Sunday, May 31, 2020

Meta-Analysis: COVID-19 Mortality Among Patients Taking ACEIs & ARBs For Hypertension

Credit CDC Hypertension













#15,295


Shortly after the emergence of COVID-19 we learned that the causative virus - SARS-CoV-2 - bound to ACE2 receptor cells (see ACE2 Is the SARS-CoV-2 Receptor Required for Cell Entry), which immediately raised questions over the risks that millions of patients currently receiving ACE Inhibitor or ARB therapy for hypertension might face.

Early on, opinions were mixed - with a number of hypothesized downsides - including:
Patients who Take ACEIs and ARBs May Be at Increased Risk of Severe COVID-19
Mar 25, 2020 by

Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) may increase the risk of severe COVID-19 cases, according to a hypothesis proposed by Professor James Diaz of Louisiana State University Health Sciences Center.

(Continue . . . )
At the same time, we saw this contrarian viewpoint:
ACEI/ARB Treatment May Benefit Patients With COVID-19 and Hypertension
Florence Chaverneff, Ph.D.
Treatment of patients with hypertension who are infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II type 1 receptor blockers (ARBs) may improve clinical outcomes, according to study results published in Emerging Microbes and Infections. 
          (Continue . . . )

Despite this uncertainty, a number of leading journals cautioned against halting ACE or ARB therapy, citing insufficient evidence of harm (see AHA news release).

Three weeks ago, in WHO Scientific Brief: COVID-19 & The Use Of ACE Inhibitors or ARBsthe World Health Organization published a scientific brief that reviewed the (scant) existing literature - and while not exactly a ringing endorsement - found:
 `. .. low-certainty evidence that patients on long-term therapy with ACE inhibitors or ARBs are not at higher risk of poor outcomes from COVID-19.'
Although the evidence remains weak, early indications have been encouraging for those of us dependent upon these critical drugs.

While far from being the last word on the subject, today we have a meta-analysis published in the AHA journal Hypertension, which find decreased mortality ( among patients with hypertension) who are receiving ACEI or ARB therapy.

Decreased Mortality of COVID-19 with Renin-Angiotensin-Aldosterone System Inhibitors Therapy in Patients with Hypertension: A Meta-Analysis
Xiaoming Guo, Yueli Zhu, and Yuan HongOriginally published 27 May 2020https://doi.org/10.1161/HYPERTENSIONAHA.120.15572Hypertension. ;0
Abstract

The coronavirus disease 2019 (COVID-19) is caused by the infection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), having gradually developed into a pandemic and endangered global health. 
The continued use of angiotensin converting enzyme inhibitor (ACEIs) and angiotensin II receptor blockers (ARBs) which are part of renin-angiotensin-aldosterone system (RAAS) inhibitors in COVID-19 patients with hypertension has become controversial. 
We conducted a meta-analysis by searching Pubmed, Web of Science, Scopus and Embase up to 13 May 2020. Data analyses were performed by the Cochrane Collaboration's Review Manager 5.3 software. Finally, we included 9 studies comprising 3936 patients with hypertension and COVID-19 infection.
Compared with non-ACEI/ARB treatment, ACEI/ARB treatment was not associated with disease severity (OR 0.71, 95 % CI 0.46-1.08, P 0.11, I2 59%) but was related to lower mortality of COVID-19 in patients with hypertension (OR 0.57, 95 % CI 0.38-0.84, P 0.004, I2 0). 
In summary, ACEI/ARB therapy did not aggravate disease severity of COVID-19. Besides, ACEI/ARB therapy can decrease the mortality of COVID-19. Current evidence suggested that RAAS inhibitors should be continued in COVID-19 patients with hypertension. Future well-designed randomized controlled trials are needed to confirm these findings.
          PDF File


As always, I am not a doctor and none of this constitutes medical advice. Always consult your doctor before changing or stopping your medications. 

Saturday, May 30, 2020

DEFRA On India's African Swine Fever Outbreak















#15,294

One of the major infectious disease topics of 2019 BC (Before Coronavirus) was the global spread of African Swine Fever, which emerged in China in the fall of 2018, and has subsequently spread across nearly all of Eastern Asia.
ASF is also rife in Eastern Europe and Russia (see UK: DEFRA Update On ASF In Eastern Europe/Belgium), and has been blamed for the loss of more than 25% of the world's pork supply over the past two years (see New Scientist A quarter of all pigs have died this year due to African swine fever).
Five weeks ago, in  Unexplained Pig Deaths In India, we looked at initial reports of excess pig mortality in Northeastern India, and while no cause was attributed, ASF was high on our suspect list.

A week later, in India: African Swine Fever Appears To Be Confirmed In Assamwe saw local officials acknowledging ASF, but it would take more than two weeks before an OIE report would be  filed (see OIE Immediate Notification May 19th).
Although ASF doesn't infect humans, it is generally 100% fatal in pigs, and there is no vaccine or treatment available. The only solution is to cull infected (or exposed) pigs.
Given the pandemic driven supply chain issues, and warnings of increased food insecurity around the world (see Poverty and food insecurity could grow dramatically as COVID-19 spreads), anything that further depletes or stresses the global food supply is a serious concern.
So far, Western Europe, Australia, and North and South America have been spared - but continued success is far from assured.
A year ago the USDA announced enhanced testing and surveillance for ASF in American pigs, in hopes of detecting - and stamping out - any infections as early as possible. Also last summer, in Nature Sci. Rpts: Risk of African Swine Fever Virus Introduction into the United States, we looked at a study that attempted to quantify the risks ASF arriving in North America.
Even before the arrival of COVID-19, getting accurate and timely reports of ASF's spread around the globe was difficult, but we seem to be getting even less information today.
Whether we are talking about ASF, avian flu, MERS-CoV, or any other infectious disease threat, the risk of being blindsided while our attention is focused elsewhere is very real.  Luckily there are still agencies who remain focused on other threats.

Yesterday the UK's DEFRA (Department for Environment, Food and Rural Affairs) published an update on ASF activity in Asia, with a focus on the first outbreak in India. I've only included some excerpts from a much larger report, so follow the link to read it in its entirety.

Updated Outbreak Assessment #19
African swine fever (ASF) in Asia and Oceania
28 May 2020
Ref: VITT/1200 ASF Asia
Disease report
Since our last report on 20 May, India has officially reported eleven outbreaks of ASF in domestic pig populations. There have also been reports of ASF cases in wild boar in India, however these have not been officially reported to the OIE. Cases of ASF among wild boar have also been reported in South Korea.


Situation assessment
India has now reported eleven outbreaks of ASF, all in domestic pigs in the north-east of the country, dating back to the end of January (OIE, 2020). This information in summarised in the table below
The first three outbreaks were reported as starting on the 26 January across three districts in the state of Arunachal Pradesh. Of the 2,623 pigs involved in these outbreaks, there were 444 cases and 271 deaths.
From the end of February, through to mid-April, there were a further seven outbreaks in the  neighbouring state of Assam. These outbreaks affected five different districts within the state, and a total of 7,534 pigs were involved, of which there were 3,743 reported cases and 3,421 pigs died.
At the end of April, there was another outbreak in the state of Arunachal Pradesh. This involved 763 pigs, of which 12 were cases and nine died.
In all cases, disease control measures have been applied including movement restrictions, surveillance and culling of all susceptible pigs within a 1km radius of the epicentre.

Although not officially reported to the OIE, there have also been reports in the media suggesting that wild boar deaths have been linked to these outbreaks. In Arunachal Pradesh, six carcasses of wild boar were reportedly found in a community forest, with additional unverified reports of wild boar  carcasses found in East Siang and Upper Siang districts (The Hindu, 2020).
In South Korea, cases continue to be reported in wild boar, but no new cases in domestic pigs. On 27 May, eight new cases were reported in the province of Gyeonggi-Do, which surrounds the country’s capital and borders North Korea (OIE, 2020). After detecting wild boar cases outside their initial wide fenced area, South Korea have implemented third stage wide fences to try and contain the spread of ASF through wildlife. In addition, surveillance is being conducted by weekly sampling and testing of domestic pig farms within a 10km radius of each wild boar case detected (FAO, 2020).
Since our last report on 20 May, there have been no further outbreaks of ASF reported in Cambodia, China, Hong Kong, Laos, Mongolia, Myanmar, North Korea, Papua New Guinea, Philippines or Timor-Leste, though it is likely that the virus is still circulating in these areas. Taiwan still remains officially free from ASF.
The confirmation of ASF in multiple countries across Asia and Oceania, and the wide geographic range of infection found within these countries, demonstrates the potential for further spread of ASF into and within the domestic pig and wild suid populations in this part of the world.
Publicity campaigns are in place in the UK to inform the general public and discourage individuals from bringing pork products into UK. This includes targeted messages to key stakeholders such as road hauliers, hunters, pig keepers and veterinarians. 
See: https://pork.ahdb.org.uk/health-welfare/health/emerging-diseases/african-swine-fever/ a central depository for information has been created http://web.oie.int/rr-europe/eng/regprog/en_asf_depository.htm.
Conclusion
The risk of ASF introduction to the UK was raised to medium in August 2018 as a result of the number of outbreaks of ASF being reported in Eastern Europe, and subsequent detection of ASF in wild boar in Belgium in September 2018.
The current risk of ASF introduction to the UK is still considered to be maintained as medium, despite the spread of ASF within Asia and Oceania.
(SNIP)
People returning from any ASF-affected areas of the world should avoid any contact with domestic pigs in commercial holdings, smallholdings or even household pet pigs. Habitats where feral pigs or wild boar exist should also be avoided. All clothing, footwear or equipment should be disinfected before entering pig areas.
Pig keepers and veterinarians should remind themselves of the clinical signs for ASF. Any suspect cases must be reported promptly.
Please see https://www.gov.uk/guidance/african-swine-fever for more information.
We will continue to monitor the situation

A Tropical Hat-Trick For May? & Florida's Disaster Tax Holiday



60% Chance of Development over 48 Hours















#15,293

Since early April we've seen a procession of early season forecast models released by forecasters at Colorado State University, Pennsylvania State University ESSC, the Weather Channel, and the experts at University College London Tropical Storm Risk center all calling for a particularly active Atlantic Hurricane season.

Just 9 days ago, NOAA released their outlook, calling for a Busy 2020 Atlantic Hurricane Season.


Officially the Atlantic hurricane seasons doesn't start until June 1st, and we don't usually see our first name storm until around July 9th (see chart below) - but this year we've already seen two named storms in May (Arthur & Bertha), and a third may form before the month is over (see graphic at top of blog).

http://www.nhc.noaa.gov/climo/

Although preseason storms aren't all that unusual - and this latest system (if it forms) doesn't appear to pose any threat to the United States - a tropical hat-trick in May would set a record.  What that portends for the rest of the year is unknown, but this is 2020, and apparently the old rules no longer apply. 
I advocate hurricane (and a more general `all hazards') preparedness every year in this blog, and as we discussed two weeks ago (see Why Preparing For This Year's Hurricane Season Will Be `Different'), preparing for - and riding out - any emergency this year will be more difficult due to the COVID-19 pandemic. 
The State of Florida, which is no stranger to hurricanes, actively promotes disaster preparedness, and every year designates one week in late May - early June as a state tax holiday for emergency supplies. 



While the worst hurricanes usually occur in latter half of the season (Aug-Sept-Oct) we have seen some June storms of note, including Alma in 1966 and Agnes in 1972 and 1957's infamous Category 3 Audrey, which claimed 550 lives after it made landfall in eastern Texas and western Louisiana.

June climatology suggests most June storms will form in the Caribbean, the Gulf of Mexico, or along the southeastern coast of the United States. 


While these storm are apt to be less mature, and generally less destructive, than the long-lived Cape Verde storms of August and September, they usually spin up and threaten the coast with far less advance warning.

To help you get ready, below is a list of this month's hurricane preparedness blogs:
Hurricane Preparedness Week: Day 7 - Complete A Written Plan
Hurricane Preparedness Week: Day 6 - Help Your Neighbors
Hurricane Preparedness Week: Day 5 - Strengthen Your Home
Hurricane Preparedness Week: Day 4 - Get An Insurance Check-up
Hurricane Preparedness Week: Day 3 - Assemble Disaster Supplies
Hurricane Preparedness Week: Day 2 - Develop An Evacuation Plan
National Hurricane Preparedness Week: Day 1 - Determine Your Risk
Hurricane Preparedness Week 2020
 

Friday, May 29, 2020

JPIDS: Multisystem Inflammatory Syndrome in Children : A Case Series

Credit NIAID











#15,292


Just over a month ago we saw the first alert go out - issued by the UK's NHS - on a newly recognized inflammatory syndrome in children which as been tentatively and temporally linked to COVID-19 (see PICS: NHS Alert On Possible Severe Pediatric COVID-19 Complication). 

Since then we've seen a barrage of reports - both in the UK and in the United States - including:
RCPCH: Case Definition For Pediatric Inflammatory Syndrome
NYC HAN Alert On Pediatric Multi-System Inflammatory Syndrome
New York DOH Advisory On Pediatric Multi-System Inflammatory Syndrome
Update On Pediatric Multi-System Inflammatory Syndrome 
Two weeks ago the CDC released their own HAN Advisory (see CDC HAN: Multisystem Inflammatory Syndrome In Children (MIS-C)), instructing doctors across the nation on how recognize and report the condition, and 10 days ago the CDC held a COCA Call on Multisystem Inflammatory Syndrome in Children (MIS-C).
Around the same time the World Health Organization issued a Scientific Brief: Multisystem Inflammatory Syndrome in Children & Adolescents with COVID-19with a new case definition, and instructions for reporting cases.
As fresh reports come in from around the country of more children diagnosed with this poorly understood syndrome (see herehere, and here), we are beginning  to see some published studies, including:
Septic shock presentation in adolescents with COVID-19
Multisystem inflammatory syndrome with features of Atypical Kawasaki disease during COVID-19 pandemic: Report of a case from India
Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic

Yesterday the Journal of the Pediatric Infectious Diseases Society published a case study of six children presenting with this syndrome; 5 female, 1 male - ages 5 to 14 - all critically ill.
While the popular perception has been that children are generally spared from serious illness with COVID-19 - and statistically speaking, that is true - for some small fraction of kids this infection can produce dramatic, and truly life threatening complications. 
I've only posted the abstract, so follow the link to read the full case study. 
Multisystem Inflammatory Syndrome in Children during the COVID-19 pandemic: a case series

Kathleen Chiotos, MD, MSCE, Hamid Bassiri, MD, PhD, Edward M Behrens, MD, Allison M Blatz, MD, Joyce Chang, MD, Caroline Diorio, MD, Julie C Fitzgerald, MD, MSCE, Alexis Topjian, MD, MSCE, Audrey R Odom John, MD, PhD
Journal of the Pediatric Infectious Diseases Society, piaa069, https://doi.org/10.1093/jpids/piaa069Published: 28 May 2020 Article history

PDF
Abstract
We present a series of six critically ill children with Multisystem Inflammatory Syndrome in Children (MIS-C). Key findings of this syndrome include fever, diarrhea, shock, and variable presence of rash, conjunctivitis, extremity edema, and mucous membrane changes.
          (Continue . . . )

CDC Updated (May 28th) COVID-19 Forecasts









#15,291

Anyone who has been caught off guard by an unpredicted storm, or monitors the shifting forecast tracks of hurricanes - which can change radically between model runs - knows that even with the power of supercomputers, forecasting is an inexact science.
As George E. P. Box (18 October 1919 – 28 March 2013) - Professor Emeritus of Statistics at the University of Wisconsin - famously said : “All models are wrong, but some models are useful.”
Pandemic models often come up in this blog, and while necessary for planning purposes, they need to be taken with a sizeable grain of salt. All are based on assumptions - and as we've seen with the modeling on COVID-19 - all are subject to change.

Six weeks ago, when there were fewer than 25,000 COVID-19 deaths in the United States, a limited number of forecast models suggested we might top out at between 60,000 and 70,000 deaths by the end of summer. 
Conditions - and assumptions - change over time, and today we are well over 100,000 COVID-19 related deaths. 
The initial forecast, made back in mid-April, was based on just five models.  This week, 15 models are used, and the CDC continues to tinker with the ensemble line-up. 

While the rate of deaths appears to be dropping, there remains much uncertainty over what will happen as more states ease social distancing restrictions and reopen their economies. The CDC's latest forecast now calls for in excess of 115,000 deaths by June 20th. 

Interpretation of Cumulative Death Forecasts
This week CDC received 15 individual national forecasts.
This week’s national ensemble forecast indicates that the rate of increase in cumulative COVID-19 deaths is continuing to decline. Nevertheless, total COVID-19 deaths are likely to exceed 115,000 by June 20.
Ensemble forecasts indicate that the rate of new deaths will vary among the states. In some states, cumulative deaths will increase at roughly the same rate as they have in recent weeks, while other states are likely to experience only a small number of additional deaths from COVID-19.
National Forecast
These forecasts show cumulative reported COVID-19 deaths since February and forecasted deaths for the next four weeks in the United States.
Models make various assumptions about the levels of social distancing and other interventions. See model descriptions below for details.
State Forecasts
State-level forecasts show observed and forecasted state-level cumulative COVID-19 deaths in the US. Each state forecast uses a different scale, due to differences in the numbers of COVID-19 deaths occurring in each state.
Forecasts fall into one of three categories
  • The Auquan, CAN, ERDC, ISU, LANL and UMass-MB forecasts do not explicitly model the effects of individual social distancing measures but assume that implemented interventions will continue, resulting in decreased growth.
  • The Geneva, GA_Tech, MIT, MOBS, UCLA, UA, and UT forecasts assume that existing social distancing measures will continue through the projected time period.
  • The Columbia, JHU, and YYG forecasts forecasts make different assumptions about how levels of social distancing will change in the future.
Download state forecasts pdf icon[12 pages]
Download forecast data excel icon[1 sheet]
(Continue . . . )
  

Thursday, May 28, 2020

Study: Genotyping & Reassortment Analysis of HPAI H5N8 and H5N2 viruses from Egypt

image


#14,590

In mid-March of 2013 - at a time when HPAI H5N1 was the world's primary avian flu concern - we examined a research article (see EID Journal: Predicting Hotspots for Influenza Virus Reassortment that identifies 6 key geographic regions for avian flu reassortment (see graphic above).
The two biggest contenders?  Coastal China, and the Nile Valley region of Egypt.
Since timing is everything, just a little over 2 weeks later, China announced their first outbreak of LPAI H7N9, a virus that would evolve into both LPAI and HPAI strains (and two lineages) and spark 5 yearly epidemics (see below) before an effective vaccine was deployed in 2017.

H7N9 Epidemic Waves - June 14th - Credit FAO

Eighteen months after the emergence of H7N9, Egypt saw the world's biggest HPAI H5 human outbreak (see EID Dispatch: Increased Number Of Human H5N1 Infection – Egypt, 2014-15), resulting in at least 165 infections, and 51 deaths.
Since then, Egypt has only reported sporadic human infections, but their surveillance and reporting has long been intermittent (see Revisiting Egypt’s Murky H5N1 Battle).
But what we have seen has been a continual evolution of HPAI H5Nx viruses, with the introduction of HPAI H5N8 in 2016, and their reassortment with LPAI H9N2 (introduced in 2010).  In the spring of 2019, a new, novel H5N2 appeared in Egypt (see Viruses: A Novel Reassortant H5N2 Virus In Egypt), which identified it as clade 2.3.4.4.
Eight months later, yet another novel H5N2 (a reassortment of H5N8 & H9N2) was described in the EID Journal (see Novel Reassortant HPAI A(H5N2) Virus in Broiler Chickens, Egypt).
While Egypt has long maintained a poultry vaccination program, it has been plagued with vaccine failures and lapses in application (see Sci. Reports: Efficacy Of AI Vaccines Against The H5N8 Virus in Egypt) - which, unlike in China - has done little to curb the spread and evolution of avian flu viruses.

A few recent blogs include:
Emerg. Microbes & Inf.: Active Surveillance & Genetic Evolution of Avian Influenza Viruses in Egypt, 2016–2018

Two Studies On The Recent Evolution Of HPAI H5 Viruses In The Middle East

J. Virology:Genetic Compatibility of Reassortants Between Avian H5N1 & H9N2 Influenza Viruses
To this growing list we can add a new study, published this week in Infection, Genetics and Evolution, that finds the pace of HPAI H5Nx evolution in Egypt continues to quicken, and warns that these viruses are picking up increased antiviral resistance as well. 
Genotyping and reassortment analysis of highly pathogenic avian influenza viruses H5N8 and H5N2 from Egypt reveals successive annual replacement of genotypes
Kareem E.Hassan Noha Saad Hassanein H.Abozeid Salama Shany  Magdy F.El-Kady Abdelsatar Arafa Azza A.A.EL-Sawah Florian Pfaff Hafez M.Hafez  Martin Beer Timm Harder  
https://doi.org/10.1016/j.meegid.2020.104375 
Highlights
  • Systematic reassortment analysis of all publicly available Egyptian whole genome sequences of HP H5N8, reassortant HP H5N2 and LP H9N2 viruses revealed presence of at least seven different genotypes of HPAI H5Nx viruses of clade 2.3.4.4b in Egypt.
  • Heat mapping and tanglegram analyses suggested that several internal gene segments in both HP H5Nx and H9N2 viruses originated from avian influenza viruses circulating in wild bird species in Egypt.
  • Amino acid substitutions in the Matrix (M2) and the Neuraminidase (NA) proteins of newly established sequences suggested presence of resistance against both Amantadine and Oseltamivir.

Abstract

Highly pathogenic (HP) H5N1, clade 2.2.1, and low pathogenic avian influenza (LPAI) H9N2 viruses, G1-B lineage, are endemic in poultry in Egypt and have co-circulated for almost a decade. Surprisingly, no inter-subtypic reassortment events have been reported from the field during that time.
After the introduction of HPAIV H5N8, clade 2.3.4.4b, in Egyptian poultry in 2016, suddenly HP H5N2 reassortants with H9N2 viruses emerged. The current analyses focussed on studying 32 duck flocks, 4 broiler chicken flocks, and 1 turkey flock, suffering from respiratory manifestations with moderate to high mortality reared in two Egyptian governorates during 2019. Real-time RT-PCR substantiated the presence of HP H5N8 in 21 of the 37 investigated flocks with mixed infection of H9N2 in two of them.
HP H5N1 was not detected. Full hemagglutinin (HA) sequencing of 10 samples with full-genome sequencing of three of them revealed presence of a single genotype. Very few substituting mutations in the HA protein were detected versus previous Egyptian HA sequences of that clade. Interestingly, amino acid substitutions in the Matrix (M2) and the Neuraminidase (NA) proteins associated with conferring both Amantadine and Oseltamivir resistance were present.
Systematic reassortment analysis of all publicly available Egyptian whole genome sequences of HP H5N8 (n = 23), reassortant HP H5N2 (n = 2) and LP H9N2 (n = 53) viruses revealed presence of at least seven different genotypes of HPAI H5Nx viruses of clade 2.3.4.4b in Egypt since 2016.
For H9N2 viruses, at least three genotypes were distinguishable.
Heat mapping and tanglegram analyses suggested that several internal gene segments in both HP H5Nx and H9N2 viruses originated from avian influenza viruses circulating in wild bird species in Egypt. Based on the limited set of whole genome sequences available, annual replacement patterns of HP H5Nx genotypes emerged and suggested selective advantages of certain genotypes since 2016.
         (Continue . . . )


While China and Southeast Asia have historically been world's primary hotspot for avian flu evolution, the Middle East - with its less-than-stellar infection control and a growing stable of circulating avian flu strains - has to be viewed as a serious contender. 

Seoul South Korea: Reinstating Social Distancing Measures Due to Spike In COVID-19



#15,289


Yesterday, in South Korea Reports Another Uptick In Domestic COVID-19 Cases, we saw the biggest one-day total (n=50)  of COVID-19 cases in seven weeks, with many of these cases linked to an e-commerce logistics center in Bucheon, west of Seoul. 

Today, South Korea's Ministry of Health reports another jump in their case count(n=79), and announced renewed social distancing rules for the capital Seoul and surrounding metropolitan areas.











Admittedly, 79 cases over 24 hours in a country the size of South Korea (pop 51 million) isn't a lot, but just over 3 weeks ago they were reporting daily totals in the single digits.
Given how rapidly COVID-19 exploded on the peninsula in late February (a 100-fold increase over 10 days), authorities are wasting no time trying to contain this resurgence. 
Starting tomorrow (Friday) - and lasting for at least the next 16 days (June 14th) - the MOH has recommended enhanced - albeit, often voluntary - social distancing measures for the Seoul Metropolitan area, and ordered the closing of public venues such as parks, museums and theaters (see translated order below).

Reinforced quarantine measures for metropolitan areas
(5.29. ~ 6.14.)
Registration Date: 2020-05-28 [Last Modified Date: 2020-05-28 ]

Department in charge: Coronavirus Infectious Diseases-19 Central Accident Remediation Headquarters


Reinforced quarantine measures for metropolitan areas (5.29. ~ 6.14.)

-Follow-up measures for emergency relations meeting (5.28 days) related to the outbreak of the metropolitan area-
-△ (Entertainment facilities / PC rooms, etc.) Administrative measures △ (Residents / business sites) Advise on the prevention regulations-
□ Today, an emergency relations ministers' meeting was held by Prime Minister Jung Se-gyun, together with related ministries and local governments, to discuss measures to control the prevention of the metropolitan area, reflecting the surge in patients in the metropolitan area (Seoul, Incheon, Gyeonggi).
At this meeting, participants agreed that more measures to prevent infections in the metropolitan area were needed to minimize the spread of infection, and decided to implement strengthened measures in the metropolitan area.
□ Accordingly, the government announced that the following measures were strengthened for residents and facilities in the metropolitan area from 18 pm on Friday, May 29 to 24 hours on Sunday, June 14, for a total of 17 days. And requested active cooperation and participation from the people.
➊ (Administrative Measures) Administrative measures will be implemented for entertainment stores, singing workshops, academies, and PC rooms in the metropolitan area.
○ In accordance with this measure, it is recommended to refrain from operating the facility, and if it is inevitably operated, an obligation to comply with the quarantine rules * is imposed. 【Reference: Prevention policy for each facility】
* The anti-distribution rules already distributed for entertainment facilities are also applied to the metropolitan area based on the revised quarantine rules as of 18:00 on May 29th.
○ Regular on-site inspections will be conducted for the facility, and actions * such as prosecution / prohibition of collection may be taken if the operation is performed without complying with the quarantine regulations.
* In accordance with the 「Infectious Disease Prevention and Management Act」, fines (less than 3 million won) are imposed on facility owners and users or collective bargaining measures are implemented.
➋ (Suspension of operation of public facilities, etc.) Suspension of operation of public facilities located in the metropolitan area used by a large number of unspecified persons indoors and outdoors,
○ In addition, events organized by the government, local governments, or public institutions in the metropolitan area will be canceled or postponed if unavoidable.
유연 (Flexible work for public institutions) Government agencies, public corporations, and other public institutions located in the metropolitan area actively utilize flexible work such as telecommuting and rush hour work to minimize close contact with many people.
➍ (Recommendation) The government recommends that residents of the metropolitan area refrain from going out, meetings, and events that are unnecessary.
After work, I return home as soon as possible, and I ask you to refrain from going outside unless it is necessary, such as purchasing daily necessities or visiting medical institutions.
It is recommended that each company actively take various measures to revitalize flexible work, such as time rush hour or telecommuting, and to disseminate closeness within the workplace.
○ Each business site designated a quarantine manager and requested that thorough quarantine management such as checking the bequest box, wearing a mask, and putting a distance.
○ Even in the case of religious facilities, it was urged to strictly observe the quarantine rules and to refrain from contact-to-face meetings where it is not easy to manage quarantine.
➎ (Infectious and vulnerable facilities) For organizations concerned about collective infection such as medical institutions and nursing facilities, it was decided to continue preventive management such as visiting restrictions, wearing masks, and monitoring worker symptoms.
Minister of Health and Welfare Park Neung-Hoo (Corona 19, Central Disaster Safety Policy Headquarters), about two weeks from now is important to prevent the spread of infection in the metropolitan area. Saying that we have no choice but to return
○ It is said that our children need the efforts and devotion of adults in order to continue their school life, and emphasized that residents of the metropolitan area, business owners, religious people, etc., are encouraged to cooperate in their respective places.
Public schools remain open for now, but Health Minister Park Neung-hoo stated on Thursday afternoon that off-line classes could be canceled if the outbreak worsens. 
This renewed clampdown comes just weeks after South Korea relaxed their social distancing rules, allowing restaurants and movie theatres to open, and baseball games to resume. 
In March and April South Korea showed the world how to effectively shut down a nationwide outbreak of COVID-19, and has rightfully been held up as an example for other countries to follow.
But despite their initial success, the past 3 weeks have shown how easily COVID-19 hotspots and flare ups can emerge, even when daily case counts were approaching zero. 
Hopefully, over the next couple of weeks, they will conduct another masterclass showing the world how to quickly contain a post-reopening flare up.

Because if it can happen in South Korea, it can happen anywhere.

Wednesday, May 27, 2020

NHC: 70% Chance Of Tropical Development Off South East Coastline




UPDATED: 0830 hrs EST

NHC Upgrades system to Tropical Storm Bertha
A Tropical Storm Warning is in effect for...
* Edisto Beach SC to South Santee River SC


#15,288

Although we are used to getting 36 to 48 hours warning prior to landfall, every once in awhile - particularly very early or very late in the Atlantic tropical season - we see a tropical storm pop up very near the coast providing us with very little advance warning.
Such is likely the case for a low pressure area, which has been lingering over Florida for the past couple of days producing heavy showers, that is now given a 70% chance of becoming the second named storm (Bertha)  of this busy pre-season before making landfall later today. 
At 7:35 am EST the National Hurricane Center issued the following special tropical update.



Special Tropical Weather Outlook NWS 
National Hurricane Center Miami FL 725 AM EDT Wed May 27 2020
For the North Atlantic...Caribbean Sea and the Gulf of Mexico: Special Tropical Weather Outlook issued to discuss the area of low pressure near the southeast U.S. coast. Radar imagery indicates that the area of disturbed weather located just offshore the South Carolina Coast has become significantly better organized over the past few hours. 
Reports from an offshore buoy are showing that this system is producing tropical-storm-force winds. If these development trends continue, then this system is likely to become a tropical storm before it moves inland later today. 
Heavy rainfall could cause flash flooding over portions of the Carolinas today. Gusty winds could also produce rough marine conditions and life-threatening surf and rip currents along the coasts of Georgia and the Carolinas through today.
1. For additional information, see products from your local National Weather Service office. The next Special Tropical Weather Outlook on this system will be issued by 3PM EDT Wednesday, or earlier if necessary.
* Formation chance through 48 hours...high...70 percent.
* Formation chance through 5 days...high...70 percent.
Forecaster Latto
While these immature tropical storms generally lack a lot of punch, they can occasionally surprise us.
In June of 1982 a `no-name' storm sprung up overnight off the southwest coast of Florida - catching everyone by surprise - doing millions of dollars worth of damage and claiming at least 3 lives. 
Last week, we saw NOAA's Busy 2020 Atlantic Hurricane Season Outlook, which calls for an unusually active 2020 hurricane season.


I spent last weekend charging up my rechargeable batteries, refreshing 30 gallons of fresh water supplies, and going over my hurricane plans and supplies.  If you live anywhere in `hurricane country' - and haven't already done so - now would be a good time to get prepared.
As we discussed a couple of weeks ago in Why Preparing For This Year's Hurricane Season Will Be `Different', our concurrent COVID-19 pandemic, and supply chain issues, will only further complicate preparation, and evacuation.
To help you prepare, below is a list of this month's hurricane preparedness blogs:
Hurricane Preparedness Week: Day 7 - Complete A Written Plan
Hurricane Preparedness Week: Day 6 - Help Your Neighbors
Hurricane Preparedness Week: Day 5 - Strengthen Your Home
Hurricane Preparedness Week: Day 4 - Get An Insurance Check-up
Hurricane Preparedness Week: Day 3 - Assemble Disaster Supplies
Hurricane Preparedness Week: Day 2 - Develop An Evacuation Plan
National Hurricane Preparedness Week: Day 1 - Determine Your Risk
Hurricane Preparedness Week 2020

Your primary source of forecast information 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 @FEMA, @NHC_Atlantic, @NHC_Pacific and @ReadyGov and of course take direction from your local Emergency Management Office.

HHS ASPR-TRACIE: Promising Practices For COVID-19 Workforce











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As we emerge from our prolonged societal lockdown, the focus now is on how we can live and work as safely as possible while COVID-19 still circulates. We've seen a steady barrage of official guidance from agencies like the CDC, ECDC, and WHO, but much of this advice has been generic. 
The HHS's office for ASPR (Assistant Secretary for Preparedness and Response) is charged with preparing for Public Health and Medical Emergency Support during any crisis or disaster. Among the many documents on ASPR's TRACIE website (Technical Resources, Assistance Center, and Information Exchange), are a number that deal with COVID-19.
Most are `official' documents, but nestled among the federally generated advice you'll find a growing number of links to `promising practices' - including webinars  and other resources -  many of which have been created and submitted by local and state governments, hospitals, or other agencies or organizations.
Currently there are 20 promising practices for workforces solutions spread across 9 categories, and more are expected.  
Rather than re-inventing the wheel, a visit to this website could you how others have tackled thorny pandemic problems, possibly saving you, your organization, or your business a lot of time, money, and aggravation.

Topic Collection: COVID-19 Workforce Solutions from the Field

This collection highlights webinars and other resources sharing promising practices from the field related to workforce capacity and addressing workforce issues.
Please refer to CDC’s Coronavirus Disease 2019 webpage for the most up-to-date clinical guidance on COVID19 outbreak management.
If you are a decision-maker and have COVID-19 promising practices, plans, tools, or templates to share with your peers, please visit the ASPR TRACIE Information Exchange COVID-19 Information Sharing Page (registration required) and place your resources under the relevant topic area. Resources specific to decision-making on healthcare workforce can be placed under the COVID-19 Workforce Virtual Toolkit Topic.

NOTE: inclusion of any reference in this document does not constitute an endorsement, acknowledgment, or suggestion that the reference is the only or best example for that topic. References are included as examples which were provided as suggestions at the time the document was developed.
All guidance posted is accessible to the public, and non-federal resources are noted with an asterisk (*). Linking to a non-federal website does not constitute an endorsement by the U.S. government, or any of its employees, of the information and/or products presented on that site.
Promising Practices in 911
Promising Practices in Critical Care Nursing Staffing
Promising Practices in Developing and Implementing COVID-19 Surge Plans
Promising Practices in Long-Term Care
Promising Practices in PPE Match and Medical Supplies Match
Promising Practices in PPE Preservation
Promising Practices in Repurposing of Staff 
Promising Practices to Support Staff Availability: Childcare
Promising Practices to Support Staff Availability: Housing

South Korea Reports Another Uptick In Domestic COVID-19 Cases



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During the last 10 days of February South Korea saw their number of confirmed COVID-19 cases rise from just 31, to 3150; a 100-fold increase. In early March - with hundreds of new COVID-19 cases being reported each day -South Korea declared `war' on the virus.
They began testing aggressively and isolated any positive cases, potentially exposed individuals were quarantined, and they heavily promoted social distancing along with hand and respiratory hygiene.
By the end of March, their total number of cases had tripled (n=9583), but their daily increases had dropped precipitously, often down into the double digits.  April and May saw further reductions -  with many days only adding single digit increases in cases - and a shift from domestic to imported cases. 

On May 10th, however, in South Korea Reports Uptick In Domestic COVID-19 Cases, we saw the biggest uptick in cases in nearly a month (27 = Domestic, 34 =Total), most of which were linked to a 29-year-old man who tested positive after spending time at five clubs and bars in Itaewon.
As result, on May 9th the Mayor of Seoul issued an Administrative Order closing all bars and nightclubs in the city for at least the next 30 days.
Since then, the number of new daily cases has declined, averaging about 20 per day (domestic and imported). At least until the past 24 hours, during which time 40 new cases were reported (37 domestic). 


* Local government epidemiologic investigations are in progress, subject to change depending on epidemiological investigation results

○ 3 people were added for the group occurrence of the Original Bible Study Society, and a total of 12 people * have been confirmed so far. The additional contributors were two Rapachi Prayer Centers located in Nowon-gu, Seoul, and one elementary school teacher located in Bucheon-si, Gyeonggi-do.

* 1 Grace Methodist Church in Yangcheon-gu, Seoul, 1 Grace Church in Dobong-gu, Seoul, 2 Rapachi Prayer Centers in Nowon-gu, Seoul (new), 6 Hwadouri Church in Namyangju-si, Gyeonggi-do, 1 Jusarang Church in Uijeongbu-si, Gyeonggi-do, and 1 contact with confirmed persons (new) Etc

○ There were 27 additional confirmed cases compared to the previous day related to the collective occurrence of the Coupang Logistics Center in Bucheon-si, Gyeonggi-do, and 36 confirmed persons have been identified.
* 32 distribution center employees, 4 contacts (family living together) / Incheon 22, Gyeonggi 10, Seoul 4

Most of this latest spike appears to be linked to employees working at an e-commerce logistics center located in Bucheon, west of Seoul (see Reuters Coronavirus outbreak at South Korea e-commerce warehouse drives spike in new cases).
The index case at the e-commerce center, who was diagnosed over the weekend, appears to be linked to the nightclub cluster earlier in the month. 
Although most countries half their size would be happy to report just 40 new cases in a single day, this is a reminder that no matter how close you get to zero - even with continued vigilance - there are always going to be opportunities for the virus to flare again. 

Tuesday, May 26, 2020

COVID-19: Back To The Mink Farm



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Not quite a month ago, in Netherlands: COVID-19 In Farmed Mink, we looked at preliminary reports released by the Netherlands' National Institute for Public Health - RIVM, on the detection of SARS-CoV-2 at two mink farms - located roughly 5 km apart - in the south-central part of the country.
While this was the first confirmed SARS-CoV-2 infection reported in mink, it was hardly surprising. 
Nearly two months ago, in Susceptibility of Ferrets, Cats, Dogs & Other Domestic Animals to SARS-CoV-2, we looked at the experimental infection of a variety of farmed animals and household pets with the novel coronavirus. The authors wrote:
We found that SARS-CoV-2 replicates poorly in dogs, pigs, chickens, and ducks, but efficiently in ferrets and cats. We found that the virus transmits in cats via respiratory droplets.
Mink are quite similar to ferrets - both being members of the Mustela genus - and have a long history of being susceptible to a variety of novel flu and respiratory viruses (see below). 
Nature: Semiaquatic Mammals As Intermediate Hosts For Avian Influenza
That Touch Of Mink Flu (H9N2 Edition)
Vet. MicroB.: Eurasian Avian-Like Swine Influenza A (H1N1) Virus from Mink in China
Over the past few days the Netherlands have reported additional mink farms affected by the pandemic virus, including a spillover into cats, and possibly even some mink-to-human transmission. The following (translated) report comes from Wageningen Bioveterinary Research (WBVR).
COVID-19 detected at four mink farms
Published on May 26, 2020
On April 26, two mink companies in Gemert-Bakel and Laarbeek detected infections of COVID-19 in different minks. On May 7, two other mink companies in De Mortel and Deurne were found to be contaminated. The minks showed various symptoms including respiratory problems and increased mortality. Some employees at both companies had symptoms of the coronavirus. Research shows that mink on the farm have transmitted the virus to each other. Furthermore, it is plausible that two contaminations have occurred from mink to human.

The Animal Health Service (GD), Utrecht University (UU) and Erasmus MC and Wageningen Bioveterinary Research (WBVR) are conducting research to gain more insight into the virus, the spread of the virus and the spread in the environment. Samples of sick and healthy animals have been collected and air and dust samples have also been taken in the vicinity of the farms as a precaution. GGD is involved in sampling and research into contamination of employees.
Virus transferred between minks
Previous research shows that ferrets, and therefore also minks, are susceptible to COVID-19 contamination. Pneumonia was seen in sections on animals and SARS-CoV-2 was detected in organs and throat swabs. Based on the variations in the genetic codes of the virus, it could be concluded that mink farms have transmitted the virus to each other.
Possible contamination from animal to human
Minister Schouten of Agriculture, Nature and Food Quality (LNV) reports in a letter to parliament dated 19 May that it is plausible that a coronavirus infection has occurred from mink to man. In a letter to parliament dated 25 May , the minister reports that there is very likely a second infection.
The minister has announced additional measures for mink farms. All companies are screened and visitors are banned from visiting the stables. A reporting obligation had already been introduced and employees were already required to wear protective clothing.
Virus in dust particles in the stables
Virus RNA has been detected in dust particles in the stables, indicating that people in the stables with infected mink can be exposed to coronavirus.
No virus in the air samples outside the house
In the letter to parliament of 8 May from Minister Schouten of LNV to the House of Representatives, it appears that the initial results of the investigation show that no virus was found in the air samples outside the house. RIVM indicates that the risk of exposure of people to the virus outside the house is negligible.
Area precaution is no longer required
In the second sampling series, the virus was no longer found inside or outside the house in the dust particles in the air. Minister Schouten announced this in the letter to parliament of 15 May . The previous RIVM advice not to walk or cycle in a 400-meter zone around an infected mink farm has therefore been withdrawn.
Three cats infected
The study also tested eleven cats at one of the infected business locations. Antibodies to COVID-19 have been demonstrated in three of these cats. That means the cats have been infected.
Ut is important to further investigate the role of cats in potential virus transmission of this respiratory infection. In this context, research into, among other things, (virus) transmission in cats is carried out by the Netherlands Center for One Health partnership . It unites: Faculty of Veterinary Medicine at Utrecht University, Wageningen Bioveterinary Research, Erasmus University Rotterdam and research centers in human health care.
WBVR tested the animals
Wageningen Bioveterinary Research (WBVR) has performed confirmation tests on samples from the mink. In addition, further research is being started in collaboration with GD, UU and EMC.

In a (translated) Letter to parliament  (May 25th) on developments in COVID-19 on mink farms, Ministers De Jonge and Schouten summarize the most recent developments and research results concerning COVID-19 on mink farms.
(Excerpt)
In our letter of May 19, we reported that there are three farm cats on it an infected mink farm tested positive for serological testing. On this further investigation has taken place. In total, seven of the 24 sampled farm cats tested positive at a serological site research. That is, these positive cats have antibodies created against the virus.
One of the positive cats was under investigation virus detected, however the amount of virus detected is probably too little to unravel the genetic code. The other six cats could no virus can be detected. That means these last six cats have a CoV 2 have gone through infection and no longer shed virus. Because cats being infected with CoV-2 has been previously known to infected mink farms advised to ensure that their cats cannot enter the company premises leave. 
Farmed Mink being susceptible to SARS-CoV-2 poses far less of a concern than if the virus had an affinity for pigs or poultry - but it is important to monitor other potential hosts for the virus - as they could provide additional opportunities for the virus to adapt and evolve outside of our view.

As far as felines are concerned, over the past couple of months we've looked at a number of field reports, and some limited research, on the susceptibility of cats to the COVID-19 pandemic and their potential for transmitting the SARS-CoV-2 virus to others.
CDC: Pets & Other Animals and COVID-19
NEJM: Transmission of SARS-CoV-2 in Domestic Cats
APHIS: Confirmation of COVID-19 in Two Pet Cats in New York
The evidence thus far suggests your cat is far more likely to contract the SARS-CoV-2 virus from you, or another human, than to spread it to humans   What is known as Reverse Zoonosis. 


We are, of course, still learning about this pandemic virus. For those looking for more information, the AVMA (American Veterinary Medical Association) maintains a detailed webpage (updated May 15th) on what is currently known about animal infection with the SARS-CoV-2 virus.


While the infection risk to, and from, animals is believed to be low at this time, the AVMA recommends the following precautions:

         (Excerpt)
SUMMARY AND CURRENT RECOMMENDATIONS
Despite the number of global cases of COVID-19 surpassing the 4 million mark as of May 9, 2020, we are aware of only a handful of pets and captive or farmed wild animals that have tested positive for SARS-CoV-2. In all cases, the source of the infection for these animals was presumed to be one or more persons with confirmed or suspected COVID-19. At this point in time, there is also no evidence that domestic animals, including pets and livestock, can spread COVID-19 to people. 
Therefore, the AVMA maintains its current recommendations regarding SARS-CoV-2 and animals. These recommendations, which are supported by guidance from the US Centers for Disease Control and Prevention (CDC) and World Organization for Animal Health (OIE), are that:
  • Animal owners without symptoms of COVID-19 should continue to practice good hygiene during interactions with animals. This includes washing hands before and after such interactions and when handling animal food, waste, or supplies.
  • Do not let pets interact with people or other animals outside the household.
  • Keep cats indoors, when possible, to prevent them from interacting with other animals or people.
  • Walk dogs on a leash, maintaining at least 6 feet from other people and animals. Avoid dog parks or public places where a large number of people and dogs gather.
  • Until more is known about the virus, those ill with COVID-19 should restrict contact with pets and other animals, just as you would restrict your contact with other people. Have another member of your household or business take care of feeding and otherwise caring for any animals, including pets. If you have a service animal or you must care for your animals, including pets, then wear a cloth face covering; don’t share food, kiss, or hug them, and wash your hands before and after any contact with them.
  • At this point in time, there is no evidence to suggest that domestic animals, including pets and livestock, that may be incidentally infected by humans play a role in the spread of COVID-19.
  • Routine testing of animals for SARS-CoV-2 is NOT recommended. Veterinarians are strongly encouraged to rule out other, more common causes of illness in animals before considering testing for SARS-CoV-2.
  • Human outbreaks are driven by person-to-person transmission. Accordingly, we see no reason to remove pets from homes even if COVID-19 has been identified in members of the household, unless there is risk that the pet itself is not able to be cared for appropriately.
During this pandemic emergency, animals and people each need the support of the other and veterinarians are there to support the good health of both.