Saudi MOH Announces 3 MERS Cases, 1 Fatal

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The intermittent and belated MERS updates from the Saudi MOH - which began in late January - continue today with the posting overnight of the 9th and 10th update of the month (Feb 21st & 23rd).  

Since January 29th, 17 days have not seen updates. During this time we've also seen at least two cases mentioned on their Arabic list, that do not appear on the English list.

Since some of the days this month that have been posted (see below) show no new cases, deaths or recoveries, the reasons behind the sporadic nature of these postings remains unclear. 

Today however we get a report for February 23rd announcing 3 new cases, including 1 case contact (F,45) of a patient from Rafhaa who was listed with `indirect camel contact' on the 17th, a new primary case (61, M) with no known exposure history from Madinah, and an already deceased 75 y.o. male from Riyadh with recent camel contact.
 

Whenever we see a report showing a new case already expired we have to wonder whether this indicates a delay in reporting or in diagnosis. Early diagnosis and isolation are critical - particularly in a hospital environment - to prevent further spread of the virus.

While the Saudis have done a much better job the past couple of years preventing, or limiting, large nosocomial outbreaks, HCW and hospital patient infections continue to be reported. 

Hopefully we'll see a return of more consistent reporting from the MOH, and an update soon from the WHO that can help us sort out the inconsistencies between the English and Arabic language reports.

It Happens Every Spring

Severe Storm Prediction Feb 24th 2018

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Like flu and hurricane seasons, our spring tornado and severe storm season varies in intensity every year, but even in a mild year hundreds of tornadoes will be spawned across the Midwest and Deep South over the spring and early summer.

Today, the NOAA/NWS Storm Prediction Center has issued a forecast calling for an enhanced risk of severe thunderstorms across a wide swath running from Northeastern Texas to the Ohio Valley.

While we've seen a string of mild-to-moderate tornado seasons over the past 6 years, in 2011 - during a three days (Apr 25th-28th) - a storm system of epic proportions generated  351 confirmed tornadoes across five southern states, killing 338 persons in Alabama, Arkansas, Georgia, Mississippi, and Tennessee.

Before and after imagery depicting tornado damage in the vicinity of the intersection of 15th St. E. and McFarland Blvd. E. in southeast Tuscaloosa, AL.

This was the the third deadliest tornado outbreak in U.S. History. More than a dozen of these twisters reached intensities of 4 or 5 on the Enhanced Fujita [EF] scale, which can produce near total devastation.

All but a small part of the United States is vulnerable to these storms, and while more common in the spring and summer, they can happen anytime of the year. 

The strongest generally occur in an area we call Tornado Alley (below Left), which runs from middle Texas north though Oklahoma, Kansas, Nebraska and South Dakota. This is the area where you will generally find the largest and most powerful tornadoes; the F5 wedge type.

Tornado Alley   -   Dixie Alley

Fortunately, much of the mid-west is sparsely populated, and so the number of tornado deaths that occur here are actually less than in other areas of the country.    

DIXIE ALLEY (above right) sees more frequent, albeit usually less severe tornadoes.  Due to a higher population density, more deaths occur in Dixie Alley than in Tornado Alley most years.

Which is why every home and office should have a NOAA weather radio. Once thought of as mainly a source of local weather information, it has now become an `All-Hazards' alert system as well.

Having a safe place to go in your home during a tornado can be life saving.  A basement is best, but an interior hallway or windowless room may provide some protection as well.

In 2012 the CDC’s MMWR issued an analysis of the 2011 massive tornado outbreak, that stressed the importance of safe rooms.  Due to the length of the report, I’ve only reproduced a few excerpts.

Follow the link to read:

Tornado-Related Fatalities — Five States, Southeastern United States, April 25–28, 2011

July 20, 2012 / 61(28);529-533
(Media Synopsis)

Individuals who work or live in a tornado-prone area should develop a tornado safety plan prior to severe weather.

During April 25–28, 2011, the third deadliest tornado disaster occurred in the southeastern U.S. despite modern advances in tornado forecasting, advanced warning times, and media coverage.  CDC reviewed data from the American Red Cross, death certificates and the National Weather Service to describe the fatalities by demographic characteristics, shelter used, cause of death, and tornado severity in the affected states of Alabama, Arkansas, Georgia, Mississippi and Tennessee. Of the 338 deaths, approximately one-third were older adults, almost half occurred in single-family homes, and a quarter happened in mobile homes.  One-half of the 27 tornadoes were rated powerful (EF-4 or EF-5) and were responsible for almost 90 percent of the deaths. The use of safe rooms is crucial to preventing tornado-related deaths.

(Continue . . . .)

FEMA has a good deal of advice on exactly how to construct a safe room – either above or below ground.

Residential Safe Rooms

The information below will help you understand how having a safe room in your home can protect your family and save the lives of those you care about.

Find answers to your Questions about Building a Safe Room, including:

• What is the cost of installing a safe room?
• Can I install a safe room in an existing home?
• Can I build the safe room myself?
• Where is the best location for the safe room?
• Where can I find plans for safe room construction?

And more....

Building a Safe Room in Your House

For more details about how you can build a safe room in your home, go to the FEMA P- 320, Taking Shelter from the Storm: Building a Safe Room for Your Home or Small Business page before downloading it from the FEMA Library.  

Having a good (and well rehearsed) family emergency plan is essential for any disaster. Even with a safe room, family members could become separated (they may be sent to different hospitals or shelters) in the post-disaster chaos.

Some may be injured and unable to provide information about their families.

So it is important to set up a plan, including meeting places and out-of-state contacts, and individual wallet information cards -  before you need it (see #NatlPrep : Create A Family Communications Plan).

Together with adequate emergency supplies, a solid first aid kit, and an emergency battery operated NWS Weather Radio, these steps will go a long ways to protecting you, and your family, from a wide variety of potential disasters.

For more on all of this, a partial list of some of my preparedness blogs include:

When 72 Hours Isn’t Enough

In An Emergency, Who Has Your Back?

#NatlPrep: The Gift Of Preparedness 2017

FluView Week 7: Influenza Activity Remains Elevated Across The United States

Week 7 ILI Outpatient Visits Still Very High

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While influenza activity appears to be backing off the record highs reported two weeks ago, the number of visits for ILI (influenza-like illness) remains very high (see chart above), and continues to exceed all of the peaks reported since the H1N1 pandemic of 2009.

Influenza related hospitalizations continue to soar, beating the end-of-season totals from the past 6 seasons handily (see mashup chart below), with several weeks of flu season to go.

The 2014-15 season was estimated to have seen around 700,000 hospitalizations, and while we have no totals yet, this year looks to exceed that number by a pretty good margin. 

Worst affected have been those aged 65+ (322.7 per 100,000 population), followed by adults aged 50-64 (79.9 per 100,000 population) and children aged 0-4 years (52.6 per 100,000 population).

P&I Mortality numbers have dropped a bit (see below), but there continue to be data collection delays, and the final numbers are apt to see adjustment upward.  

The number of pediatric deaths (often a lagging indicator) jumped by another 13 cases, with several being delayed reports from earlier in the season.

While H3N2 continues to hold the lead, as the season progresses we continue to see both influenza B and H1N1 making gains.  

 

We continue to see some states - particularly in the west - report a reduction in ILI activity (see map below), although most of the country remains in the grip of the grippe.

Some highlights from a much more detailed FluView include:

2017-2018 Influenza Season Week 7 ending February 17, 2018

All data are preliminary and may change as more reports are received.
Synopsis:

During week 7 (February 11-17, 2018), influenza activity remained elevated in the United States.

Viral Surveillance: The most frequently identified influenza virus subtype reported by public health laboratories during week 7 was influenza A(H3). The percentage of respiratory specimens testing positive for influenza in clinical laboratories remained elevated.
Pneumonia and Influenza Mortality: The proportion of deaths attributed to pneumonia and influenza (P&I) was above the system-specific epidemic threshold in the National Center for Health Statistics (NCHS) Mortality Surveillance System.
Influenza-associated Pediatric Deaths: Thirteen influenza-associated pediatric deaths were reported.
Influenza-associated Hospitalizations: A cumulative rate of 74.5 laboratory-confirmed influenza-associated hospitalizations per 100,000 population was reported.
Outpatient Illness Surveillance:The proportion of outpatient visits for influenza-like illness (ILI) was 6.4%, which is above the national baseline of 2.2%. All 10 regions reported ILI at or above region-specific baseline levels. New York City, the District of Columbia, Puerto Rico and 39 states experienced high ILI activity; five states experienced moderate ILI activity; three states experienced low ILI activity; and three states experienced minimal ILI activity.
Geographic Spread of Influenza:The geographic spread of influenza in Puerto Rico and 48 states was reported as widespread; the District of Columbia, Guam and two states reported local activity; and the U.S. Virgin Islands reported no activity.

 As always, it isn't too late to get the flu shot.  And with influenza B and H1N1 rising, it could still offer some valuable protection.  But most of all, now is the time to practice good flu hygiene. 

Stay home if you are sick, avoid crowds, wash your hands frequently, and cover your coughs and sneezes. 

While we may have passed the peak of this flu season, there is undoubtedly a good deal of flu in store for the next few weeks, and the numbers will continue to come in for weeks after that.

EID Journal: Multiple Introductions Of HPAI H5N8 In Egypt

https://wwwnc.cdc.gov/eid/article/24/5/17-1935-f1

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After starting out as an exclusively Chinese and Southeast Asian problem early in the last decade, avian HPAI H5 viruses have spread globally via migratory birds - and while many areas outside of Asia have been affected - no region has reported as much consistent HPAI H5 activity over the past decade as Egypt and the Middle East. 

Despite this, we see relatively few in-depth reports on avian flu viruses coming from that part of the world, and when we do, it is nearly always from Egypt.

Often the reporting of avian flu outbreaks to the OIE is either fragmented, belated, or - far too often -  simply not done by many countries in the Middle East (and elsewhere).  

Admittedly, for many nations, this may be due to the remote location of outbreaks, the reluctance of farmers to report poultry deaths, or a lack of resources.

Even novel human infections may go undetected or reported, with only about 1/3rd of the countries of the world currently self-reporting they have met the core requirements of the 2005 International Health Regulations (see Adding Accountability To The IHR).

The unfortunate result is - at least compared to Europe, North America, and parts of Asia - we don't really have a good handle on what novel viruses are circulating in many places around the globe, or what changes may be occurring in them.

Today, however, we have a Research Letter appearing in the EID Journal that gives us some valuable new insight on the late 2016 arrival, and subsequent multiple introductions of HPAI H5N8, to Egypt during 2017.

Of particular note, four genetically distinct H5N8 viruses were characterized, and all carried previously identified mammalian-adaptation and virulence markers (see Evaluation of phenotypic markers in full genome sequences of avian influenza isolates from California) that raise potential public health concerns.

I've only included some extracts from the letter (bolding mine), so follow the link to read it in its entirety.  I'll return with a brief postscript. 

Volume 24, Number 5—May 2018
Research Letter

Multiple Introductions of Influenza A(H5N8) Virus into Poultry, Egypt, 2017

Ahmen H. Salaheldin, Hatem Salah Abd El-Hamid, Ahmed R. Elbestawy, Jutta Veits, Hafez M. Hafez, Thomas C. Mettenleiter, and Elsayed M. Abd El-Whab

Abstract

After high mortality rates among commercial poultry were reported in Egypt in 2017, we genetically characterized 4 distinct influenza A(H5N8) viruses isolated from poultry. Full-genome analysis indicated separate introductions of H5N8 clade 2.3.4.4 reassortants from Europe and Asia into Egypt, which poses a serious threat for poultry and humans.

In Egypt, highly pathogenic avian influenza A(H5N1) clade 2.2.1 virus was introduced to poultry via migratory birds in late 2005 (1) and is now endemic among poultry in Egypt (2).

Also in Egypt, the number of H5N1 infections in humans is the highest in the world, and low pathogenicity influenza A(H9N2) virus is widespread among poultry and has infected humans (2).

Despite extensive vaccination, H5N1 and H9N2 viruses are co-circulating and frequently reported (2). In 2014, highly pathogenic avian influenza A(H5N8) virus clade 2.3.4.4 was isolated, mostly from wild birds, in several Eurasian countries and was transmitted to North America. However, in 2016 and 2017, an unprecedented epidemic was reported in Asia, Africa, and Europe (3).

In Egypt, during November 30–December 8, 2016, a total of 3 H5N8 viruses were isolated from common coot (Fulica atra) (4) and green-winged teal (Anas carolinensis) (5). To provide data on the spread of the virus in poultry, we genetically characterized 4 distinct H5N8 viruses isolated from commercial poultry in Egypt in 2017.

(SNIP)

The hemagglutinin (HA) and neuraminidase (NA) genes of the 4 viruses shared 95.8%–99.2% nt and 93.1%–99.4% aa identity and shared 96.5%–99.2% nt and 94.2%–99.7% aa identity with viruses from wild birds in Egypt (4,5). Other segments showed 92.6%–99.6% nt and 96%–99.7% aa identity, where the polymerase acidic (PA) genes and proteins of viruses from Dk18 showed the lowest similarity to those of other viruses (Technical Appendix 1[PDF - 1.22 MB - 5 pages] Figure 1).

All viruses possess the polybasic HA cleavage site PLREKRRKR/G and contain mammal-adaptation and virulence markers (9) in polymerase basic (PB) 2 (T63I, L89V, G309D, T339K, Q368R, H447Q, R477G), PB1 (A3V, L13P, K328N, S375N, H436Y, M677T), PA (A515T), HA (T156A, A263T; H5 numbering), matrix (M) 1 (N30D, T215A), and nonstructural (NS) 1 (P42S, T127N, V149A) proteins.

Therefore, protection of humans and risk assessment of bird-to-human transmission is crucial.

(SNIP)

These data suggest 4 different introductions of H5N8 virus into poultry in Egypt, independent of viruses isolated from captive birds (4,5). Multiple separate introductions of H5N8 virus into Europe also occurred (10). Further studies are needed to identify the source(s) of introduction. The separate introductions of different reassortants of H5N8 clade 2.3.4.4 virus from Europe and Asia into Egypt indicates a serious threat for poultry and human health.

Mr. Salaheldin is a doctoral student at the Institute of Poultry Diseases, Freie-Universität-Berlin. His main interests are molecular virology, vaccine development, and epidemiology of avian influenza viruses.

Thus far HPAI H5N8 (and it's reassorted progenies H5N6 & H5N6) have shown few signs of infecting mammals and no human infections have been reliably reported.

We did see early reports out of South Korea in 2014 of dogs having been infected (see MAFRA: H5N8 Antibodies Detected In South Korean Dogs (Again)) and less than a year ago saw J. Vet. Sci.: Experimental Canine Infection With Avian H5N8.

So we know that mammalian infection with at least some genotypes of H5N8 is at least possible.

Over the past year we've looked at a number of studies that have explored the potential for H5N8 or its spinoffs to evolve into a human health threat. A few include:

J Vet Sci: Evolution, Global Spread, And Pathogenicity Of HPAI H5Nx Clade 2.3.4.4 

Study: Virulence Of HPAI H5N8 Enhanced By 2 Amino Acid Substitutions

Sci Rpts: H5N8 - Rapid Acquisition of Virulence Markers After Serial Passage In Mice 

Perhaps most telling of these came last September in J. Virulence : Altered Virulence Of (HPAI) H5N8 Reassortant Viruses In Mammalian Models, which found:

Taken together, our study demonstrates that a single gene substitution from other avian influenza viruses can alter the pathogenicity of recent H5N8 viruses, and therefore emphasizes the need for intensive monitoring of reassortment events among co-circulating avian and mammalian viruses.

Last October's J. Virulence Editorial: HPAI H5N8 - Should We Be Worried? reviewed and summarized the literature, and found enough reasons to be concerned over the future evolutionary path of H5N8, stating that:

The extensive distribution of HPAI H5N8, as well as the gene reassortment with other circulating avian viruses already observed for H5N8 suggests there is a potential risk for human cases of H5N8 infections.

While none of this means there is a human adapted H5N8 virus in our future, considering the continual evolution of the virus - particularly in areas of the world where we have little or no visibility - we can't ignore the possibility of someday being blindsided by an abrupt change in the virus's behavior.

Making studies like this one particularly valuable.

NEJM: Flu Season A Risk Factor For Developing Post-Cardiac Surgery ARDS

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ARDS (Acute Respiratory Distress Syndrome) is a rapidly progressing - often life-threatening complication - hallmarked by the leaking of fluid into the small air sacs (alveoli) of the lungs, usually as the result of a direct or indirect lung injury.

ARDS can be caused by a variety of insults to the lung, including aspiration, chemical or smoke inhalation, pneumonia, septic shock, or trauma.  It is often seen in critically ill patients with liver of kidney failure.

With the build up of fluids from ARDS, the patient is unable to pass oxygen efficiently  through their lung's alveoli into the the bloodstream, even when placed on a ventilator.

Low oxygen levels (hypoxia) can lead to further organ damage and even death.

ARDS is most often observed in patients already hospitalized for another serious illness, and while survival rates vary depending on age, the underlying cause, and comorbidities  - some estimates put the mortality rate somewhere between 33%-50%.

As the following excerpt from the 2016 study (Acute respiratory distress syndrome following cardiovascular surgery: current concepts and novel therapeutic approaches) explains, ARDS is a rare, but serious complication following cardiac surgery.

Cardiac surgery is a known risk factor for ARDS, especially when using cardiopulmonary bypass (CPB), because CPB induces a systemic inflammatory response and pulmonary ischemia-reperfusion injury. Today more high-risk patients undergo cardiac surgical interventions and an increasing number of patients is provided with complex procedures [2,3].

To date there are eight clinical studies that analyzed the incidence, risk factors, and mortality of ARDS following cardiac surgery (overview in [4▪]). The incidence of ARDS varied from 0.17 to 2.5% and mortality from 15 to 91.6%.

Yesterday the NEJM published a correspondence which suggests that post-cardiac surgery ARDS complications may occur more frequently during flu season, even when the patient shows no signs of influenza infection.

Influenza Season and ARDS after Cardiac Surgery

February 22, 2018

N Engl J Med 2018; 378:772-773
DOI: 10.1056/NEJMc1712727

To the Editor:

A number of concurrent risk factors are associated with development of the acute respiratory distress syndrome (ARDS). One such risk factor might be asymptomatic respiratory viral infection — for example, influenza — which could prime the lungs for ARDS in patients with another overt risk factor. Patients who undergo cardiac surgery could potentially carry these viruses yet have no clinical signs or symptoms.1

(Continue . . . )

The correspondence, along with a 24-page Supplementary Appendix, continue on to describe a two-year single-center observational cohort study on cardiac patients at the ICU of a tertiary university hospital in the Netherlands.

While patients were not tested for flu, the study found that the incidence of ARDS complications following cardiac surgery doubled during flu season, even though the surgical patients showed no signs of respiratory infection before surgery.

 In the discussion section of the supplemental file, the authors wrote:

Cardiac surgery during influenza season is an independent risk factor for development of postoperative ARDS compared to surgery during seasons with little respiratory virus transmission.

The main finding of the present study is that the risk for the development of ARDS after  cardiac surgery is about twice increased during the influenza season as compared to seasons with low burden of respiratory virus infections.

Moreover, the influenza season did increase the duration of mechanical ventilation. The influenza season was estimated on the basis of weekly reporting of influenza-like illness within the community by sentinel surveillance at general practitioner offices, confirmed by detecting influenza in nasopharyngeal samples.

On multivariate modelling, the influenza season proved to be an independent risk factor for the development of ARDS postoperatively, besides well known factors like EuroSCORE and total time on CPB.

Of note, the 2009 pandemic fell within the study period. 

Since influenza tests (or other respiratory panels) were not conducted, the authors point out that they haven't proven that an underlying viral infection causes increased ARDS in cardiac surgery patients. They wrote:

Our study also has several weaknesses. First and for all, our cohort study shows an association but does not prove a causal relation between viral infection and ARDS in cardiac surgery patients. There are potential confounders that vary by season, such as vitamin D level or ambient temperature, for which we could not adjust.

Still, if confirmed by other studies, this research raises interesting questions about the potential value of pre-surgical testing for viral infection, even when a patient appears to be asymptomatic.

WHO Update & Risk Assessment On Avian H7N4

Jiangsu Province - Credit Wikipedia

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Just a little over a week after the initial announcement from China of the first known human infection with an avian H7N4 virus, we are starting to get details about both the patient and the virus, with a genetic characterization released earlier today (see WHO: Genetic Characteristics Of Avian H7N4).

The World Health Organization has also just released their first update, and a preliminary risk assessment on this emerging virus.  

While additional human cases are possible, the lack of infection among 28 close contacts to the first case is encouraging. We will, of course, be anxious to get further information about this virus, including the results of ferret transmission studies, and its prevalence in poultry.

Human infection with avian influenza A(H7N4) virus – China

Disease outbreak news
22 February 2018

On 14 February 2018, the National Health and Family Planning Commission (NHFPC) of China notified the World Health Organization (WHO) of one case of human infection with avian influenza A(H7N4) virus. This is the first human case of avian influenza A(H7N4) infection to be reported worldwide.

The case-patient was a 68-year-old woman from Jiangsu Province with pre-existing coronary heart disease and hypertension and she developed symptoms on 25 December 2017. Seven days later, she was admitted to a local hospital for treatment of severe pneumonia and was discharged after 21 days. On 12 February, the Chinese Center for Disease Control and Prevention (China CDC) confirmed that the case-patient’s samples were positive for avian influenza A(H7N4). The NHFPC confirmed the diagnosis on 13 February 2018. The case-patient had reported a history of exposure to live poultry before onset of symptoms.

Genetic sequencing of this A(H7N4) virus shows that all the virus segments originated from avian influenza viruses. This virus is sensitive to adamantanes and neuraminidase inhibitors based on genetic sequencing.

Twenty-eight close contacts of the case-patient have been under medical observation. Among close contacts, no abnormal findings have been found and all throat swabs from her contacts have tested negative.

Public health response

The Chinese government conducted a risk assessment, and has enhanced prevention and control measures, surveillance and epidemiological investigations including contact tracing and laboratory testing. Public risk communication and information sharing is ongoing.

WHO is in contact with national authorities and is following the event closely. WHO is facilitating information-sharing with Member States and is closely monitoring the situation, in line with the International Health Regulations (2005).

WHO risk assessment

This is the first report of a human case of avian influenza A(H7N4) infection globally and the case reported exposure to live backyard poultry before illness onset. Genetic analysis of this influenza A(H7N4) virus indicates that it is of avian origin.

Close contacts of the case-patient tested negative for avian influenza A(H7N4) and remained asymptomatic. Current evidence suggests that this virus does not have the ability of sustained transmission to humans, thus the likelihood of sustained human to human transmission is low. Any animal influenza virus that develops the ability of human to human transmission can theoretically cause a pandemic.

It is possible that additional human cases of avian influenza A(H7N4) will be detected, however only one human case has been detected so far, and information on the circulation of avian influenza A(H7N4) in birds is not currently available. Further information needs to be gathered to increase the confidence in this assessment.

WHO advice

The public should avoid contact with high-risk environments such as live animal markets/farms and live poultry, or surfaces that might be contaminated by poultry feces. Hand hygiene with frequent washing or use of alcohol hand sanitizer is recommended. WHO does not recommend any specific different measures for travellers.

WHO does not advise special screening at points of entry with regard to this event, nor does it recommend that any travel or trade restrictions be applied.