WHO EMRO: Influenza Activity In The Middle East - April 2019

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We are nearly a week into the Holy month of Ramadan - a time when as many as a million religious pilgrims will travel to Saudi Arabia to perform Umrah - and as was mentioned in late April, (while well down from their winter peaks) KSA continues to see the highest flu activity levels in the Middle East (see WHO EMRO map below).

As we've discussed previously (see EID Journal: ARI’s In Travelers Returning From The Middle East), researchers have found that respiratory infections are the most commonly reported illness among religious pilgrims.

This study also found that `Pneumonia is the leading cause of hospitalization at Hajj, accounting for approximately 20% of diagnoses on admission.’

All of which complicates screening for potential MERS infections during mass gatherings like Ramadan and the Hajj, particularly during periods of elevated flu activity. 

Because of the difficulties in identifying cases, the WHO continues to advise:

It is not always possible to identify patients with MERS-CoV early because like other respiratory infections, the early symptoms of MERS-CoV are non-specific. Therefore, healthcare workers should always apply standard precautions consistently with all patients, regardless of their diagnosis.

Droplet precautions should be added to the standard precautions when providing care to patients with symptoms of acute respiratory infection; contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection; airborne precautions should be applied when performing aerosol generating procedures.

We've the latest EMRO Influenza report for the month of April, which finds the highest influenza activity (predominantly A/H1N1) in Saudi Arabia.

Influenza monthly update

Source of data: FluNet and EMFLU
Epidemiological week: 14-17/2019

In the WHO Eastern Mediterranean Region, influenza activity continues to increase in the month of April in many countries reporting data to FluNet and EMFLU namely, Afghanistan, Bahrain, Egypt, Iran (Islamic Republic of), Iraq, Jordan, Kuwait, Lebanon, Morocco, occupied Palestinian territory (oPt), Oman, Pakistan, Qatar, Saudi Arabia, Sudan,Syrian Arab Republic, Tunisia and United Arab Emirates.

In April 2019, Proportion of tested cases for influenza in EMR is 85% out of 6,775 enrolled cases, 16% of the tested cases is positive and 84% is negative. 

Cumulative numbers of positive Influenza specimens by type/subtype reported to EMR , April 2019 

• In April 2019, no new cases of human influenza A(H5N1) were reported in Egypt.

• In the northern Africa influenza transmission zone, Egypt continued reporting low influenza activity with all seasonal subtypes co-circulating. Morocco and Tunisia reported no activity.

• In the western Asia influenza transmission zone, Oman, Saudi Arabia, Qatar and Kuwait continued reporting co-circulation of influenza types A and B with influenza B virus predominating in Qatar. Jordan, Iraq, reported sporadic circulation of A(H1N1)pdm09 while Lebanon and oPt reported circulation of Influenza A(H1N1)pdm09 and A(H3N2) viruses. Syria and Sudan reported no activity.

• In southern Asia transmission zone, influenza activity continued to decrease with all seasonal influenza subtypes co-circulating in Afghanistan and Iran (Islamic Republic of); Pakistan reported no activity.

Circulating influenza viruses in the EMR by subtype, April 2019 

• During April 2019, national influenza centres and influenza laboratories in the Region tested a total of 5,753 specimens for influenza viruses of which 896 tested positive (16%).

• The average percentage of positivity rates is 16%, with highest positivity rate recorded in Lebanon and Saudi Arabia.

• Of the viruses tested; 504 (57%) were influenza A viruses, including 277 (31%) influenza A(H1N1)pdm09 virus, 84 (10%) were influenza A(H3) virus and 143 (16%) were influenza A(not subtyped) virus. Influenza B (Lineage Not determined) virus accounted for 351 (39%).

For some recent blogs on the difficulties in diagnosing MERS-CoV cases, you may wish to revisit:

J. Inf. Pub. Health: Diagnostic Delays in MERS Coronavirus Patients & Health Systems

AJIC:Intermittent Positive Testing For MERS-CoV

JIDC: Atypical Presentation Of MERS-CoV In A Lebanese Patient

A Review Of Asymptomatic MERS Cases

Evaluation of a Visual Triage for the Screening of MERS-CoV Patients