually caused by enteroviruses such as Coxsackieviruses and EV71. EV71 infection is of particular concern as it is more likely to be associated with severe medical complications and even death.

Today the CHP issued the following statement:
 

Heightened vigilance urged amid increasing activity of hand, foot and mouth disease and enterovirus 71 infection

The Centre for Health Protection (CHP) of the Department of Health today (May 25) urged the public to maintain strict personal and environmental hygiene as the local activity of hand, foot and mouth disease (HFMD) and enterovirus (EV) 71 infection has been increasing in the past two weeks.

According to the CHP's surveillance data, the number of institutional HFMD outbreaks recorded increased from five (affecting 23 persons) to 14 (affecting 60 persons) from the week of May 6 to that of May 13. As of yesterday (May 24), 15 outbreaks involving 59 persons had been reported this week. In the last four weeks, most outbreaks occurred in kindergartens and child care centres as well as primary schools.
 
As for EV71 infection, while only one case of infection was recorded per month in February and March this year, the number of cases increased to seven in May. As of yesterday, nine cases had been recorded this year.
 
"HFMD occurs throughout the year. Apart from a summer peak from May to July, a smaller peak may also occur from October to December. As young children are more susceptible, parents should stay alert to their health. Institutional outbreaks may occur where HFMD can easily spread among young children with close contact," a spokesman for the CHP said.
 
"We have issued letters to doctors, child care centres, kindergartens and primary and secondary schools to alert them to the latest situation. Schools are reminded to follow the Guidelines on Prevention of Communicable Diseases on preventive and control measures as well as management of outbreaks, which should be reported to the CHP for prompt follow-up," the spokesman added.

Management of venues with play facilities should pay special attention to the CHP's Public Health Advice for Play Facilities on appropriate infection control in activities involving young children under 6 during the peak season.

"We noted that HFMD activity in neighbouring areas such as Guangdong and Taiwan has also increased recently. Parents travelling with their children in the coming holidays or summer vacation should pay special attention to personal and environmental hygiene while attending play facilities or having close contact with other children," the spokesman added.

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

• Maintain good air circulation;
• Wash hands before meals and after going to the toilet or handling diapers or other stool-soiled materials;
• Keep hands clean and wash hands properly, especially when they are dirtied by respiratory secretions, such as after sneezing;
• Cover the nose and mouth while sneezing or coughing and dispose of nasal and oral discharges properly;
• Clean children's toys and other objects thoroughly and frequently with diluted household bleach (by adding one part of household bleach containing 5.25 per cent sodium hypochlorite to 99 parts of water), followed by rinsing or wiping with clean water;
• Children who are ill should be kept out of school until their fever and rash have subsided and all the vesicles have dried and crusted;
• Avoid going to overcrowded places; and
• Parents should maintain close communication with schools to let them know the latest situation of the sick children.

The CHP's weekly report, EV SCAN (www.chp.gov.hk/en/view_content/21639.html), is issued every Friday to report the latest local situation of HFMD. The public may also visit the CHP's page on HFMD and EV71 infection for more information.

Ends/Friday, May 25, 2018

Issued at HKT 19:05

 

While EV-71 continues to have its biggest impact in Asia and the Eastern Pacific, in recent years we've seen an increasing number of outbreaks in Europe (see ECDC Rapid Risk Assessment Of EV-71 Outbreak In Spain), and there are no guarantees that this virus won't become a bigger factor in Europe of North America in the years ahead.

Among the challenges of controlling EV71 outbreaks are:

• No currently available vaccine (outside of China).
• EV-71 is a moving viral target, with new strains evolving and emerging over time
• Many children can carry (and shed) the virus asymptomatically (see Incidence Rates of Enterovirus 71 Infections in Young Children during a Nationwide Epidemic in Taiwan, 2008–09)
• Patients may shed virus for month or longer (see Long persistence of EV71 specific nucleotides in respiratory and feces samples of the patients with Hand-Foot-Mouth Disease after recovery)

For now, control and prevention are limited to promoting good hygiene, and removing children with signs of the disease from child care or school environments.