Hong Kong: Epidemiological Update On Imported H7N9 Case

 

# 9499

 

Hong Kong’s Centre For health Protection (CHP) was formed in the wake of that city’s disastrous SARS epidemic a little over a decade ago.  Since then the CHP has gained a reputation for openness, and mounting a rapid response to any disease threat.  

 

Today they’ve released a detailed statement on their investigation into the first imported H7N9 case from the Chinese mainland this winter.

 

While human-to-human transmission of the H7N9 virus has only rarely been reported, the incubation period is thought to be up to 10 days, and so arrangement are being made for asymptomatic contacts to be quarantined at the Lady MacLehose Holiday Village in Sai Kung (description below).

Located within Sai Kung Country Parks at Pak Tam, Sai Kung, the Lady MacLehose Holiday Village has an air of tranquility and presents a charming view of the woody hillsides. Each bungalow, which can accommodate 3 to 15 persons, is self-contained with a sitting room, bedroom(s) and a toilet with shower facilities. The Camp has a capacity of 280 campers. Hirers please note that Camp facilities, such as bungalows, recreational facilities, canteen, etc., are located on different spots of a slope and connected by pavements.

We’ve seen similar arrangements in the past both in Hong Kong and in Singapore (see Singapore MOH Puts Quarantine Chalets On Standby).  This is the 11th imported case of H7N9 in Hong Kong, and they are well practiced in the handling of such cases.

 

Update of human case of avian influenza A(H7N9)

The Department of Health (DH) today (December 28) reported the latest updates of the first confirmed human case of avian influenza A(H7N9) in Hong Kong this winter, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

Epidemiological investigations and control measures
---------------------------------------------------
Epidemiological investigations by the Centre for Health Protection (CHP) of the DH so far located 12 close contacts and 47 other contacts of the patient.

(A) Close contacts

The close contacts have been put under quarantine and prescribed with antiviral presumptive treatment until the completion of the five-day treatment or ten days after last exposure to the patient, whichever is earlier. They include:

• Seven family members (revised from nine after further enquiries) in which one was symptomatic and tested negative for H7 virus while the rest being asymptomatic; and
  
• Five in-patients admitted to the same cubicle as the patient in Tuen Mun Hospital (TMH) in which one was symptomatic and tested negative for H7 virus while the rest being asymptomatic.
  
• Two travel collaterals are yet to be reached and follow-up is underway.
  

(B) Other contacts

The other contacts have been put under medical surveillance and they include:

• A total of 42 healthcare workers who took care of the patient in TMH in which two were symptomatic and tested negative for H7 virus while the rest being asymptomatic;
• Three asymptomatic ambulance officers involved in patient transfer; and
• Two asymptomatic visitors of the cubicle to which the patient was admitted.

The two private doctors whom the patient consulted are yet to be reached and follow-up is underway.
The CHP is communicating with the health authorities of Guangdong Province to follow up the situation during the patient's stay in the Mainland.

As the patient did not visit any wet markets or contact live poultry in Hong Kong during the incubation period, based on information available thus far, it is classified as an imported case. Investigations are ongoing.

The Lady MacLehose Holiday Village in Sai Kung under the Leisure and Cultural Services Department is being converted as a quarantine centre. Asymptomatic close contacts will be quarantined there.

Upon activation of the Serious Response Level (SRL) under the Preparedness Plan for Influenza Pandemic last night (December 27), the DH immediately commenced enhanced surveillance, enhanced port health measures and risk communication accordingly.

Enhanced surveillance
---------------------
The CHP has enhanced surveillance of suspected cases in public and private hospitals, and will activate electronic reporting system to monitor cases real-time with the Hospital Authority. Clinicians should pay special attention to patients with fever or influenza-like illness who visited wet market with live poultry or had contact with poultry in affected areas within the incubation period, that is 10 days before onset.

Letters to doctors, hospitals, kindergartens, child care centres, primary and secondary schools as well as residential care homes for the elderly and the disabled have been issued to alert them to the latest situation.

The case has been notified to the World Health Organization, the National Health and Family Planning Commission (NHFPC), the health authorities of Guangdong and Macau, and the quarantine authority of Shenzhen.

As winter approached, the number of human cases of H7N9 in the Mainland has been increasing. As of yesterday, 16 cases with onsets since September were notified to the CHP by the NHFPC. Based on the seasonal pattern, it is likely that the activity of avian influenza viruses might further increase in winter and heightened vigilance is warranted.

As of yesterday, 470 cases (including at least 184 deaths) have been reported since March 2013, including 454 cases in the Mainland and 16 cases exported to Hong Kong (eleven cases), Taiwan (four cases) and Malaysia (one case).

Enhanced port health measures
-----------------------------
All boundary control points have implemented health surveillance measures. Thermal imaging systems are in place for body temperature checks of inbound travellers. Suspected cases will be immediately referred to public hospitals for follow-up. The DH's Port Health Office has enhanced body temperature checks by handheld devices.

Regarding health education for travellers, the display of posters and broadcasting of health messages in departure and arrival halls, environmental health inspection and provision of regular updates to the travel industry and other stakeholders will be enhanced.

Risk communication
------------------
The CHP's hotline (2125 1111) for public enquiries has been set up and will operate from 9am to 6pm today and tomorrow. The CHP's main page (www.chp.gov.hk/en) has been updated with the activation of the SRL.

Travellers, especially those returning from avian influenza-affected areas with fever or respiratory symptoms, should immediately wear masks, seek medical attention and reveal their travel history to doctors. Healthcare professionals should pay special attention to patients who might have had contact with poultry, birds or their droppings in affected areas.
     The public should remain vigilant and take heed of the advice against avian influenza below:

• * Do not visit live poultry markets and farms. Avoid contact with poultry, birds and their droppings;
• If contact has been made, thoroughly wash hands with soap;
• Avoid entering areas where poultry may be slaughtered and contact with surfaces which might be contaminated by droppings of poultry or other animals;
• Poultry and eggs should be thoroughly cooked before eating;
• Wash hands frequently with soap, especially before touching the mouth, nose or eyes, handling food or eating; after going to the toilet or touching public installations or equipment (including escalator handrails, elevator control panels and door knobs); and when hands are dirtied by respiratory secretions after coughing or sneezing;
• Cover the nose and mouth while sneezing or coughing, hold the spit with a tissue and put it into a covered dustbin;
• Avoid crowded places and contact with fever patients; and
• Wear masks when respiratory symptoms develop or when taking care of fever patients.

     The public may visit pages below for more information:

• The CHP's avian influenza page (www.chp.gov.hk/en/view_content/24244.html); and
• Global statistics and affected areas of avian influenza in the CHP's website

(www.chp.gov.hk/files/pdf/global_statistics_avian_influenza_e.pdf).

Ends/Sunday, December 28, 2014
Issued at HKT 20:02

ECDC Epidemiological Update – MERS In Turkey (ex KSA)

 

# 9231

 

 

Although there is nothing confirmed yet, Turkish media is reporting that several `suspected’ MERS cases with recent travel history to Saudi Arabia are under investigation (see FluTrackers thread), and the Turkish MOH has stated they are following up on contacts of their single confirmed imported case (see Turkey Announces MERS Fatality – ex KSA).

Today the ECDC published the following epidemiological update on this latest exported MERS case from Saudi Arabia.

 

 

Epidemiological update: MERS-CoV case imported to Turkey

22 Oct 2014

​On 18 October 2014, the Ministry of Health Turkey reported that a Turkish citizen working in Saudi Arabia died on 11 October 2014, ten days after onset of a confirmed MERS-CoV infection. The case returned to Turkey on 10 October 2014. It is assumed that the case was symptomatic during the flight. The local health authorities are conducting contact tracing.

Worldwide situation

Overall, 906 laboratory-confirmed cases of MERS-CoV have been reported to the public health authorities worldwide, including 361 deaths as of 21 October 2014 (Figure 1).

Figure 1. Distribution of confirmed cases of MERS-CoV reported as of 21 October 2014, by date and place of probable infection (n=906)

Most of the cases have occurred in the Middle East (Saudi Arabia, United Arab Emirates, Qatar, Jordan, Oman, Kuwait, Egypt, Yemen, Lebanon and Iran) (Table 1).

Between 1 September and 21 October 2014, the health authorities in Saudi Arabia reported 29 cases, 15 of which were in Taif. Twenty-four of them (83%) are male, of which 20 (83%) above 40 years of age. Comorbidities were reported in 20 of the 29 cases. Four cases were reported among healthcare workers. Several cases had contact with animals, including camels, and some reported having drunk camel milk.

On 20 October, the Ministry of Health of Saudi Arabia issued a press release about the implementation of measures to control the cluster of cases in Taif, in particular addressing the dialysis units. 

<SNIP>

Conclusions

• The incidence of cases in September and October 2014 is slightly higher than in July and August 2014. This pattern was also observed in 2012 and 2013. The majority of MERS-CoV cases are still being reported from the Arabian Peninsula, specifically from Saudi Arabia, and all cases have epidemiological links to the outbreak epicentre.

• According to the pattern observed in 2012 and 2013, more cases could be observed in the coming weeks.

• The latest importation to the EU (Austria) and to Turkey are not unexpected and do not indicate a significant change in the epidemiology of the disease. Importation of MERS-CoV cases to the EU remains possible. However, the risk of sustained human-to-human transmission remains very low in Europe.

ECDC Ebola Epidemiological Update – Oct 10th

 

# 9178

 

The ECDC has produced another of their data and graphic rich epidemiological updates on the Ebola outbreak, which includes a listing of all cases evacuate to the United States & Europe, the most recent stats, and a listing of key events in this outbreak since it first made headlines last March.

 

Follow the link below for the full update, including an impressive selection of maps and charts.

 

Epidemiological update: outbreak of Ebola virus disease in West Africa

10 Oct 2014

Chronology of events – key dates

22 March 2014: the Guinea Ministry of Health notified WHO about a rapidly evolving outbreak of EVD [1]. The first cases occurred in December 2013. The outbreak is caused by a clade of Zaïre ebolavirus that is related but distinct from the viruses that have been isolated from previous outbreaks in central Africa, and clearly distinct from the Taï Forest ebolavirus that was isolated in Côte d’Ivoire from 1994–1995 [2-4]. The first cases were reported from south-eastern Guinea and the capital Conakry.

May 2014: the first cases were reported from Sierra Leone and Liberia [5,6] to where the disease is assumed to have spread through the movement of infected people over land borders.

End of July 2014: a symptomatic case travelled by air to Lagos, Nigeria, where he infected a number of healthcare workers and airport contacts before his condition was recognised to be EVD.

8 August 2014: WHO declared the outbreak a Public Health Event of International Concern (PHEIC) [7] and confirmed on 22 September that the 2014 Ebola outbreak in West Africa continued to constitute a Public Health Emergency of International Concern.

29 August 2014: the Ministry of Health in Senegal reported a confirmed imported case of EVD in a 21-year-old male native of Guinea.

18 September 2014: the United Nations Security Council recognised the EVD outbreak as a 'threat to international peace and security' and unanimously adopted a resolution on the establishment of an UN-wide initiative which focuses assets of all relevant UN agencies to tackle the crisis [8].

23 September 2014: A study published by the WHO Ebola response team forecasted more than 20 000 cases (5740 in Guinea, 9890 in Liberia, and 5000 in Sierra Leone) by the beginning of November 2014 [9]. The same study estimated the doubling time of the epidemic at 15.7 days in Guinea, 23.6 days in Liberia, and 30.2 days in Sierra Leone.

30 September 2014: the US Centers for Disease Control and Prevention (CDC) announced the first imported case in US of Ebola linked to the current outbreak in West Africa.

3 October 2014: In Senegal, all contacts of the imported EVD case have completed a 21-day follow-up period. No local transmission of EVD has been reported in Senegal.

6 October 2014: The Spanish authorities reported a confirmed case of Ebola virus disease (EVD) of a healthcare worker who participated in the treatment in Spain of the second Spanish patient with Ebola infection repatriated to Spain.

Epidemiological update

Situation in West Africa

Since December 2013 and as of 5 October 2014, 8 032 cases of EVD, including 3 865 deaths, have been reported by WHO (Figure 1) [10].

The distribution of EVD cases by affected countries is as follows and is presented in figure 1:

• Guinea: 1 298 cases and 768 deaths as of 5 October 2014;
• Liberia: 3 924 cases and 2 210 deaths as of 4 October 2014;
• Sierra Leone: 2 789 cases and 879 deaths as of 5 October 2014;
• Nigeria: 20 cases and 8 deaths, with last confirmed case in Lagos on 5 September 2014 (30 days as of 5 October 2014) and in Rivers State on first September 2014 (34 days as of 5 October);
• Senegal: 1 case, no deaths, confirmed on 28 August 2014 (38 days as of 5 October). All contacts have completed 21 days of follow-up.

 

(Continue . . . )

ECDC Epidemiological Update On Ebola In West Africa

Credit CDC PHIL

 

# 8933

 

The ECDC has produced a new Epidemiological update, based primarily on the numbers posted by the World Health Organization.  The data we have is crude at best, with basically only the number of (confirmed, probable, suspected) cases reported from each country, and the number of fatalities.

 

Demographic information, such as age or gender, hasn’t been available beyond some anecdotal mentions in the media.

 

Due to suboptimal surveillance and reporting capabilities in these West African nations, and a reluctance of many of those sick to come forward – the case counts we have likely under represent the actual number of cases in the region. 

 

It is too early to draw conclusions over the apparent differences in mortality rates (Guinea 74% – Sierra Leone 42%), as the onset and progression of this disease has varied by country.  Differences in surveillance, reporting, and willingness of their citizens to seek treatment could greatly influence these numbers as well.

 

 

Epidemiological update: outbreak of Ebola virus disease in West Africa

08 Aug 2014

On 8 August, the World Health Organisation declared the outbreak of Ebola virus disease (EVD) evolving in West Africa a Public Health Emergency of International Concern (PHEIC).

The outbreak started in December 2013 and it is currently accelerating. The outbreak is growing in Guinea, Liberia, Sierra Leone and more recently in Nigeria, a newly affected country with locally acquired infections. Transmission has occurred in large cities of these four countries (Conakry, Freetown, Monrovia and Lagos).

As of 6 August, the cumulative number of cases reported was 1779, including 961 deaths, making this EVD outbreak by far the largest ever recorded in terms of geographical spread and number of cases and deaths reported. Of these, 815 (46%) cases including 358 deaths were reported in the past four weeks.

On 29 July 2014, WHO was notified of a probable EVD case in Nigeria. The case travelled by air and arrived in Lagos, Nigeria, on 20 July via Lomé, Togo, and Accra, Ghana and was symptomatic at the time of arrival.

As of 7 August, medical evacuations of EVD sick patients were performed to USA (two patients) and Spain (one patient).

The distribution of cases by week of reporting since the start of the outbreak is the following:

Weekly number of EVD cases in West Africa (Guinea, Sierra Leone, Liberia and Nigeria) up to 06/08/2014

All countries

Per country

Source: adapted from WHO (Ebola virus disease, West Africa – update)
Data for the week 32/2014 are incomplete.

Situation by country as of 6 August (source WHO)

Guinea: 495 cases (355 confirmed), including 367 deaths (case-fatality ratio 74%).
Liberia: 554 cases (148 confirmed cases), including 294 deaths (case-fatality ratio 53%).
Nigeria: 13 cases (0 confirmed, 7 probable, and 6 suspected), including 2 deaths.
Sierra Leone: 717 cases (631 confirmed), including 298 deaths (case-fatality ratio 42%).

Overview of EVD cases (confirmed, probable and suspected) and deaths in Guinea, Liberia, Sierra Leone and Nigeria, as of 6 August 2014

Read more

Latest ECDC Rapid Risk Assessment Outbreak of Ebola virus disease in West Africa

ECDC Epidemiological Update On Ebola – July 17th

MSF (Médecins Sans Frontières) health staff in protective clothing constructing perimeter for isolation ward.

Credit CDC Ebola Webpage

 

 

# 8843

 

While stressing that the risk to travelers visiting Guinea, Sierra Leone, and Liberia remains very low – and that their previously published Risk Assessment for the EU remains unchanged – the ECDC today has published their latest epidemiological assessment of the ongoing Ebola Outbreak in Western Africa.

This outbreak – which first made headlines in March– is now considered to be the largest Ebola epidemic on record.

 

In the most recent ECDC Rapid Risk Assessment on Ebola (June 9th), experts worked out several scenarios where the Ebola virus might travel to the European Union:

Scenario 1: Suspicion of exposure to Ebola virus.

Scenario 2: Person presenting with symptoms compatible with EVD.

Scenario 3: Passenger with symptoms compatible with EVD on board of an airplane.

Scenario 4: Patients and healthcare workers having been exposed to an unrecognised Ebola patient

However they reassure that the capacity to detect and confirm cases of EVD in the EU is considered to be sufficient, and that the risk of a traveler developing the disease after returning to the EU as `extremely low’.

For some additional background on this disease, you may with to revisit A Brief History Of Ebola.

.

Epidemiological update: Outbreak of Ebola Virus Disease in West Africa

17 Jul 2014

​An outbreak of Ebola Virus Disease (EVD) with onset in December 2013 is still evolving in Guinea, Liberia and Sierra Leone. The first cases were reported from Guéckédou prefecture, a forested region of south-eastern Guinea near the border with Liberia and Sierra Leone. After a slow-down in April, new cases and deaths attributed to EVD have continued to be reported. The largest increase in cases since the previous ECDC update in 2 July was in Sierra Leone, followed by Liberia and Guinea.

From 8–12 July 2014, 85 new cases including 68 deaths were reported. As of 12 July, the cumulative number of cases and deaths was 964 and 603 respectively, making this the largest ever documented outbreak of EVD, unprecedented in the number of cases and geographical spread.

Current situation

The case count as of 12 July is displayed in the table below. The data are based on best available information reported by Ministries of Health through the World Health Organization Regional Office for Africa. 

 

Source: Adapted from WHO (Ebola virus disease, West Africa – update). The total number of cases is subject to change due to reclassification, retrospective investigation, consolidation of cases and laboratory data, and enhanced surveillance

While outbreaks of EVD are not new in Africa, this is the first documented outbreak in West Africa. Various patterns of transmission complicate the control of the current EVD outbreak: the affected area is vast and in parts difficult to access; there are multiple hotspots of transmission; differences in beliefs, cultural practices and traditions among the affected populations; and substantial movement of people between rural and urban areas and across national borders. Transmission occurs in rural areas, in peri-urban areas notably in capitals in Guinea (Conakry), Liberia (Monrovia), and Sierra Leone (Freetown), and in districts alongside country borders in Guinea, Sierra Leone and Liberia.

On 16 July 2014, WHO established a sub-regional outbreak coordination centre in Conakry, Guinea  to better meet the needs to control the outbreak, as a follow up action to the Emergency Ministerial meeting in Accra that was convened by WHO in Accra, Ghana, 2-3 July. The centre will act as a control and coordination platform, consolidating and harmonising the technical support to the West African countries including assisting in resource mobilisation.

WHO and international organisations are closely supporting the Ministry of Health of Guinea, Ministry of Health & Social Welfare of Liberia and Ministry of Health and Sanitation of Sierra Leone in their EVD prevention, contract tracing, health care and control related activities.

Conclusions

Despite the efforts to limit the spread, a substantial number of new cases have continued to be reported from all three affected countries since the previous ECDC Epidemiological Update of 2 July 2014 showing that the outbreak has not yet been brought under control. While the speed of transmission remains stable in Guinea, it seems to have accelerated in Liberia and Sierra Leone.

The risk of infection for travellers visiting Guinea, Liberia and Sierra Leone is considered very low. Most human infections result from direct contact with bodily fluids or secretions from an infected human, and the highest risks of infection are associated with caring for infected patients, particularly in hospital settings, unsafe medical procedures, including exposure to contaminated medical devices, such as needles and syringes and unprotected exposure to contaminated bodily fluids.

WHO does not recommend any travel or trade restrictions be applied to Guinea, Liberia, or Sierra Leone based on the current information available for this event.

ECDC continues to closely monitor the situation on the Ebola outbreak in the West Africa region. The conclusions of the assessment provided in the ECDC rapid risk assessment (RRA) on the 9 June 2014 remain valid.

Read more

Rapid Risk Assessment "Outbreak of Ebola virus disease in West Africa"

PAHO Chikungunya Epidemiological Update – May 30th

# 8695

 

 

Although it only first appeared in the Americas last November, we’ve gone from a handful of cases on the French Part of St. Martins to more than 100,000 cases spread across much the the Caribbean, in just six months.  A demonstration of just what an emerging  virus, aided and abetted by a competent and ubiquitous vector, can do to a highly susceptible and immunologically naive population.

 

In recent weeks we’ve looked at how Florida Prepares For Chikungunya , a Study on Chikungunya’s Growing Threat To The Americas, and several CDC presentations, including a Chikungunya Update & CDC Webinar Online.

 

 

Today, a brief update from PAHO on the most recent reporting week (22) for Chikungunya across the Caribbean.

 

Chikungunya

PAHO / WHO received on December 6, 2013 the confirmation of the first cases of autochthonous transmission of Chikungunya virus in the Americas. Existing cases are registered and weekly updated in the following table:

• Number of Reported Cases of Chikungunya Fever in the Americas.

 

:: Technical guidelines and recommendations

PAHO / WHO recommends that countries with a presence of the transmitting mosquito establish and maintain their capacity to detect and confirm cases; manage patients; and implement an effective communication strategy to reduce the presence of the mosquito. It is also recommended to strengthen laboratory capacity to identify and confirm the virus in a timely manner.

ECDC Epidemiological Update On MERS – May 16th

Credit ECDC

 

# 8629

 

 

With the recent spike in MERS cases in Saudi Arabia and the UAE - combined with its recent exportation to the US, Greece, Egypt, Malaysia, and the Netherlands – the ECDC has taken to updating their epidemiological update on this emerging coronavirus on a weekly basis.

 

In this edition the ECDC takes note of both the IHR Meeting this week, and the continued spread of the virus, but assesses the risks to the EU as being unchanged at this time:

 

ECDC continues to monitor information on the situation on MERS-CoV worldwide. In earlier Rapid Risk Assessments, ECDC concluded that the risk of importation of MERS-CoV to the EU was expected to continue and the risk of secondary transmission in the EU remains low. The conclusions of the assessment provided in the ECDC rapid risk assessment (RRA) on 24 April 2014 remain valid.

 

As we’ve come to expect, these ECDC updates are both current, and filled with terrific graphics. Follow the link to read:

 

 

Epidemiological update: Middle East respiratory syndrome coronavirus (MERS-CoV)

16 May 2014

​

ECDC notes the decision of Margaret Chan, the Director General of WHO, on 14 May 2014 not to call the Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak a Public Health Emergency of International Concern (PHEIC) as the conditions have not been met yet. This decision was based on the advice of the WHO Emergency Committee under the IHR on MERS-CoV. However the committee indicated that, based on current information, “the seriousness of the situation had increased in terms of public health impact, but that there is no evidence of sustained human-to-human transmission.”

Since April 2012 and as of 16 May 2014, 621 cases of MERS-CoV infection have been reported globally, including 188 deaths.

On 11 May 2014 a second imported case of MERS-CoV was confirmed by the United States Centers for Disease Control.

On 13 May 2014, National Institute for Public Health and the Environment (RIVM) in the Netherlands reported the first imported case of MERS-CoV in the country. On 15 May 2014 a second case, who travelled with the first case, was reported.

Confirmed cases and deaths by region:

Middle East:
Saudi Arabia: 511 cases/160 deaths
United Arab Emirates: 67 cases/9 deaths
Qatar: 7 cases/4 deaths
Jordan: 9 cases/4 deaths
Oman: 2 cases/2 deaths
Kuwait: 3 cases/1 death
Egypt: 1 case/0 deaths
Yemen: 1 case/1 death
Lebanon: 1 case/0 deaths

Europe:
UK: 4 cases/3 deaths
Germany: 2 cases/1 death
France: 2 cases/1 death
Italy: 1 case/0 deaths
Greece: 1 case/0 deaths
Netherlands: 2 cases/0 deaths

Africa:
Tunisia: 3 cases/1 death

Asia:
Malaysia: 1 case/1 death
Philippines: 1 case/0 deaths

Americas:
United States of America: 2 cases/0 deaths

Most cases have either occurred in the Middle East or have direct links to a primary case infected in the Middle East. Local secondary transmission following importation was reported from the United Kingdom, France, and Tunisia.

(Continue . . . )

ECDC Epidemiological Update On MERS-CoV

Credit ECDC - More than half of all known MERS Cases Reported in last 30 days

 

# 8553

 

With the end of the month upon us, it is a bit sobering to realize that we’ve just seen more MERS cases reported during the past 30 days than had been reported in the entire two years prior to April 1st. While it isn’t clear at this point whether this MERS outbreak has got `legs’ or not, this rapid increase in cases has caught just about everyone’s attention in the world of infectious diseases. 

 

Today the ECDC has posted an epidemiological update on the MERS coronavirus with a number of new graphics, excerpts which you find below.

 

Epidemiological update: Middle East respiratory syndrome coronavirus (MERS-CoV)

30 Apr 2014

​As of 30 April 2014, 424 cases of MERS-CoV have been reported globally, including 131 deaths. All cases have either occurred in the Middle East or have direct links to a primary case infected in the Middle East.

• Middle East
  Saudi Arabia: 342 cases / 105 deaths
  United Arab Emirates: 49 cases / 9 deaths
  Qatar: 7 cases / 4 deaths
  Jordan: 5 cases / 3 deaths
  Oman: 2 cases / 2 deaths
  Kuwait: 3 cases / 1 death
  Egypt: 1 case/ 0 deaths
• Europe
• UK: 4 cases / 3 deaths
  Germany: 2 cases / 1 death
  France: 2 cases / 1 death
  Italy: 1 case / 0 deaths
  Greece: 1 case/ 0 deaths
• Africa
  Tunisia: 3 cases / 1 death
• Asia
  Malaysia: 1 case / 1 death
  Philippines: 1 case / 0 deaths

The primary case for each chain was infected in the Middle East, and local secondary transmission following importation was reported from the United Kingdom, France, and Tunisia.

The number of reported cases increased markedly in April 2014 (Figure 1) with 217 cases and 38 deaths. Between March 2013 and March 2014 the monthly average number of reported cases was 15.

During April 2014, 217 cases were reported, as compared to the 207 cases reported from the beginning of the outbreak (March 2012) to 31 March 2014. Among these 217 cases, 179 (82%)  were reported by Saudi Arabia, 32 cases (15%) by the United Arab Emirates, 2 cases were reported by Jordan and one case each by Egypt, Greece, Malaysia and Philippines (Figure 4).

Healthcare workers have been more frequently reported during the month of April 2014 than previously. Since April 2012, 95 cases have been healthcare workers, of whom 62 (65%) were reported in April 2014. Seventy (74%) of the healthcare workers were reported from Saudi Arabia, twenty-three (24%) from the United Arab Emirates, and one each from Philippines and Jordan.

The cause of the rapid increase in cases in April is unknown. The Rapid Risk Assessment of 24 April considers the possible scenarios that might explain this, notably:

• More sensitive case detection through more active case finding and contact tracing or changes in testing algorithms,
• Increased zoonotic transmission with subsequent transmission in healthcare settings,
• Breakdown in infection control measures or otherwise increased transmission in the local healthcare setting,
• Change in the virus resulting in more effective human-to-human transmission, resulting in both nosocomial clusters, and increased numbers of asymptomatic community acquired cases, or
• False positive lab results.

On 26 April, Christian Drosten of Bonn University published a report in ProMed describing the preliminary results from sequence analysis of three viruses recovered from recent cases. These results suggest that the virus has not undergone major genetic changes compared to MERS/CoV sequenced earlier in the outbreak. The report also provide evidence against the hypothesis of a laboratory contamination causing this increase in reported cases.

ECDC continues to monitor information on the situation on MERS-CoV worldwide. In earlier Rapid Risk Assessments, ECDC concluded that the risk of importation of MERS-CoV to the EU was expected to continue and the risk of secondary transmission in the EU remains low. The assessment provided in the ECDC Rapid Risk Assessment on 24 April 2014 remains valid.

Read more on MERS-CoV

ECDC Epidemiological Update: Chikungunya Spreads In Caribbean And Into South America

Credit CDC

 

# 8322

 

Earlier this week, in COCA Call On Chikungunya –  Feb 18th, I blogged on the CDC’s efforts to inform clinicians of the recent arrival of the Chikungunya virus to the Americas.  Those who missed it can find additional information on that webinar HERE.

 

Until a decade ago, Chikungunya (aka `Chik’) was only found in parts of central Africa, and then only occasionally sparked small outbreaks. 

 

In 2005, however, it jumped to Reunion Island in the Indian Ocean, where it sparked a major epidemic. Since then it has spread rapidly to counties such as India, Thailand, Vietnam, Indonesia, Myanmar, Pakistan, and others in  Asia and  the Western Pacific.

 

Quite famously, Chik was carried by an international traveler from India to Northern Italy in 2007, where it sparked a local outbreak involving roughly 300 people (see It's A Smaller World After All). 

 

While that outbreak was eventually contained, that introduction of the virus to Italy showed that Europe and  the Americas were vulnerable to the importation of the virus, prompting the CDC & PAHO to publish a document  in 2011 called Preparedness and Response for Chikungunya Virus Introduction in the Americas.

 

As predicted, the virus showed up last November (see WHO: Chikungunya In Caribbean – French Part of St. Martins), and since then has spread rapidly between the Leeward and Windward Islands, and has now appeared on the South American continent.

 

Today, the ECDC provides the following Epidemiological update, indicating nearly 6,000 suspected infections have been reported since the fall.

 

 

Epidemiological update: autochthonous cases of chikungunya fever in the Caribbean region and South America

21 Feb 2014

​An outbreak of chikungunya in the Caribbean region was reported from the French part of the island of Saint Martin on 6 December 2013. It is the first time that autochthonous transmission of the virus has been documented in the Americas.

An ECDC risk assessment of the outbreak published on 12 December 2013 concluded that the risk of the disease spreading to other islands in the Caribbean region was high. Since then, autochthonous transmission of chikungunya has been reported from several islands in the Caribbean and recently for the first time in South America (French Guiana).

As of 21 February 2014, more than 5 900 suspected cases have been reported in the following locations:

Caribbean:

• Saint Martin (FR): 1 780 suspect cases
• Sint Maarten (NL): 65 confirmed cases
• Saint Barthélemy: 350 suspect cases
• Martinique: 3 030 suspect cases
• Guadeloupe: 1 380 suspect cases
• British Virgin Islands, Jost Van Dyke islands: 5 confirmed cases;
• Dominica: 45 confirmed cases including one imported case
• Anguilla: 5 confirmed cases including one imported case;
• Island Aruba: one confirmed imported case
• Saint Kitts & Nevis: one confirmed case

South America:

• French Guiana: 7 confirmed/probable cases including 2 autochthonous cases and 5 imported cases.

This overview indicates that the chikungunya outbreak in the Caribbean is still ongoing and reaching now South America.

The chikungunya transmission was detected during a concomitant dengue outbreak in the Caribbean. Both arboviruses are transmitted by the same Aedes aegypti mosquito species. The naïve population, the presence of an effective vector in the region and the movement of people in and between islands and territories are factors that make it likely that the outbreak will continue to spread geographically and increase in numbers.

The conclusions and recommendations of the rapid risk assessment published on 12 December 2013 remain valid.

Clinicians and travel medicine clinics should remain vigilant regarding imported dengue and chikungunya cases from the Caribbean and French Guiana.

 

As with West Nile Virus, Malaria, and Dengue fever – the mosquito vectors for spreading Chikungunya are abundant across much of the United States.

 

Although we’ve seen sporadic cases of viremic CHKV infected travelers to the United States in the past (see 2011 CID Journal report Chikungunya Fever in the United States: A Fifteen Year Review of Cases), those numbers have been small (109 between 1995- 2009), and so far (unlike dengue and WNV), we haven’t seen any evidence of local transmission.

 

But with CHKV now in the Americas, the number of CHKV infected travelers to the United States may well increase,  and any who are viremic (producing large quantities virus in their blood) while visiting regions where suitable mosquito vectors are present, could potentially introduce the virus to the local mosquito population.

Hong Kong: Epidemiological Update On 5th Imported H7N9 Case

 

# 8294

 

As we’ve come to expect, Hong Kong’s Centre For Health Protection (CHP) has very quickly released an epidemiological update on yesterday’s announced imported H7N9 case, including details on contact tracing, testing, and quarantines.

 

Epidemiological investigation and follow-up actions by CHP on confirmed human case of avian influenza A(H7N9)

Thursday, February 13, 2014 Issued at HKT 19:56

The Centre for Health Protection (CHP) of the Department of Health (DH) today (February 13) provided an update on the fifth confirmed human case of avian influenza A(H7N9) affecting a man aged 65.

"The epidemiological investigations, enhanced disease surveillance, port health measures and health education against avian influenza are all ongoing," a spokesman for the DH said.

As of 4pm today, six close contacts and 82 other contacts have been identified.

The close contacts are the five family members of the index patient in Hong Kong and a patient who had stayed in the same ward with the index patient in Kwong Wah Hospital (KWH).

The five family members have remained asymptomatic while the patient in KWH had onset of symptoms before contact with the index patient. Upon preliminary laboratory testing by Princess Margaret Hospital (PMH), their respiratory specimens were all negative for Influenza A virus. They remain under observation.

Other contacts included the index patient's other family members, staff and patients of the private clinic which the patient attended, healthcare workers of relevant public hospitals and the officers at Lo Wu Boundary Control Point. Among them, two are symptomatic and their specimens were negative for Influenza A virus upon PMH's preliminary testing. They are all under medical surveillance.

"In view of human cases of avian influenza A(H7N9) confirmed in Hong Kong and multiple cases notified by the Mainland, the activity of the virus is expected to be higher in the winter season. Those planning to travel outside Hong Kong should maintain good personal, environmental and food hygiene at all times," the spokesman urged.

(Continue . . . )

 

Despite the large number (relative to other avian flu viruses) of human cases, and a handful of clusters, a year’s worth of contact tracing in China, Taiwan, and Hong Kong has yet to turn up more than a small handful of infected cases – a pretty good sign that this virus is not yet ready for prime time.

 

The concern is that it may only take a small number of genetic changes to the virus to increase its transmissibility, and so extensive epidemiological investigations like this one not only help prevent the potential spread of the virus, they serve as an important early warning system as well.

Hong Kong: CHP Epidemiological Investigation Into Imported H7N9 In Poultry

Credit HK CHP

 

 

# 8233

 

While the announcement yesterday on the detection of H7N9 in Hong Kong was in reference to imported poultry, those who had contact with the infected fowl are now the subject of contact tracing and medical surveillance by the Centre For Health Protection. 

 

With the openness and efficiency we are used to seeing from Hong Kong’s CHP, less than 24 hours after that first announcement we have the their first epidemiological update.

 

First the text of the update, then some excerpts from a letter sent to local doctors informing them of the situation.

28 January 2014

Epidemiological investigation by CHP on live poultry imported from Mainland tested positive for avian influenza A(H7) virus 

The Centre for Health Protection (CHP) of the Department of Health today (January 28) provided an update on the epidemiological investigation after samples of live chicken imported from the Mainland tested positive for the avian influenza A(H7) virus.

The poultry worker responsible for transporting the consignment of live chickens concerned, being a close contact, has been located. He has remained asymptomatic and was admitted to Princess Margaret Hospital this morning for observation. His respiratory specimen tested negative for the H7 virus upon preliminary laboratory testing by the CHP's Public Health Laboratory Services Branch (PHLSB).

In collaboration with the Food and Environmental Hygiene Department and the Agriculture, Fisheries and Conservation Department, as of 4pm today, a total of 95 other contacts comprising 11 staff members of Man Kam To Animal Inspection Station (MKTAIS), 35 poultry workers at Cheung Sha Wan Temporary Wholesale Poultry Market and 49 workers involved in the culling operation have also been identified. They were put under medical surveillance and health advice was given. The CHP will follow-up on their health condition.

Among them, an officer of MKTAIS developed non-specific symptoms and his respiratory specimen tested negative for H7 upon preliminary testing by the PHLSB.

"We have issued letters to doctors and hospitals to keep them abreast of the latest situation. Doctors should remain vigilant and immediately report to the CHP if there is any suspected case," a spokesman for the CHP said.

Ends/Tuesday, January 28, 2014

 

 

 

Our Ref. :   (122) in DH SEB CD/8/6/1 Pt.27      

28 January 2014

Dear Doctor,

Live poultry imported from Mainland tested positive for H7 avian influenza virus

Further to our letter to you dated 21 January 2014, I would like to draw your attention to the report that a number of samples from a batch of live chicken imported from a registered poultry farm in Shunde  District of Foshan City of Guangdong Province were confirmed H7 positive by H7 Polymerase Chain Reaction test (genetic test) on 27 January 2014. This batch of chicken had not yet been released to the retailed markets. The Agriculture, Fisheries and Conservation Department (AFCD) has declared the Cheung Sha Wan Temporary Wholesale Poultry Market as an infected place.  All of the some 20 000 live poultry in the market will be culled.  The market has also been closed for 21 days until 18 February for thorough disinfection and cleansing. During the closure period, trading of live poultry (including Mainland and local live poultry) will be suspended. The Government has notified the relevant Mainland authorities for tracing the exact source of infection. The Centre for Health Protection (CHP) of the Department of Health (DH) has put the wholesalers and workers of the Man Kam To Animal Inspection Station and Cheung Sha Wan Temporary Wholesale Poultry Market who might have been exposed to this batch of chicken under medical surveillance.

Since the occurrence of  H7N9 avian influenza cases in the Mainland in March last year, Hong Kong has been on high alert and carried out measures to safeguard against the disease. Starting from  last April, H7 genetic tests on imported live poultry at the boundary control point have been conducted and more than 14 000 samples have been tested since then and they were all negative for H5 and H7 viruses. It is the first time that H7 virus was found in imported poultry in Hong Kong. In accordance with the Preparedness Plan for Influenza Pandemic on the Serious Response Level, the Government has adopted corresponding contingency measures to prevent the virus from spreading in the community and safeguard public health. Among others, the DH will enhance surveillance to detect any potential human cases.

As mentioned in our letter to you earlier, most human cases have reported contact with poultry or live animal markets. Knowledge about the main virus reservoirs and the extent and distribution of the virus in animals remains limited. Since avian influenza A(H7N9) virus causes only subclinical infections in poultry, it is possible that the virus continues to circulate among poultry  without any warning signals to human. In this connection, poultry workers might be at a higher risk of avian influenza A(H7N9) infection. In fact, a proportion of the cases reported in Mainland were also poultry workers.

In this connection, we would like to remind you that working in live poultry industry has been included as one of the epidemiological criteria since 6 December 2013. The reporting criteria for human influenza A (H7N9) infection are available on CENO On-line website (http://ceno.chp.gov.hk/).

Please also be reminded that the list of affected areas is regularly uploaded to CHP website (http://www.chp.gov.hk/files/pdf/global_statistics_avian_influenza_e.pdf). 

(Continue . . . )

Hong Kong: Epidemiological Update On Third H7N9 Case

 

# 8147

 

Yesterday Hong Kong announced their third detection of the H7N9 virus in a 65-year-old man who had recent travel history to Shenzhen, in neighboring Guangdong Province. Today, we’ve the first update on their epidemiological investigation. 

 

The good news is that so far, none of this patient’s contacts has tested positive for the H7 virus.  However, 5 close contacts along with 90  lesser contacts, will be under medical surveillance for the next 10 days.

 

Epidemiological investigation and follow-up actions by CHP on confirmed human case of avian influenza A(H7N9)

The Centre for Health Protection (CHP) of the Department of Health (DH) today (January 9) provided an update on the confirmed human case of avian influenza A(H7N9) affecting a man aged 65.

"The epidemiological investigations, enhanced disease surveillance, port health measures and health education against avian influenza are all ongoing," a spokesman for the DH said.

As of 2pm today, five close contacts and over 90 other contacts had been located.

Close contacts have been put under quarantine for ten days since their last contact with the patient and were prescribed with the antiviral Tamiflu for prophylaxis, followed by ten more days of medical surveillance. They include:

* One family member of the patient; and
* Four patients who stayed in the same cubicle with the patient in Queen Mary Hospital.

All of them have not developed symptoms after contacting the patient. Their respiratory specimens all tested negative for the H7 virus upon preliminary laboratory testing by the CHP's Public Health Laboratory Services Branch.

Other contacts include another family member of the patient, healthcare workers (HCWs) of relevant healthcare facilities, clients and visitors of such facilities, an officer at border control point (BCP) and the patient's neighbours. They will remain under medical surveillance.

Among them, five developed non-specific symptoms. The respiratory specimens of three of them, including an HCW, tested negative for H7 virus while the result of the remaining two samples are pending.

Locally, enhanced surveillance over suspected cases in public and private hospitals is underway.

"We will remain vigilant and maintain liaison with the World Health Organization (WHO), the Mainland and overseas health authorities. Local surveillance activities will be modified according to the WHO's recommendations," the spokesman said.

All BCPs have implemented disease prevention and control measures. Thermal imaging systems are in place for body temperature checks of inbound travellers. Random temperature checks by handheld devices will also be arranged. Suspected cases will be immediately referred to public hospitals for follow-up investigation," the spokesman added.

Regarding health education for travellers, distribution of pamphlets, display of posters in departure and arrival halls, in-flight public announcements, environmental health inspection and provision of regular updates to the travel industry via meetings and correspondence are all proceeding.///

"We have enhanced publicity and health education against avian influenza. The CHP has also sent letters to government departments and related organisations to reinforce health advice against avian influenza," the spokesman said.

Since the first confirmed human case of avian influenza A(H7N9) in Hong Kong on December 3, the CHP hotline (2125 1111) has been set up for public enquiries. As of 4pm today, 118 calls had been received.

"Travellers, especially those returning from avian influenza-affected areas and provinces with fever or respiratory symptoms, should immediately wear masks, seek medical attention and reveal their travel history to doctors. Healthcare professionals should pay special attention to patients who might have had contact with poultry, birds or their droppings in affected areas and provinces," the spokesman advised.

Members of the public should remain vigilant and take heed of the preventive advice against avian influenza below:

• Do not visit live poultry markets. Avoid contact with poultry, birds and their droppings. If contact has been made, thoroughly wash hands with soap;
• Poultry and eggs should be thoroughly cooked before eating;
• Wash hands frequently with soap, especially before touching the mouth, nose or eyes, handling food or eating; after going to the toilet or touching public installations or equipment (including escalator handrails, elevator control panels and door knobs); or when hands are dirtied by respiratory secretions after coughing or sneezing;
• Cover the nose and mouth while sneezing or coughing, hold the spit with a tissue and put it into a covered dustbin;
• Avoid crowded places and contact with fever patients; and
• Wear masks when respiratory symptoms develop or when taking care of fever patients.
  

The public may visit the CHP's avian influenza page (www.chp.gov.hk/en/view_content/24244.html) and website (www.chp.gov.hk/files/pdf/global_statistics_avian_influenza_e.pdf) for more information on avian influenza-affected areas and provinces.

Ends/Thursday, January 9, 2014
 

Hong Kong: Epidemiological Update & Letter To Doctors On H9N2 Case

Credit Hong Kong’s CHP

 

# 8115

 

Although not considered as serious as H7N9 or H5N1, the announcement yesterday (see Hong Kong: Isolation & Treatment Of An H9N2 Patient) recently arrived from neighboring Shenzhen has unleashed another epidemiological investigation, and forced the medical surveillance of this patient’s recent contacts. 

 

As part of their response, late yesterday the Hong Kong CHP issued a letter to local doctors and hospitals and this morning published a follow up press release, both of which are excerpted below.

 

Our first stop, the CHP notification letter to local doctors.

 

Surveillance And Epidemiology Branch 
Our Ref. :   (116) in DH SEB CD/8/6/1 Pt.27
30 December, 2013

Dear Doctor,

A confirmed imported case of Influenza A(H9N2) infection

We are writing to inform you that we have confirmed an imported human case of influenza A (H9N2) infection  involving an 86-year-old man with underlying illnesses.  He lived in Shenzhen with his daughter and presented with low grade fever, chills, cough and sputum since 28 December, 2013. He travelled back to Hong Kong and was admitted to North District Hospital on the same day. Sputum collected on 28 December was tested positive for influenza A M gene and negative for H1/H3 and was subsequently confirmed positive for influenza A(H9N2) by Public Health  Laboratory Services Branch  (PHLSB) today. His condition is stable with fever subsided since 29 December and currently being isolated in hospital.

Investigations by the Centre for Health Protection (CHP) revealed that the patient had no recent poultry contact,  consumption of undercooked poultry, or contact with patients. His home contact is asymptomatic.

Human influenza A (H9N2) infection  is not new to Hong Kong and cases were reported in 1999, 2003, 2007, 2008 and 2009.  Unlike influenza A (H5N1) infection, previous cases with influenza A (H9N2) infection usually presented with mild illness and all recovered. According to scientific literature and local poultry surveillance data, influenza A (H9N2) virus is commonly found in the poultry population in this region and recently it was noted that it could also be transmitted by sparrows and crows.  Sporadic cases of human influenza A (H9N2) infection are anticipated in Hong Kong.

Influenza A (H9) is a statutory notifiable disease in Hong Kong. Any suspected case meeting the reporting criteria (https://ceno.chp.gov.hk/casedef/casedef.pdf) should be immediately reported to the Central Notification Office of CHP via fax (2477 2770), phone (2477 2772) or CENO On-line (www.chp.gov.hk/ceno). Please also contact the Medical Control Officer (MCO) of DH at Pager: 7116 3300 call 9179 when reporting any suspected case.

For updates on the latest situation of avian influenza, please visit CHP website at  http://www.chp.gov.hk/en/view_content/24244.html. Thank you for your ongoing support in combating communicable diseases.

Yours faithfully,

(Dr. Yonnie LAM)
for Controller, Centre for Health Protection
Department of Health

 

And as we’ve come to expect, Hong Kong’s CHP continues to provide daily updates whenever a they detect an event with potential public health ramifications.   The good news, aside from the patients mild symptoms and no signs of spread, is that preliminary genetic analysis of the virus reveals `no evidence of genetic reassortment with genes of human influenza origin or resistance to the antiviral Tamiflu.’

31 December 2013

Epidemiological investigation and follow-up actions by CHP on confirmed human case of avian influenza A(H9N2) 

The Centre for Health Protection (CHP) of the Department of Health (DH) today (December 31) provided an update on the confirmed human case of avian influenza A(H9N2) affecting a man aged 86.

"The epidemiological investigations, enhanced disease surveillance, port health measures and health education against avian influenza are all ongoing," a spokesman for the DH said.

The patient's home contact in Shenzhen has remained asymptomatic.

The 51 health-care workers (HCWs) of North District Hospital (NDH) and the ambulance service remain under medical surveillance. Among them, an HCW of NDH presented with productive cough and sore throat and the respiratory specimen tested negative for the influenza A virus upon testing by the CHP's Public Health Laboratory Services Branch (PHLSB).

The officer who handled the patient upon his entry at Lo Wu Border Control Point is also asymptomatic. He has been put under medical surveillance. So far, there are no newly located contacts.

As the patient was staying in Shenzhen for the whole incubation period, the case is classified as an imported one. The CHP has passed investigation findings to the health authority of Guangdong for follow-up.

"Upon analysis by the PHLSB, the genes of the virus were determined to be of avian origin. They do not show significant differences from avian influenza viruses detected in Hong Kong and the Mainland in recent years. There is no evidence of genetic reassortment with genes of human influenza origin or resistance to the antiviral Tamiflu. We will continue to liaise and share the gene sequence with other health authorities based on established arrangements," the spokesman remarked.

The public is advised to avoid contact with poultry and wild birds, including chickens, ducks and sparrows.

"Travellers, especially those returning from avian influenza-affected areas and provinces with fever or respiratory symptoms, should immediately wear masks, seek medical attention and reveal their travel history to doctors. Health-care professionals should pay special attention to patients who might have had contact with poultry, birds or their droppings in affected areas and provinces," the spokesman advised.

<SNIP>

Ends/Tuesday, December 31, 2013

 

Anytime public health authorities detect a novel influenza virus infection in a human, understandably alarm bells tend to go off. But we need to keep in mind that no one really knows how rare – or common – such infections really are.

 

The vast majority of people who develop `flu-like’ symptoms around the world never seek medical care, and even among the minority that do, most are never tested. Certainly not with lab tests that would pick up a novel influenza virus.

 

With enhanced surveillance in Hong Kong for both MERS-CoV and Avian H7N9 (and H5N1), however, the odds of detecting novel flu cases goes up considerably.  Whether we are seeing an actual uptick in the number of these types of infections, or are just getting better at detecting them, is something we don’t have enough data to discern.

 

But with enhanced surveillance ongoing in Hong Kong, and across Asia, for these three strains we are also gaining information about H6N1, H10N8, and nH9N2.

 

The serendipitous result of surveillance work is that you sometimes can learn a good deal about things you weren’t looking for at the time.  And that can often pay unexpected dividends further down the line.