Saudi MOH Announces 4 New MERS Cases, 4 Fatalities

 

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Although we’ve seen several lulls in reporting this summer – some lasting a week or more – we continue to see new MERS cases emerge – particularly from the Riyadh region.   Yesterday there were two new cases reported in the Capital city, and today we are notified of three more – plus one case in Najran.

Additionally, four recent cases – all from Riyadh – have died, including a 32 year-old who was admitted to the hospital on July 19th, and was listed having no comorbidities.

 

Of the five cases reported from Riyadh over the past 2 days, four are listed as contacts of known cases.   Recent WHO GAR updates have identified both family and nosocomial exposures as propelling this recent surge of cases in Riyadh.

 

 

While exposure risks in these clusters are often easy to identify, in far too many cases the source of infection isn’t known.  The 32-year-old who died had no known exposure risk, and simply presented himself at a local hospital with symptoms two weeks ago.

 

Last May, in WHO EMRO: Scientific Meeting Reviews MERS Progress & Knowledge Gaps we examined some of the deficits in our understanding of this disease, and the glaring lack of a well mounted case-control study, after more than three years.

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South Korean President Replaces MOH Over Handling Of MERS

 

 

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Although it is not listed as a known side effect on any of the the WHO FAQ sheets, one of the prominent side effects of large MERS outbreaks have been its chilling effects on the careers of a number of Minister’s of Health – first in Saudi Arabia (see Saudi Arabia Replaces Minister Of Health (Again)) – and now in South Korea .

 

With South Korea’s MERS epidemic now fully contained, the nation’s President has decided the time has come to replace her embattled Minister of Health.  First a brief report from the AP, followed by the Health & Human Welfare announcement on their proposed replacement:

 

 

South Korea to replace health minister after MERS outbreak

SEOUL, South Korea (AP) — South Korea's president has decided to replace her health minister, officials said Tuesday, in the wake of criticism over the government's handling of the MERS virus outbreak that killed 36 people and infected nearly 200 others.

Last week, South Korea announced that it was virtually free of Middle East respiratory syndrome, which had rattled the country since an outbreak was declared in May. More than 16,000 people had been isolated at hospitals and homes as the government tried to contain the disease's spread.

South Korean media have criticized the government for failing to swiftly cope with MERS in the initial stage of its landing in the country.

President Park Geun-hye nominated local medical professor Chung Chin Youb to replace Moon Hyung-pyo as health minister, Park's office said in a statement. The statement described Chung as a person who can bolster South Korea's public health care.

(Continue . . .)

 

The outgoing Minister – Dr. Moon Hyung-pyo – held the office since December of 2013.  The following short bio on his proposed replacement comes from the Ministry of Health & Welfare.
 

 

(machine translation)

Secretary of health and human services devoted to the candidate leaves □

❍ Name: Jung Jin leaves (鎭 燁) CHUNG CHIN YOUB

❍ Besides science classroom at Seoul National University position: Professor, Seoul National University bundang hospital, orthopaedic/orthopaedic faculty

Seoul National University bundang hospital former occupations: ❍

❍ Date of birth: March 10, 1955 (aged 60)

❍ Ex. Saint: Seoul

❍ E-mail : chin@snu.ac.kr

❍ Bell Bridge: Christian

❍ Blood output type: O type

❍ Education

1973-Seoul high school graduate

-Department of Seoul National University in 1980, aerosol

Seoul National University, graduate school of medicine, Ms aerosol-1988

Seoul National University, graduate school of medicine and Dr. Sol-1993

❍ Experience (note)

-Seoul National University Hospital in 1984, resident

Senior Hospital Physician-1988 nuclear

-In 1992, the United States, the children's Hospital the way Lett Fellow

-Assistant Professor, Seoul National University Hospital orthopedic classrooms in 1993, Associate Professor, Professor (County)

Seoul National University bundang hospital Education Center 2002

-Seoul National University bundang hospital care 2004, Deputy

Seoul National University bundang hospital 2008-2013-

-2008-2013 for the Managing Director and Finance Chairman of the Hospital Association's hospital information

2008-2009-2010 President of the Pediatric Orthopedic for craniocervical

Oversees the operation of the mutual medical devices Forum 2012-Chairman (present)

❍ Sang-Hoon

-The Prime Minister Award (2008), Korea global executives (2011), Korea health industry special prize (2011), industrial packaging (2011)

❍ Publications

Besides the Pediatric orthopaedic Sciences ' cradle ' (1996), ' Besides the science of orthopaedic for students ' (1998)

❍ Family

-(Spouse) on July 10, 1958, delayed

-(Daughter) stop on October 24, 1983, Yoon

-(Daughter) be suspended August 8 1988

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Updating The NYC Legionella Outbreak

Legionella Bacteria - Photo Credit CDC PHIL

 

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Last Wednesday, in NYC DOH: Investigating A South Bronx Legionella Outbreak, we saw a statement from the New York City Department of Health on an ongoing Legionnaire’s disease outbreak, which at that time had infected 31 people, and killed 2.

 

Today NYC media are reporting the number of cases has jumped to 71, and the number of deaths now sits at 4. 

 

Four dead in Legionnaires’ disease outbreak in New York

Posted 1:22 pm, August 3, 2015, by CNNwire

NEW YORK — The number of deaths in the New York City Legionnaires’ disease outbreak is up to four.

Seventy-one cases of the flu-like disease have been reported since mid-July in the South Bronx, up from 31 on Thursday, the city Department of Health and Mental Hygiene said Sunday.

Legionnaires’ disease is a respiratory bacterial infection usually spread through mist that comes from a water source, such as cooling towers, air conditioning or showers. It is not transmitted person to person. Symptoms of the disease include fever, chills and a cough.

Most people recover, but between 5% to 30% of those who get the disease die, according to the U.S. Centers for Disease Control and Prevention.

The four victims were all older adults with additional underlying medical problems, the city said. Fifty-five individuals are hospitalized.

(Continue . . . )

 

The Legionella bacteria thrives in warm water, such as is commonly found in air-conditioning cooling towers, hot tubs, and even ornamental water fountains. When water is sprayed into the air the bacteria can become aerosolized and inhaled.

 

Those who are susceptible (often smokers, immunocompromised, elderly, etc.) can develop serious – even life threatening – pneumonia.

 

Tonight, a town hall meeting is scheduled to inform residents on the progress of the investigation, and to assure them that this is not a contagious disease, and that it is not being spread by the city water supply.

 

The NYC Department of Health also posted the following update on their website today.

 

Updated 8/3/2015

South Bronx Legionnaires’ Disease Outbreak

Frequently Asked Questions

What is the difference between a water tank and a cooling tower?

A cooling tower contains water and is used by some buildings as part of their air conditioning, ventilation and/or heating systems.

A water tank is a totally separate system. Some taller buildings use a water tank to store water used for drinking, washing dishes and/or showering. No water tanks are associated with the current South Bronx outbreak.

Is the tap water in the South Bronx safe to drink, wash and bathe with?

Yes. It is safe to drink, wash and bathe with the tap water in the South Bronx and throughout the city.

What has the Health Department done at the South Bronx buildings with cooling towers that tested positive for Legionella?

There are five South Bronx buildings with cooling towers that tested positive for Legionella. These buildings have completed short-term cleaning and disinfection. The Health Department remains in constant contact with management at all five buildings and is working very closely with management on long-term procedures to keep those cooling towers free of Legionella.

Is it safe for people to remain in the five buildings that tested positive for Legionella, especially if they continue to run their air conditioning systems?

Yes. All cooling towers have been disinfected. That process immediately reduces or eliminates the likelihood of Legionella being released.

Will the Health Commissioner issue an order for the entire South Bronx or the entire City requiring all buildings with cooling towers to disinfect and clean their cooling towers, regardless of whether the towers were inspected/tested for Legionella?

The City is evaluating whether a wide-scale cleaning and disinfection program would be appropriate. Currently, only five buildings have tested positive for Legionella. All five have undergone rapid disinfection and cleaning. We will continue to monitor the outbreak and evaluate whether additional steps are necessary.

 

While large outbreaks of Legionella are often traced to specific causes, quite often the source of the infection for sporadic cases remains a mystery. 

 

A few outbreaks have been quite large, as with the 2001 Murcia, Spain outbreak that affected more than 800 people (killing 6), and last year’s outbreak in Portugal (see WHO: Legionnaire’s Disease Outbreak – Portugal) which saw at least 336 people infected and 11 fatalities.

 

Legionella got it’s name after it was identified as the bacterial cause of a large pneumonia outbreak at Philadelphia’s Bellevue Stratford Hotel during an American Legion convention in 1976. During that outbreak, 221 people were treated and 34 died.

 

We now know Legionella to be a major cause of infectious pneumonia, and that it can sometimes spark large outbreaks of illness. 

 

According to the CDC between 8,000 and 18,000 Americans are hospitalized with Legionnaire's Disease each year, although many more milder cases likely occur. For background information on the disease, the CDC maintains a fact sheet at Patient Facts: Learn More about Legionnaires' disease.

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Saudi MOH Reports Two Additional MERS Cases In Riyadh

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After a 4 day break, the Saudi MOH is reporting two more MERS cases from Riyadh.  One of the cases is listed as a contact of confirmed case, while the other case is still under investigation. 

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JMII: Epidemiology Of Human Influenza A(H7N9) Infection In Hong Kong

 

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Since the H7N9 virus emerged in Mainland China in the spring of 2013, sparking the first of three mini-epidemics, 13 cases have turned up in Hong Kong.  All are considered imported cases, as all had recent travel to the mainland, and no secondary infections among their contacts have been reported.

 

Ten of these cases were imported during the 2013-14 winter season, and today we’ve got a detailed epidemiological report on them from researchers at Hong Kong’s Centre for Health Protection.

 

The full text of the report is available (online or in PDF format), and is well worth reading it its entirety, as it sheds additional light on the demographics, symptomology, incubation period, duration of viral shedding, and effects of antiviral treatment with H7N9 cases.

 

First a brief excerpt from the abstract with appears in the Journal of Microbiology, Immunology and Infection (JMII), after which I’ll return with a bit more regarding one of their conclusions.

 

Epidemiology of human influenza A(H7N9) infection in Hong Kong

Yiu-hong Leung, May-kei To, Tsz-sum Lam , Shui-wah Yau, Oi-shan Leung, Shuk-kwan Chuang

Centre for Health Protection, Department of Health, Hong Kong, China

Published Online: July 25, 2015

DOI: http://dx.doi.org/10.1016/j.jmii.2015.06.004Abstract

 

Results

A total of 10 cases were reported and all were imported infection from Mainland China. Four patients died and the cause of death was related to influenza A(H7N9) infection in two patients. The median interval from illness onset to initiation of oseltamivir treatment for the severe cases (4.5 days) was significantly longer than the mild cases (2 days; p = 0.025). Severe cases had a significantly longer viral shedding duration than mild cases (p = 0.028). The median incubation period for cases with a single known exposure date was 4 days. Nasopharyngeal aspirate taken from the 88 close contacts of the 10 patients all tested negative for influenza A virus using reverse transcription polymerase chain reaction.

Conclusion

Delayed administration of antiviral treatment may be associated with a more severe illness for influenza A(H7N9) infection. Despite our aggressive contact tracing policy with laboratory testing of all close contacts, no secondary case was identified which implied that the potential of human-to-human transmission of the circulating influenza A(H7N9) virus remains low.

(Continue . . . )

 

Although based on a limited number of cases (n=10), this study adds a bit more  to the growing body of evidence that the early administration of antivirals can help reduce morbidity and mortality in cases of severe influenza.

 

While that won’t come as much of a surprise to most medical experts, given demonization that antivirals have received online and in the `popular press’ over the past few years,  it is worth highlighting.

 

Much of the ire surrounding these drugs has been due to Roche’s long-standing resistance to releasing all of their testing data, and that has led to critical editorials in the BMJ, and frequent excoriation in the British press  (see Daily Mail: Ministers blew £650MILLION on useless anti-flu drugs)..

 

As a result of this sort of hyperbolic coverage, many people have come away with the erroneous impression that these drugs are worthless – or worse.

 

While its benefits may be limited in mild influenza in healthy adults, we’ve seen numerous observational studies that show antivirals are useful in the treatment of severe flu (see Study: Antivirals Saved Lives Of Pregnant Women  and  Study: The Benefits Of Antiviral Therapy During the 2009 Pandemic), particularly in those with heightened risk factors.  

 

And even more impressively (and perhaps, more importantly with avian flu viruses on the rise again), in 2010’s Study: Antiviral Therapy For H5N1, a study of outcomes of H5N1 patients who either received, or did not receive, antiviral treatment found:

 

Out of 308 cases studied, the overall survival rate was a dismal 43.5%.  But . . . of those who received at least one dose of Tamiflu . . .  60% survived . . .  as opposed to only 24% who received no antivirals.

 

Evidence which helps explain why, we’ve seen a push back by many public health agencies (see The CDC Responds To The Cochrane Tamiflu Study & UK PHE’s  Revisiting Influenza Antiviral Recommendations), strongly recommending the early administration of antivirals in cases of severe flu or in patients with elevated risk factors.

 

While far from perfect, and not a `cure’ for flu, antivirals remain our best pharmaceutical option for the treatment of severe influenza.

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RESEP UDANG BALADO MERAH PEDAS PRAKTIS

Resep Udang Balado Pedas - Bumbu merah bisa menjadi variasi menu udang lainnya karena diolah dengan cara memasak yang praktis dan berbahan sederhana. Bermacam jenis udang dapat dimasak dengan bumbu balado ini karena daging udang yang gurih sangat enak jika berpadu dengan rasa pedas dari bumbu balado khas Padang.

Daging udang memiliki cita rasa yang khas dan gurih sedangkan bumbu balado padang sangat diminati karena rasa pedas sudah sangat akrab di lidah sehingga hampir menjadi hidangan wajib dalam melengkapi menu makan. Membuat sambal yang disatukan dengan masakan tentu menjadi pilihan praktis apalagi rasanya sangat pas di lidah.

RESEP UDANG PEDAS BALADO
Bahan dan bumbu :

• 150 gram udang dibuang kepala dan cuci bersih
• 100 ml air
• 1/2 sendok teh garam
• 1/2 sendok teh kaldu bubuk atau penyedap rasa sesuai selera
• 1 sendok teh gula merah
• 2 cm lengkuas digeprek
• minyak untuk menumis

Haluskan :

• 6 buah cabe merah besar
• 3 buah cabe rawit merah atau sesuai selera
• 3 butir bawang merah
• 1 siung bawang putih
• 2 cm jahe

CARA MEMBUAT UDANG BALADO PEDAS :

1. Panaskan minyak secukupnya kemudian tumis bumbu halus dan lengkuas hingga wangi. Masukkan udang, aduk-aduk hingga berubah warna lalu tuang air, garam, gula merah dan kaldu bubuk.
2. Selanjutnya aduk hingga rata lalu masak hingga kuah menyusut, matikan api kemudian angkat dan siap untuk disajikan.

Menu makan enak berbahan dasar udang lainnya adalah Resep Udang Saus Padang yang sama-sama berkarakter pedas khas masakan minang Sumatra Barat.

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PLoS One: Structural and Functional Studies of Influenza Virus A/H6 Hemagglutinin

Flu Virus binding to Receptor Cells – Credit CDC

 

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Although ubiquitous in birds, until a couple of years ago, avian H6 viruses as human health threats were essentially flying under the radar.  While implicated in the creation of H5N1 (see Hatta & Kawaoka, 2002), its history suggested that it posed little or no direct threat to human health – and after the return of H5N1 in 2003 – relatively little attention was paid to it

 

All that changed in May of 2013 when Taiwan health officials  – employing heightened surveillance due to the outbreak of  H7N9 on the Chinese mainland – stumbled across the first known human infection with an avian H6 virus (see Taiwan CDC Reports Human Infection With Avian H6N1)

The patient was described as a 20-year-old female who presented at local hospital with mild pneumonia on May 8th, was hospitalized and treated with oseltamivir, and who was released 3 days later.  None of 36 close contacts followed up on were found to be infected with the H6N1 virus.

Six months later, in Taiwan CDC: Epidemiological Analysis Of Human H6N1 Infection, researchers warned that a (emphasis mine) “unique clade of H6N1 viruses with a G228S substitution of haemagglutinin have circulated persistently in poultry in Taiwan. These viruses continue to evolve and accumulate changes, increasing the potential risk of human-to-human transmission.”

 

Since then, we’ve seen a growing body of research emerge suggesting that H6 viruses in general – and H6N1 in particular – are possibly evolving towards a more human-adapted virus, and are therefore worthy of both our increased attention and surveillance.

 

• In TSRI: H10N8 and H6N1 Bind Poorly To Human Receptor Cells researchers warned that both of these viruses bind differently than other avian viruses we’ve seen, and that our understanding of how these viruses mutate and evolve isn’t complete enough to warrant complacency.
• Last May, in EID Journal: Seropositivity For H6 Influenza Viruses In China, we looked at a study that found a low, but significant level of antibodies – particularly among live bird handlers – to the avian H6 virus in China. 
• Again in May, a study documented recent changes in the receptor binding characteristics of the H6N1 virus (see Adaptation of avian influenza A (H6N1) virus from avian to human receptor-binding preference).
• And just last month, another study that found traces of Influenza A(H6N1) Circulating In Dogs, Taiwan.

 

Before avian influenza viruses can pose a serious threat to human health they must acquire a number of mammalian adaptations.  Some we know about – like binding to human receptor cells and replicating at the lower temperatures found in mammalian airways – and others we don’t.

 

Arguably the most important step: the virus must be able to attach to the surface of cells in the respiratory tract, and in humans, that means binding to α2-6 receptor cells that are abundant in the upper airway (trachea).

 

Since avian flu viruses bind preferentially to the alpha 2,3 receptor cells found in the gastrointestinal tract of birds, a series of amino acid changes are needed in its RBS (Receptor Binding Site) to allow it to attach to human receptor cells.  Some avian viruses can bind to both types of cells, although α2-6 binding is usually much weaker.

 

In the studies mentioned above there is growing evidence that the pendulum of binding preference in H6N1 may be swinging from avian to human receptors.  Today, we’ve another study that adds weight to those concerns. 

 

It’s a lengthy and highly technical report, and I would invite those so inclined to read it in its entirety at the link below.  I’ve only excerpted the abstract.

 

The bottom line, however, is they found that the Taiwan H6 HA has a slight preference for human receptors, and that it may represent an intermediate step towards a complete human adaptation.

 

Research Article

Structural and Functional Studies of Influenza Virus A/H6 Hemagglutinin

Fengyun Ni, Elena Kondrashkina, Qinghua Wang

Published: July 30, 2015

DOI: 10.1371/journal.pone.0134576  

Abstract

In June 2013, the first human infection by avian influenza A(H6N1) virus was reported in Taiwan. This incident raised the concern for possible human epidemics and pandemics from H6 viruses. In this study, we performed structural and functional investigation on the hemagglutinin (HA) proteins of the human-infecting A/Taiwan/2/2013(H6N1) (TW H6) virus and an avian A/chicken/Guangdong/S1311/2010(H6N6) (GD H6) virus that transmitted efficiently in guinea pigs.

Our results revealed that in the presence of HA₁ Q226, the triad of HA₁ S137, E190 and G228 in GD H6 HA allows the binding to both avian- and human-like receptors with a slight preference for avian receptors. Its conservation among the majority of H6 HAs provides an explanation for the broader host range of this subtype. Furthermore, the triad of N137, V190 and S228 in TW H6 HA may alleviate the requirement for a hydrophobic residue at HA₁ 226 of H2 and H3 HAs when binding to human-like receptors.

Consequently, TW H6 HA has a slight preference for human receptors, thus may represent an intermediate towards a complete human adaptation. Importantly, the triad observed in TW H6 HA is detected in 74% H6 viruses isolated from Taiwan in the past 14 years, suggesting an elevated threat of H6 viruses from this region to human health. The novel roles of the triad at HA₁ 137, 190 and 228 of H6 HA in binding to receptors revealed here may also be used by other HA subtypes to achieve human adaptation, which needs to be further tested in laboratory and closely monitored in field surveillance,

(Continue . . .)

 

The finding that 74% of the H6N1 samples isolated from Taiwan over the past 14 years now carry this N137/V190/S228 triad, which allows the binding to both avian- and human-like receptors, suggests that these H6 viruses may represent a growing threat to human health.

While there is no clear winner in the avian flu sweepstakes, the field continues to broaden with each passing year.  Where once we worried only about H5N1, over the past two years we’ve seen serious human infections with H7N9, H6N1, H5N6, and H10N8.   

While the odds of any one of these subtypes becoming a `humanized’  flu strain are likely pretty long, the more candidates you have, the greater the chances are that one will succeed. 

 

So we watch the evolutionary progress of viruses like H6N1 closely, in hopes that we’ll have some advance warning if it becomes a more tangible threat.

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