Upcoming PAHO Zika Briefing (May 3rd)

 

Zika virus - Credit CDC

 

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Just a quick head's up on a Zika briefing tomorrow afternoon (h/t Pathfinder on FluTrackers) by Dr. Anthony Fauci, head of the NIH's NIAID, and Dr. Sylvain Aldighieri, Zika Incident Manager for PAHO (Pan American Health Organization).

This event will be live-streamed as part of a hemispheric conference on the Zika Virus.  

Dr. Fauci will be presenting the keynote address, Zika Virus: A Pandemic in Progress.  This was also the title of his hour-long video presentation nearly two months ago (see NIH Webcast: Zika Virus - A Pandemic In Progress) which is still available for viewing online. 

Briefing on Zika by Dr. Anthony Fauci and Dr. Sylvain Aldighieri

Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases (NIAID), and Dr. Sylvain Aldighieri, Zika Incident Manager for the Pan American Health Organization (PAHO), will brief reporters at PAHO on Tuesday, May 3 at 2:30 p.m.

Both scientists are participating in a hemispheric conference on Zika Virus Risk Communication Challenges, sponsored by the PAHO and the United States Department of Health and Human Services.

Dr. Fauci is giving the keynote address, Zika Virus: A Pandemic in Progress. Dr. Aldighieri is giving an update on the current epidemiological situation. Each will give a brief summary of their presentations and then answer questions.

WHAT: Briefing on Zika
WHO: Dr. Anthony Fauci (NIAID) and Dr. Sylvain Aldighieri (PAHO)
WHEN: Tuesday May 3 at 2:30 p.m.
WHERE: Room B, 2nd floor, PAHO Headquarters,
525 23rd St., N.W., Washington, DC

HOW: In person and via livestream: www.livestream.com/paho
(please copy link and open in a new browser)

Leaky Isolation Gowns (Revisited)

Credit CDC

 

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Overnight a story by Anderson Cooper (see 60 Minutes investigates medical gear sold during Ebola crisis), has made ripples across the health care industry, as he looked into allegations that a company provided faulty surgical gowns to U.S. hospitals and to the U.S. Strategic National Stockpile.

You can find additional coverage in the Florida Times Union report UF Health Jacksonville surgeons among those reporting defective surgical gowns during Ebola crisis.

Without regard to this specific case - if all of this sounds somewhat familiar - it might be because we looked at the failure rate of isolation gowns almost a year ago in NIOSH Science Blog: Not All Isolation Gowns Tested Met Standards.

While the 60 Minutes piece looked specifically at the manufacturer of one  type of gown, last July we saw testing results of 22 disposable models provided by 6 different manufacturers, where 7 (31.8%) of 22 failed to meet the required ANSI/AAMI PB70 liquid barrier performance standard.

According to NIOSH, the gowns for this test were voluntarily submitted by the manufacturers, under the understanding that:

For the purposes of this research, NIOSH agreed not to identify specific results to a particular model or manufacturer, though manufacturers did receive the results to the tests on their own gowns. The testing was conducted according to criteria established by the AAMI, and testing standards developed by the American Association of Textile Chemists and Colorists (AATCC) and ASTM.

Meaning we don't know if the gowns that were the subject of the 60 Minutes piece were among those tested.


Gowns (surgical, isolation, or low-risk `cover’) are the second most common form of barrier protection used by Healthcare workers, exceeded only by disposable gloves.  Although they come in many styles and design, the FDA recognizes four main types (see FDA - Medical Gowns)

• Level 1: Minimal risk, to be use used, for example, during basic care, standard isolation, cover gown for visitors, or in a standard medical unit
• Level 2: Low risk, to be use used, for example, during blood draw, suturing, in the Intensive Care Unit (ICU), or a pathology lab
• Level 3: Moderate risk, to be use used, for example, during arterial blood draw, inserting an Intravenous (IV) line, in the Emergency Room, or for trauma cases
• Level 4: High risk, to be use used, for example, during long, fluid intense procedures, surgery,  when pathogen resistance is needed or infectious diseases are suspected (non-airborne) 

  
With the recent introductions of Ebola and MERS into the United States, and H5N1 and H7N9 avian flu into Canada, plus the more commonly encountered blood borne pathogens like HIV, HVC & HVB, there is growing interest in the proper use, and design, of PPEs (Personal Protective Equipment) like gloves, gowns, and masks (N95 & surgical).  


Despite this renewed focus, there have been numerous challenges, including: 

NIOSH Study Finds Inconsistent Respirator Practices In Hospitals

APIC: Most HCWs Are Removing PPEs Improperly

UNMC: The Complex Procedures To Don & Doff PPEs For Ebola

All of which proves that the job of protecting hospital staff and patients is tough enough without adding faulty PPEs into the mix. 
 

Saudi MOH Announces A Primary MERS Case In Riyadh

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After a fairly quiet second-half of April, for the third day in a row the Saudi MOH has announced a new, primary MERS case - this time a 40 y.o. male in Riyadh. Of particular note, all three of these cases were  already listed in critical condition at the time they were announced.

Since March 8th we've seen 57 MERS cases reported by the Saudi MOH, of which 11 had already died at the time they were reported, while another 19 were listed in critical condition.

How much of this is due to delayed reporting and how much to belated diagnosis is difficult to say, but this is a trend worth watching.

FAO:H7N9 Case In Shandong Province

Shandong Province - Credit Wikipedia

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For more than a year most of our H7N9 notifications have come from bulk, often cryptic, announcements by China's NHFPC (see China's NHFPC Announces 17 H7N9 Cases In March), although we sometimes still see media reports or provincial announcements.


Over the past several days there have been persistent media reports of a human H7N9 infection in Shandong Province, although details have been very slim.  The following comes from Xinhua News.

Laizhou found a case of H7N9 flu cases in critical condition in a positive active treatment

2016-04-30 10:32:48 Source: Qilu network

Reporters from Yantai Laizhou Municipal Propaganda Department official micro letter informed, April 28, Laizhou City, found one case of H7N9 influenza cases. Male patient, 58 years old, is currently in critical condition, provincial and municipal experts are active treatment.

Today, the FAO has posted a notification (see below), which adds little additional information but does help confirm the case.

According to the Hong Kong CHP's latest avian flu report (dated Apr 26th), this is only the 8th case reported out of Shandong province since the virus emerged in 2013, and the second case reported over the 2015-16 winter season.

 
According to the most recent WHO: Influenza at the Human-Animal Interface - April 2016 report, China has reported the lowest level of H7N9 activity since the virus first emerged in 2013 (see chart below).  
 

 

H7N9 epi curve - Credit WHO

While a welcome trend, this reduction comes during a year where China's reporting on bird flu has deteriorated badly, with cases frequently announced weeks after the fact, and often with little or no accompanying detail.    


All of which makes it difficult to compare previous year's (generally detailed) reports with the far more limited reporting we've seen this past fall and winter.

Saudi MOH Announces Primary MERS Case In Hofuf

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In May and June of 2015, most of the MERS activity in Saudi Arabia centered around the town of Hofuf (aka `Hafoof’, `Hafuf’, etc.) in the Northeastern part of the country.

What started with a single `primary case - with camel contact' in mid-April grew into a family cluster, and then into a full blown nosocomial outbreak which ran for more than 2 months (see WHO: A Saudi MERS Infographic) infecting dozens.

While sporadic cases were reported well into the fall (see WHO MERS Update: Saudi Arabia – Nov 13th), reports dried up over the winter.  In April, however, we saw two new cases (one symptomatic, one asymptomatic) linked to camel exposure from Hofuf.


Today the Saudi MOH reports another case from Hofuf - linked to camel exposure - in a 55 year old male listed in critical condition.   Additionally, 1 death (in Najran) of previous case is announced.

 

J. Virology: H5N6 Receptor Cell Binding & Transmission In Ferrets

Flu Virus binding to Receptor Cells – Credit CDC

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Until early 2013 the only serious avian flu threat on our radar was HPAI H5N1, which first emerged in 1996, sparked a mini-epidemic in Hong Kong a year later - and then after disappearing for 5 years - resurfaced again in 2003.

By the end of 2006, it had killed millions of birds, infected hundreds of people, and had been detected in more than 60 countries. 

While there were some `also rans' - HPAI and LPAI avian flu subtypes that sparked outbreaks in poultry (H7N7, H7N3, H9N2, H5N2, etc.) -  none were regarded as posing the kind of threat to humans and the poultry industry that H5N1 did.


At least, not until the spring of 2013, when a new  LPAI H7N9 virus emerged in Eastern China.   Asymptomatic in birds, it nonetheless produced serious illness in humans, and in its first three years has nearly caught up with H5N1 in terms of human cases and deaths. 

Over the 12 months, China would see three other important avian flu viruses emerge; H10N8, H5N8, and H5N6. 

Since 2013 we've seen the number of avian flu threats explode around the globe, and new incarnations, clades, and subtypes continue to emerge.

Admittedly H5N6 has nowhere near the track record of H5N1 or H7N9, but virus continues to spread in China, has infected at least a dozen people (causing serious illness or death), and may eventually move beyond China's borders.

All of which makes it important we watch for any signs of human or mammalian adaptation of the virus. Avian adapted flu viruses bind preferentially to the alpha 2,3 receptor cells found in the gastrointestinal tract of birds.

While there are some alpha 2,3 cells deep in the lungs of humans, for an influenza to be successful in a human host, most researchers believe it needs to a able to bind to the α2-6 receptor cell found in the upper airway (trachea).  

This week we have a new study (alas, behind a pay wall) that looks at four H5N6 isolates collected from Chinese waterfowl in 2013-2014, and finds them not only `fully infective and highly transmissible by direct contact in ferrets', but that they also have a `high affinity' to binding to human α2-6 receptor cells.

J Virol. 2016 Apr 27. pii: JVI.00127-16. [Epub ahead of print]

Highly pathogenic avian influenza H5N6 viruses exhibit enhanced affinity for human type sialic acid receptor and in-contact transmission in model ferrets.

Sun H¹, Pu J¹, Wei Y¹, Sun Y¹, Hu J², Liu L¹, Xu G¹, Gao W¹, Li C¹, Zhang X¹, Huang Y¹, Chang KC³, Liu X², Liu J⁴.

Abstract

Since May 2014, highly pathogenic avian influenza (HPAI) H5N6 virus has been reported to cause six severe human infections three of which were fatal. The biological properties of this subtype, in particular its relative pathogenicity and transmissibility in mammals are not known. We characterized the virus receptor binding affinity, pathogenicity and transmissibility in mice and ferrets of four H5N6 isolates derived from waterfowl in China from 2013-2014. 

All four H5N6 viruses have acquired binding affinity for human-like SAα2,6Gal linked receptor to be able to attach to human tracheal epithelial and alveolar cells. The emergent H5N6 viruses, which share high sequence similarity with the human isolate A/Guangzhou/39715/2014 (H5N6), were fully infective and highly transmissible by direct contact in ferrets but showed less severe pathogenicity in comparison with their parental H5N1 virus. The present results highlight the threat of emergent H5N6 viruses to poultry and human health and the need to closely track their continual adaptation in humans.

IMPORTANCE:

Extended epizootics and panzootics of H5N1 viruses have led to the emergence of the novel 2.3.4.4 clade of H5 virus subtypes including H5N2, H5N6 and H5N8 reassortants. Avian H5N6 viruses from this clade have caused three fatalities out of six severe human infections in China since the first case in 2014. However, the biological properties of this subtype, especially the pathogenicity and transmission in mammals are not known. 

 Here, we found that natural avian H5N6 viruses have acquired high affinity for human-type virus receptor. In comparison with parental clade 2.3.4 H5N1 virus, emergent H5N6 isolates showed less severe pathogenicity in mice and ferrets, but acquired efficient in-contact transmission in ferrets. These findings suggest that the threat of avian H5N6 viruses to humans should not be ignored.

Copyright © 2016, American Society for Microbiology. All Rights Reserved.

Although a binding to human α2-6 receptor cells is considered the biggest single obstacle for an avian virus to overcome in order to successfully jump to humans – it isn’t the only one.
 

Avian viruses also typically replicate best at the higher temperatures found in birds, and would need to adapt to the lower (roughly 33C) normally found in the upper human respiratory tract.

There are other factors – some we know about, others we don’t – that must come in sync to allow an avian virus to become a `humanized' virus.

While H5N6 may not be the virus that pulls all of this together, the growing constellation of HPAI avian viruses in the wild increases the odds that someday one of them will.